MSK2 Flashcards
Define Clinical reasoning
process of collecting and interpreting info and formulating predictions about outcomes
Define the different models of clinical reasoning:
1) hypothestico-deductive reasoning
2) Pattern Recognition
3) collaborative model of reasoning
1) design hypothesis and set out to prove it right or wrong through physical exam
2) using past experience with a specific injury to treat a patient with similar injury (BAD!)
3) collaborative means from patients perspective. engaging patient in treatment and incorporating their goals/beliefs
List the structure of taking a History
Body Chart Current History Past History Behaviour of symptoms (24 hrs, aggs/eases) irritability of symptoms CI's / Precs Social Hx
What do you find from the body chart?
6 things
- Exact area of pain (referral pain?, # of sites of pain)
- type of pain
- intensity
- depth
- constant or intermittent
- establish relationship to symptoms
What do you find from the current Hx
6 things
- when did symptoms begin
- which symptoms
- mechanism of injury
- progress of symptoms
- treatment since injury
- info on the behaviour of symptom (irritability, severity, nature of condition)
What do you find from the Past Hx?
2 things
- past injuries
2. nature of the previous injury (compared to current injury)
For each aggravating factor you want to know….?
3 things
the vigor
the intensity
how long does it take to settle
What does the 24 hour behaviour of symptoms include?
behaviour at…
night, morning, during the day/at end of day
Mechanical Pain vs Inflammatory Pain
mechanical
- better in the morning
- worse at end of day
- worse with activity
- obvious aggravating activity causes symptoms
What are the 3 aspects of Irritability
Ease of onset
intensity
duration of symptoms
CI’s and Precs/ Special Questions. What do you need to know?
7 things
- general health
- recent unexplained weight loss
- presence or history of: inflammatory disorder, cancer, osteoporosis
- x-rays/other investigations
- medications
- steroid use
- spinal conditions
What are yellow flags? provide some examples
Risk factors that are likely to delay recovery
ex. unhelpful attitudes/beliefs/behaviour about pain compensation issues catastrophizing and fear work issues innapropriate family response
Whats included in the social hx
5 things
age/gender employment domestic role leisure activities goals of treatment
What are the principles of a physical exam?
8 items
- develop routine
- compare both sides
- target: reproduce symptoms
- asess local structures
- assess for referred pain
- assess for neural tension
- may need to evaluate complete kinetic chain (foot –> spine)
- protocol: LOOK, FEEL, MOVE
What does a physical exam include
Observation Functional Tests Palpation AMT PMT
Describe the Points in Range of a joint
P1 = onset of pain P2 = Pain limiting motion P3 = onset of resistance P4 = resistance limiting motion
What are the 5 types of Muscle testing
Isometric strength MMT endurance muscle control
What is the purpose of a muscle length test
- to determine if the musculo-tendinous unit is capable of passivley lengthening
- to isolate muscular damage
- evaluate muscle length
- isolate pain or symptom specific to anatomical site
Describe the process of a neuro exam
Sensation
strength (motor)
reflexes
Explain the aim of a neural tissue provocation test
to examine the response of movement of nerve, surrounding CT and the associated vessels
List the Special tests for contractile and non contractile
Contractile - iso mm test - muscle strength - functional strength - muscle length Non-contractile - stressful procedures - passive accessories
Percentages for Specific, non-specific, and nerve root compromise
- 1-2%
- 90%
- 5-10%
Somatic Pain vs Radicular Pain
Somatic
- evoked by stimulation of structure in lumbar spine
- aches, poorly localized, diffuse,
- can spread to lower limbs (referred) above knee
Radicular
- result of irritation of spinal nerves or nerve root
- dermatomal, shooting, sharp, localized, radiates below knee, distal worse than proximal
Red Flags for serious pathologies
7 items
- Signs/Symptoms of infection
- Signs/symptoms of inflammatory spondylarthritis
- Features of cauda equina syndrome or severe neruological deficit
- History of malignancy
significant trauma - Unexpected weight loss
- Consider minimal trauma fractures in the elderly and those on corticosteroids where there are osteoporotic risk factors
Describe Infection
cardinal feature is fever
pain
muscle spasm
decreased AMT due to pain
Describe inflammatory disease
- onset before age 40
- morning stiffness lasting >30 mins
- symptoms persisting > 3 months
- not responsive to treatment
- peripheral joint involvement
Decribe Ankolysing Spondylitis
- 2% is Aus (3:1 male to female)
- deep aching in or across buttocks
- pain in front of chest or between scapula
Describe Cauda Equina
- compression of multiple lumbar/sacral nerve root - 5th lumbar to sacral
- may be caused by disc bulging (lumbosacral dis herniation)
- clinical presentation: sphincter dysfunction, bilateral motor weakness, saddle anesthesia, gate disturbance
Describe Spinal Canal Stenosis
> 65 yrs old
- narrowing of spinal canal - hypertrophic degeneratic process
- clinical presentation: burning pain, increase in symptoms with spinal extension - standing , decrease of symptoms with spinal flexion, neurogenic claudication
Describe Vascular Claudication
throbbing pain
- absent pulses
- trophic changes
- pain not related to spinal position
- increased pain with activity
Describe Metastatic Cancer
tumours arising from breast, prostate, thyroid, lung and kidney - spread to bone
Describe osteoporosis
- decrease in bone density - increase risk of fracture
Describe spondylolysis
- defect or stress fracture of pars interarticularis or vertebral arch (L5)
- unilateral tenderness
- pain aggravated by activity and spinal extension
Red Flags for children with LBP
9 items
- progressive pain not responding to analgesia
- night pain
- fever
- unexplained weight loss
- severe constipation
- abnormal postures
- scoliosis
- gait abnormality
- sphincter dysfunction
How do you manage people with LBP
- education
- active physical therapy
- analgesic meds
- address impairment
What percentage of people in Australia suffer from LBP? globally?
29% - 6.1 million
12%
What are the risk factors for LBP?
- depression
- previous episode
- job dissatisfaction
- lifting, bending, sleep disturbance, genetics, social support, health status, type of work, obesity, smoking, physical activity
What is the Prognosis of LBP
- 1/3 of acute episode result in persistent symptoms
- 50% of patients experience a recurrence within 1 year
What are some prognostic factors for LBP?
- older age
- higher pain intensity
- longer duration LBP
- more days of reduced activity
- patient reports feeling depressed
- patients belief pain will persist
- compensation
- fear avoidance
- catastrophizing thoughts
What advice would you give to a person with NS-LBP?
reassure
advise to stay active and increase activity progressively
discourage bed rest
early return to work
When do you perform imaging in a patient with NS-LBP?
when severe or progressive deficits are present or when a serious underlying conditions are suspected
Indications for Spinal Manual therapy (SMT) - from the history
NS-LBP
msk mechanical problem
absence of CI’s
absence of red flags
Indications for SMT from physical exam
reproduced symptoms/restricted ROM on AMT tension absence of NRC symptoms reproduced in PAIVM restriction of mvmnt on PPIVM
Contraindications for SMT
tumour, metastatic disease, active inflammatory disease, fracture, infection
cancer
Grades and Dosage for Irritable people
grade 1/2, 1-3 sets, 30-45 secs
Grades and Dosage for non irritable people
grade 3-4, 3-5 sets, 45-60 secs
What do the superficial muscles of the spine do? (global muscle system)
torque generation
control of orientation
balance the external loads applied at trunk
What muscles control intersegmental movement
Deep muscles
- Transverse abdominus
- diaphragm,
- pelvic floor
- multifidus
