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PT Screening > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

What are the Goals of the MS Assessment?

A
  1. Exclude serious pathology
  2. Consider pain mechanisms (nociceptive, neurogenic, central sensitization)
  3. Determine influence of contextual factors and other co-morbidities
  4. Understand how other psychosocial factors are influencing the condition (emotions, beliefs, etc.)
  5. Identify the nature of the symptoms (joint specific, soft tissues, motor, etc.)
  6. ID appropriate **course of treatment **
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2
Q

Clinical Guidelines

A
  • Follow a framework
  • Have 4 Components
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3
Q

What are the 4 Components of Clincial Practice Guidelines?

A

Component 1: Medical Screen

Component 2: Differentiation of body functioning, acitvity, and participation restrictions associated with health conditions - “Pattern recognition”

Component 3: Assessment of severity, irritability, stage and stability of condition

Component 4: Match intervention strategies based on findings

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4
Q

Component 1: Medical Screening

A
  • PMH
  • Subjective and Objective information
  • Ransford Pain Diagram/ Visual Analog Pain Scale
  • Psychological Risk Factors (Tampa Sclae of Kinesiophobia, Pain Catastrophizing Scale)
  • Functional Outcome Measures (Ex: Shoulder Pain and Disability index)
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5
Q

Component 2: Differentiation fo Subjective and Examination Findings

A

ID Source of Pain

Differentiation of Patient Subgroups!

Pattern recongition

Standardized Examination

Patient Centered Examination

Functional Asteriks/Comparable Sign

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6
Q

ID Source of Pain

A

Nociceptive Pain (more “acute”)
Proportionate pain
Aggravatign and alleviating factors
Intermittemnt sharp or dull ache
No dysesthesia, burning or shooting
May be reffered pain (Joints, muscles, heart)

Peripheral Neurogenic (radiating pain)
Pain in dermatomal or cutaneous distribution
ULTT (Upper or Lower Tension Test) and sensitivity to nerve palpation
Hx of nerve injury

Central Sensitization
Disporpotionate pain
Disporotionate aggravating and alleviating factors (or unable to ID them)
DIFFUSE non-anatomic tenderness. Lower threshold to produce pain
Psychosocial issues – pain affected by mood, emotions, beliefs

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7
Q

Differentiation of Patient Subgroups

A
  • Cognition and Personal Beliefs
  • Mobility/Flexibility
  • Motor Function
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8
Q

Cognition and Personal Beliefs

A

Patient understanding of their condition

Fear avoidance beliefs/kinesiophobia

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9
Q

Mobility/flexibility

A

Joint Mobility (arthritis, impingement)

Soft Tissue mobility/flexibility/tone

Neurodynamic mobility

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10
Q

Motor Function

A

Motor control/coordination (Moving normal)

Muscle Strength (force)

Muscle endurance (maintain force over time)

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11
Q

Patient Centered – Identify an Asterik Signs

A

During exam, ID an asterik sign yo continually assess to determine effectiveness of intervention and refine your clinical reasoning of what is best for patient

Common are:

Specific motions, findings or functions which provoke symptoms

Qualitative and Qualitiative changes within or between session changes

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12
Q

Component 2: 2 Parts of the Examination

A
  1. Standardized Exam : Done on EVERYONE
  2. Differing Elements: Done to differentiate impairments to mobility
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13
Q

Standardized Exam - Musculoskeletal

A

Patient Interveiw

Systems Review/Screening (as needed); Integument, Neuro, CV

Structural inspection-position (Posture/gait)

Motion Assessment

Functional assessment
AROM
PROM
PROM w/overpressure

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14
Q

Differentiating elements - tests

A

Joint palpation and mobility/accessory motion

Muscle palpation and muscle length/flexibility

Neurodynamic Mobility

Motor Assessment
-Acitvation/coordination
-Strength (MMT)
-Endurance

Special Tests

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15
Q

1a. Patient Interview

A

Chloride PA

Contextual Factors

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16
Q

1b. Systems Review

A

MD referral vs patient self refferal

PMH

Surgery or no surgery

Type of meds

Subjective interview

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17
Q

1c. Structural Inspection – Assessing Posture and Gait

A

What is ideal posture?
-No ideal posture!
-Don’t teach posture can cause fear!
**Asymmetries from side to side or from what you expect
-Structural vs functional deformities
–Structure: Cannot change. Related to bone/muscle
–Functional: Can change! Body has adapted to symptoms such as pain. **
-Overall shape or area
-Deformities, swelling, atrophy

Gait (Covered later)

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18
Q

Posture and Alignment: Priority or Pointless?

A

Priority

Initial evaluation of every new patient

Is posture relevant?

Guide you assessment/treatment

Limiting Factor: STATIC ASSESSMENT; Cannot make assessment on function

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19
Q

1d. Assessing Joint Movements

A

4 Parts:
-Functional Movemnt
-AROM
-PROM
-Overpressure at end ROM

Search for Quanitity, Quality, Symptom reproduction

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20
Q

Functional Movement

A

Global assessment

Functional motions to replicate symptoms

Put on a coat

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21
Q

AROM

A

Assess contractile (muscle) actively

Assess noncontractile (bone, cartilage, tendon) tissues actively and passively

Reveals quantity and quality

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22
Q

PROM

A

a. Stress contractile structures passively by stretching them

b. Stress non-contractile tissue passively

c. Assess what occurs at end range (“end feel”, pain,etc)

d. Assess Muscle tone

Voluntary: muscle guarding (can modify it)

Involuntary: tonal abnormalities
Hypertonia – UMN
Hypotonia – LMN
Flaccidity – Both
Rigidity – UMN

Feeling of limb chnages with change in tone

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23
Q

Apply Overpressure at end range of motion assess “End-Feels” - 5 Types

A

Muscular (Elastic)
Capsular
Ligamentous
Bony
Soft Tissue Approximation

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24
Q

Muscular (Elastic)

A

Elastic feel, slow resistance, creep at the end

Ex: Hamstring

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25
Q

Capsular

A

Sudden end with firm arrest

Less creep

Ex: ER of shoulder at 90 degrees, knee extension

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26
Q

Ligamentous

A

Sudden end with firm arrest

No creep

Ex: Varus and Valgus

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27
Q

Bony

A

Hard, rigid, sudden stop

Ex: Elbow extension

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28
Q

Soft Tissue Approximation

A

Soft and Spongy

Ex: Biceps Flex

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29
Q

What are “Abnormal” End Feels?

A

Spasm/guarding/empty
Springy
Bony
Capsular
Loose (unstable)
Boggy

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30
Q

Spasm/guarding/”empty”

A

Patient prevents the PT to get to end range

Muscle guarding

Associated with pain an/or fear

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31
Q

Springy

A

Rebound effect

Cartilaginous block in joint due to intraarticular derangement

Ex: Hip – labral tears, Knee – Meniscus

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32
Q

Bony

A

In a joint not expected – OR

Occurs sooner than expected

Ex: OA

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33
Q

Capsular

A

In a joint not expected – OR

Occurs sooner than expected

Ex: Hip Capsular

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34
Q

Loose (unstable)

A

Hypermobile joint or unstable joint

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35
Q

Boggy

A

Prescence of joint effusion

Ex: Infection/Abscess in joint

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36
Q

Ex: “Capsular Pattern” to PROM Limitation

A
  • Each joint has a characteristic pattern of loss of motion if capsule is tight/restricted
  • Will observe limited motion with capsular end feel during multiple motions
  • Ex: Shoulder. Loss of ER, Abduction and IR
  • Ex: Hip. Loss of Flexion, ER, and IR
37
Q

2a. JOINT Palpation and Joint Accessory Movements

A

2 Parts:
A. Palpate joint and joint structures (when able to)
B. Assess joint “accessory motion” (aka: joint mobility or joint play)

In Search of:
* Reproduction of pain with palpation
* Abnormal findings with palpation
* Limitations of accessory joint motion
* Bilateral comparison

38
Q

Accessory Movements “joint mobility”

A
  • AKA: Joint mobility, Joint play, Arthrokinematic movements
  • Assessing the movement of the joint that the patient does not have control of
  • Normal joint mobility is necessary for full motion and function of the joint
  • Replicates the arthrokinematics the joint undergoes to achieve full active movement
  • “Roll”, “glide”, “rotation” of the joint
  • Limitations often related to capsule/ligament tightness
39
Q

Classification of Joint Movement

A

Normal
Hypomobility: Pathological
Hypermobility (Laxity): Somes pathological (Nonpathological)
Instability: Pathological

Other:
* More laxity inferiorly
* Takes lots of experience to determine “normal”
* Can help with capsular restrictions with joint mobility: improves mobility and flexibility of joint capsule

40
Q

Joint Mobility Assessment

A
  • Due to limited mobility, difficult to assess
  • Where the pain is felt indicates patients irritability
  • If patient is more irritable, pain will be seen earlier in the ROM
  • Hypomoblity seen in capsular tightness
41
Q

Assessing Congenital Hypermobility

A
  • (aka: Benign Hypermobility Joint Syndrome)
  • Hyperextension of fingers parallel to the forearm (2)
  • Place thumb on ipsilateral forearm (2)
  • Hyperextension of elbows and knees over 10° (4)
  • Lumbar flexion – able to touch palms to the ground (1)
  • **May be acquired joint laxity. **
  • More points, more likely to have general hypermobility
  • 4+ is considered hypermobility
  • Ex: Someone with this condition is more likely to dislocate shoulder
42
Q

Muscle Palpation and Muscle Length/Flexibility/Tone

A

2 Parts:
A. Muscle palpation to assess for pain/tenderness/ tone
B. Muscle length/flexibility testing

In search of:
* Reproduction of pain/symptoms with palpation
* Abnormal findings with palpation(increase tone)
* Limitations of muscle length/flexibility
* Bilateral comparison

43
Q

Which muscles are more susceptible to irritability Grouping of muscles?: Postural (tonic) vs. Phasic muscles

A

Postural (tonic)!

44
Q

Postural Muscles

A
  • “Facilitated muscles” (Increased neural input and increased neural tone; tend to be more tight/limited)
  • Tend to be biarticular
  • Increased tendency to tighten/high tone compared to phasic muscles
  • Lower irritability threshold (“Biased recruitment” AND more tender to palpation)
  • Commonly symptomatic (pain with palpation and limited flexibility)
45
Q

Biased Recruitment

A

Doesn’t take as much to cause contraction

46
Q

Phasic Muscles

A
  • “Inhibited muscles”
  • Tend to be uniarticular
  • Antagonistic to postural
  • Tend to have more limited motor control or force production deficits (get weak as a result of pain, immobility or disuse)
47
Q

Lower Cross Syndrome is also called…

A

Lumbo-pelvic complex

48
Q

Upper Cross Syndrome is also called…

A

Cervico-thoracic-scapular complex

49
Q

Lumbo-Pelvic Complex - Postural Muscles

A
  • Erector spinae
  • Latissimus dorsi
  • Quadratus lumborum
  • Iliopsoas & rectus femoris
  • TFL
  • Hip Adductors
  • Piriformis
  • Hamstring
  • Gastroc & soleus
50
Q

Lumbo-pelvic complex - Phasic Muscles

A
  • Gluteus maximus
  • Biceps femoris
  • Transversus abdominus
  • Internal oblique
  • Multifidus
  • Pelvic floor muscles
51
Q

Cervico-thoracic-scapular complex - postual muscles

A
  • Upper trapezius
  • Levator scapulae
  • Suboccipitals
  • SCM
  • Scalenes
  • Latissimus dorsi
  • Pec major / minor
52
Q

Cervico-Thoracic-Scapular Complex - Phasic Muscles

A

Deep neck flexors
Serratus anterior
Rhomboids
Mid and lower trapezius
Shoulder external rotators

53
Q

Why are muscles palpated?

A
  • Tone: as in increased tone side to side as a result of muscle guarding or increased pain
  • Pain Pressure Threshold (tenderness): How much force does it take to elicit pain. Ex: Put a pressure gauge on someone somewhere
  • Every muscle has a specific referral pattern. When you press and refers it is known as a “trigger point” (Latent trigger point “pain but no refer”)
    –People who are more sensitive are more likely to have referral pain
    – Chronic muscle irritability is more likely to refer to begin to refer symptoms
54
Q

Assessing Muscle Length/Flexiblity

A

2 Methods:
- Active Assessment
- Passive Assessment
- MUST BE AWARE OF MM INFLUENCE ON JOINTS THEY CROSS

55
Q

Altered Muscle Tone/Flexibility Theories (2)

A
  • Prolonged or habitual positioning can lead to muscle shortening or lengthening (DISPROVEN)
    OR
    - Pain and/or guarding can lead to increased tone in mm
  • Abnormal muscle tone/length may lead to:
    – Diminished joint active and passive ROM
    – Abnormal or inefficient movement patterns
    – Compensatory motions
    – Pain: sensitivity to pressure
56
Q

Neurdodynamic Mobility

A
  • Perform when pain is of neurogenic origin
  • Assess the irritability of peripheral nerves to increase in tension
  • “Limb Tension Tests”
    – Upper Limb Tension Tests (3 primary nerves of UE)
    – Lower limb Tension Tests: SLUMP Tests of LE (Sciatic Nerve of LE)
57
Q

Joint/Muscle/Nerve Mobility Assessment:

A
  • Where the pain is felt, indicates patient irritability
  • Pain before you feel resistance is a highly sensitive injury
58
Q

MS Assessment Sequence

A

Lack of AROM -> Normal PROM is likely a muscle coordination issue; strength deficits

We need to match appropriate treatment to appropriate impairment

59
Q

Altered cognition/beliefs - Pattern Recognition Example

A
  • Interview: patient states uncertainty and fear
  • AROM and PROM may be limited due to fear of movement
  • Overpressure: not allowed
  • Palpation: Tenderness and tone with apprehension
60
Q

Joint mobility deficity - Pattern Recognition Example

A
  • Feels tight in joint
  • AROM AND PROM: Limited with BOTH
  • Overpressure: capsular end feel
  • Joint mobility assessment: deficits in mobility
  • Palpation: Tenderness of joint structures
61
Q

Soft Tissue Tone - Pattern Recognition Example

A
  • Feel a stretch with motion
  • AROM may be limited
  • PROM limited if muscle stretched
  • Overpressure: muscular (elastic) end feel
  • Flexibility tests: deficits noted
  • Palpation: Tenderness of muscle structures
62
Q

What are the 4 factors that affect motor function?

A
  1. Pain
  2. Injury to nerve tissue
  3. Injury to joint
  4. Length Tension Relationship of Muscle
63
Q

Pain

A

Pain inhibition
Apprehension/Fear
Cortical mapping changes

64
Q

Injury to nerve tissues

A

PERIPHERAL NERVOUS CONDITIONS
Nerve root = Myotomal weakness
Peripheral nerve = weakness of all muscles innervated by the nerve
CENTRAL NERVOUS SYSTEM CONDITIONS (Stroke/TBI/SCI)

65
Q

Injury to Joint

A

Several studies have correlated joint injury to weakness of muscles that cross joint AND joints proximally and distally

66
Q

Length Tension Relationship of Muscle

A

Depending on position of the joint, a muscle may either be strong or weak according to its length.

Note: Optimal force is between extremes. This is why we do MMT at midlength. It is the safest for joint and can produce more force here.

67
Q

Motor function Testings - 3 Parts

A
  • Muscle Coordination/Activation/Balance
  • Strength
  • Endurance
68
Q

Muscle Coordination/Activation/Balance

A
  • Patient awareness of how to activate/contract mm on command without compensation
  • Coordinate movement patterns: dissociate movements (Move femur seperate from hip)
  • Commonly need to perform with PHASIC muscle due to pain
  • Pain inhibits phasic muscle activation
  • Assess ability of patient to activate muscle on command WITHOUT COMPENSATION OF TONIC MUSCLES
69
Q

Strength Assessment

A

Isometric testing: MANUAL MUSCLE TESTING
Manual or standardized resistance through ROM
Isotonic testing with use of machines (Manual resistance: One repetition vs. multiple repetitions)
Test strength using a constant external resistance: May use 1-RM or repetition max of a specific weight

70
Q

Advantages and Disadvantages of MMT

A

Advantages
cheap
done in variety of positions
Quick
Easy

Disadvantages
muscle length held constant
strength at only one point of the range
unreliable
inconsistent how people do it

71
Q

Endurance Testing

A

Assess ability of muscle to maintain contraction at a statice resistance against external force for a period of time.

Ex: Side Plank

72
Q

What do we assess in component 3?

A

Assess Symptom severity, irritability, nature, stage, stability : SINSS

73
Q

Severity

A
  • Intensity of symptom (0-10, How does the symptom affect life/ADL)
74
Q

Mild Severity

A

Verbal, facial or body language indicate minimal pain
No limitation of ADL’s
Recreation is minimally affected or not limited
Sleep is OK
“mild, dull, ache, annoying, tight, stiff”
Pain 0-3/10

75
Q

Moderate Severity

A

Verbal, facial or body language indicate pain and/or guarding
Modified ADL’s
Doing 40-80% recreational activity
“Throb, hot, burning, deep ache”
Meds needed
4-7/10

76
Q

Severe Severity

A

Verbal, facial or body language indicate severe pain
Some ADL’s avoided or severely limited
Recreation/work abandoned
Sx’s force pt to stop activity
Deep, boring, lancinating, shooting, stabbing
8-9/10

77
Q

Irritability

A
  • “Ability to aggravate and ease symptoms (sx’s)”
  • High, Moderate, Low
  • Based on 3 variables
    – Amount needed to cause/provoke the sx
    – Severity of sx provoked
    – Activity and time to ease sx
78
Q

Why test for irritability?

A

Guides vigor of intervention

79
Q

Non-irritable

A

Sx’s ease quickly
Symptoms provoked with OVERPRESSURE during ROM assessment

80
Q

Moderatley Irritable

A
  • 1:1 ratio of symptom ease : time to provoke
  • Symptoms provoked at end range during ROM assessment
  • Do not provide overpressure
81
Q

Severly irritable

A
  • Sx’s quickly provoked and are severe and take long time to ease
  • Symptoms provoked prior to end range during ROM assessment
82
Q

Tissue Irritability =

A

Treatment Vigor

83
Q

What limits the VIGOR of treatment?

A

Moving to a limit of Pain- Stopping at the limit where pain commences - Severe /irritable patients
Moving to the limit of Motion- Moving to end-range and appreciating end-feels - Less severe /irritable patients

84
Q

Nature of Symptoms and Pain

A

Hypothesis of structure involved and/or classification of pathology. “Pattern recognition” (Cognition, joint mobility, etc.)

Hypothesis of primary pain component

Ex:
- Cognition/personal beliefs affecting function
- Joint vs. muscle vs. nerve mobility affecting function Neurogenic vs. muscular
- Motor function affecting function

85
Q

Stage

A
  • Acute: 0-10 days (usually more nociceptive pain)
  • Subacute: 1 week to 6 weeks
  • Chronic: Beyond 6 weeks (pain becomes more central sensitization)
  • Acute on chronic: Chronic symptoms with acute exacerbation
  • Assists in determining prognosis
  • Assists with intervention

The sooner we see patients the better the prognosis

86
Q

Stability

A
  • Symptom progression over time
  • Stable: Worse/better/same
  • Worse: symptoms becoming more frequent or more intense or covering a larger area
  • Better: Less frequent, less intense, smaller area
  • Same: has been fairly stable over a period of several weeks/months
    -OR-
  • Unstable: difficult to determine a pattern
  • Assists with clinical reasoning with treatment
87
Q

What is component 4?

A

Intervention based on findings

88
Q

Intervention strategies based on findings

A

Match up appropriate intervention with appropriate impairment
- Examples
* Cognition – Patient education
* Joint mobility issue – Specific joint mobilization techniques
* Flexibility issue – soft tissue mobilization and stretching
* Motor issue – enhance muscle coordination/strength/ endurance through exercise
* THEN: ASSESS HOW THE PATIENT RESPONDS TO THE TREATMENT. ASTERISK SIGN

PT Screening (21 decks)

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