Peripheral joints Flashcards
Where do you look in your casenotes to assess severity?
- NRS (numerical rating scale ie 0-10)
- body chart (ie location of pain and whether it travels
- how disabling is the pain eg annoying or excruciating)
- sleep cycle
- any pain relief medication
Where do you look in your casenotes to assess irritability?
- How easy it is to aggravate or ease
- sleep cycle
- is it affecting their sport or their work
What would make you assess a patient’s pain as being mechanical in nature?
- movement causes pain
- intermittent pain related to movement
- mechanical usually responds well to manual therapy
What would make you assess a patient’s pain as being chemical in nature?
- Inflammatory response that irritates nociceptors
- may hurt after use
- pain is usually throbbing, pulsing etc.
- can affect sleep more
- may see swelling, heat, discolouration
- pain may be constant cf intermittent
- responds less well to manual therapy
Describe when you’d use the 4 treatment grades
Grades 1 (small amplitude) and 2 (large amplitude) are for pain reduction, and if you meet pain before resistance.
Grades 3 (large amplitude) and 4 (small amplitude) are for improving ROM, and if you meet resistance before pain
How would you decide on dosage?
- Usually want about 2 mins of treatment time but can break that down into sets and repetitions if it’s painful/ irritable
- Eg low irritability 4 sets of 30 seconds with 10 seconds rest cf high irritability 12 sets of 10 seconds with 30 seconds rest between
How does diabetes affect collagen, and how might this influence your decision making re manual therapy?
- When there is too much glucose in the bloodstream, excess sugars glue themselves to proteins and form AGEs (advanced glycation end products)
- AGEs cause crosslinking in collagen, which stiffens tissues that are normally flexible and elastic, making them stiffer and more brittle
- So choose grade 1 or 4 because they are smaller movements and more likely to be safe (more control over smaller amplitude oscillation)
- Grade 4 is generally at end of range, but because of type 2 diabetes you might decide to not do it totally at the end of range
What evidence is there about the use of manual therapy with diabetics?
Small studies:
- found to be effective for diabetics with carpal tunnel syndrome
- may be safely applied in diabetic patients with frozen shoulder
- Manual therapy increased the ankle joint amplitude and improved the static balance in individuals with diabetes
What are the two ways someone being on long term steroids eg an asthma inhaler would influence your thinking re manual therapy?
- Steroids are used in asthma as an anti-inflammatory:
- using anti-inflammatories during injury healing can mean patients get stuck in inflammatory phase for longer than normal
- if they have had an injury avoid grade 3 or 4 in proliferation phase
- grade 4 (if permitted by SIN) in remodelling as we have more control over a smaller amplitude oscillation - Steroids can have a negative effect on collagen synthesis:
- collagen laid down may be weaker
- associated with reduced bone density, fragile skin and bruising
- may choose not to work at end of range ie not grade 3 or 4
- may choose a smaller amplitude oscillation ie grade 1 or 4 for more control
How might paracetamol and NSAIDs affect your thinking re manual therapy?
Paracetamol
- purely for pain suppression
- may affect the severity or number grade they put on their pain
NSAIDs
- anti-inflammatory and a painkiller
- may affect the severity or number grade they put on their pain AND
- can delay the inflammatory process and so have a negative impact on collagen formation during healing
How long are each of the four stages of healing?
1.Bleeding – minutes
2.Inflammation (initial response): ie 0-4 days after injury – redness/ swelling/ heat
3.Proliferation (fibroblastic repair): 4 hours - 24 days after injury – unorganised scar tissue
4.Remodelling (maturation): 21 days – 2 years – realignment of collagen fibres
Describe the pain gate theory?
- when several sensory stimuli reach the spinal cord at the same location and time, one of them becomes dominant
- activation of nerves that do not transmit pain signals, called nonnociceptive fibres, can interfere with signals from nociceptive fibres, thereby inhibiting pain
- ascending inhibition/ ascending pathway – about signals going up to where the perception of pain in the brain is created being interrupted
Describe the opioid theory of pain?
- endogenous opioids such as enkephalin will inhibit the release of a neurotransmitter involved in pain transmission, thereby blocking pain transmission
- goal of this pathway is to allow the organism to function enough to respond to the pain source by reducing the pain signal through neuronal inhibition
- descending inhibition/ descending pathway ie brain decides to modulate pain – sends signal down brain stem that interrupts signal in spinal cord between synapse and sensory neuron, so no more pain signals can ascend
Give 9 ways you could be critical about manual therapy?
- Limited evidence on how much force needed to induce desired effects
- Amount of force delivered by individual therapists is subjective
- Theory that manual therapy during tissue healing and remodelling will improve extensibility and strength of a tissue: unclear whether relatively small dose of force at infrequent intervals could actually effect this
- Force applied will always be dispersed through neighbouring tissues as well as target structure
- Are you actually moving the joint or just pushing neighbouring soft tissue around studies looking at mobilisations on thumb and separately on vertebrae found no joint movement, only soft tissue deformation
- Movements are supposed to be passive ie patient completely relaxed. This will never be the case unless they are unconscious
- We use numerical rating scale for pain: individual perception. Patient saying 5 one day might forget and for same pain next time say 3
- Concave/ convex rule – there are studies observing different joint arthromechanics to that predicted by this rule (found a few re glenohumeral joint) 1 study found that AP was more effective for frozen shoulder even though rule says it should be PA. Both groups had reduction in pain though
- Even though we use an objective marker to assess ROM/ pain before and after, how do we know if it was our treatment that caused any difference? Is patient just saying what we want to hear?
Give an example intro speech to a manual therapy patient
- Hello my name is Olivia, I’ll be your sport therapist today. I propose using manual therapy on your [X]
- It’ll involve me putting my hands on you and moving your joints around. The idea is that it can help decrease pain and increase range of motion
- But it may be a little uncomfortable while I’m doing it and for a day or two after
- Do you understand?
- Do I have your consent to treat you?”
Outline your step by step treatment protocol
- Intro speech
- Objective marker – an active movement where you ask about pain on a scale of 0-10
- Test movement – the same as your treatment movement to assess pain point
- You treat first set
- Test movement
- You treat second set (etc for correct number of sets)
- Repeat objective marker
What is the concave/ convex rule?
mobilising CONVEX bone = helps with OPPOSITE movement
mobilising CONCAVE bone = helps with SAME movement
What bones are at the subtalar joint, and which is concave/ convex/ proximal/distal?
- Talus - proximal - concave
- Calcaneus - distal - convex
What bones are at the talocrural joint, and which is concave/ convex/ proximal/distal?
- Talus - convex - distal
- Tibia - concave - proximal
What bones are at the tibiofemoral joint, and which is concave/ convex/ proximal/ distal?
- Tibia - distal - concave
- Femur - proximal - convex
What bones are at the patellofemoral joint, and which is concave/ convex/ proximal/ distal?
- Patella - distal - convex
- Femur - proximal - concave
