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Musculoskeletal Lecture > Principles in the PT Management of pts inconvenienced by musculoskeletal pathology > Flashcards

Principles in the PT Management of pts inconvenienced by musculoskeletal pathology Flashcards

1
Q

steps of PT care

A

Exam, evaluation, diagnosis, prognosis, intervention, outcomes

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2
Q

Review of Systems (ROS)

A

historically collecting data from pt about different systems of body

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3
Q

systems review

A

tests and measures (objective measurements)

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4
Q

principles

A

a fundamental guiding sense of the requirements and obligations of right conduct

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5
Q

management

A

to take charge, control or care of

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6
Q

patient

A

individuals who are recipients of PT management who have a disease, disorder, condition, impairment, functional limitation and/or disability

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7
Q

what does it take to become a successful PT

A
  1. cognitive realm
  2. affective realm
  3. psychomotor realm
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8
Q

what is a history and why is it useful?

MORE TO ADD HERE

A

systemic gathering of data
-related to why PT services are requested
Use data to form initial hypothesis of diagnosis and etiology

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9
Q

Obtaining the history

A
  • chart or medical record review

- typically obtained during your interview, but may be augumented by questionnaires or other sources

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10
Q

what do we get from the history

A
  • demographic profile
  • social/family/history
  • occupational employment
  • living working, playing environment
  • current and past general health history
  • current and past functional status
  • prior medical alternative, or other interventions
  • current condition
  • current complaints
  • patient expectations/goals
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11
Q

Patient-Therapist History Interview

A
  • first impressions
  • LISTEN TO THE PATIENT
  • Appropriate for age, gender, culture, etc
  • taken in an orderly or systematic sequence
  • may result in arriving at a PT diagnosis
  • focus the pt on relevant information
  • attempt to start the interview “open ended” and progress to “close ended”
  • AVOID LEADING THE PATIENT
  • -when did this episode begin
  • -does this reproduce your symptoms?
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12
Q

P-T history interview: open ended approahc

A
  • guides but not restricts discussion
  • patient is allowed to express what they feel is important
  • often enhances rapport building
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13
Q

P-T history interview: closed ended interview

A
  • direct question approach
  • list of predetermined questions
  • answers are assumed to fall into predetermined categories
  • be cautious not to “lead” the patient
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14
Q

the Patient history interview sequence

A
  • age, gender, referral source, Dx, hand dominance
  • occupation (employment and recreation)
  • -requirements, elections or aspirations
  • -environment (home environment as well)
  • -status
  • why has the pt come for help? (overview of present condition, chief complaint)
  • onset of condition (traumatic/insidious)
  • previous related injuries or episodes
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15
Q

Pt history interview: symptoms

A
  • quality
  • anatomical location
  • constant/intermittent
  • pattern
  • provocative or associated activities
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16
Q

functional status

A
  • past and present

- parameters

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17
Q

symptom quality

A
  • mechanical c/o (locking, stiffness/tightness, clicking/popping/snapping/grinding=degenerative instability, giving way/buckling/slipping out=instability)
  • –something in joint if locking, sitff/tight could be bone on bone
  • color and/or temperature changes (infection, inflammation, lack of color, ecchymosis)
  • numbness, parathesias, dysathesias
  • weakness
  • spasm
  • pain
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18
Q

numbness

A

nothing felt at all

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19
Q

parathesias

A

loss, tingling, half of body (one arm vs the other)

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20
Q

dysathesias

A

altered sensations

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21
Q

pain quality

A

see note chart

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22
Q

anatomical location of symptoms

A
  • localized pain
  • de-localized pain
  • -referred vs radicular
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23
Q

referred pain

A
  • within a sclerotome

- emanates from deep somatic tissue, confusion of brain

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24
Q

radicular pain

A
  • dermatome/myotome
  • nerve root
  • spreads down one arm
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25
Q

patient history interview: other risk factors and co-morbitities

A
  • lifestyle (smoking, alcohol, drugs, nutrition, actvity level, social history)
  • family history
  • any similar symptoms
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26
Q

patient history interview: residual patient thoughts

A
  • other important/significant thoughts or concerns regarding:
  • -symptoms
  • -contextual relevance of condition
  • -goals, needs or desires
  • -expectations of PT intervention
  • patient opinions as to what the problem is
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27
Q

systems review

A
  • brief screening procedure
  • provides information about the bodily systems involved in the pts current condition or health
  • helps identify possible health problems that require consult or referral to other health care professionals
  • results may effect further examination and intervention procedures
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28
Q

how does history affect the systems review

A

-determines the necessity and extent of the review

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29
Q

systems to be screened objectively

A
  • cardiovascular/pulmonary
  • integumentary
  • neuromuscular
  • musculoskeletal
  • communication ability
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30
Q

Screen exam

A
  • upper/lower quarter screen
  • musculoskeletal subset of the system review that emphasizes joints of the body to help determine where the pathology is located
  • -r/o referral of symptoms from other issues
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31
Q

5 reasons to perform a screen

A
  1. no history of trauma (insidious)
  2. suspect referred/radicular symptoms
  3. doubt about locatoin of pathologies exists
  4. altered sensation
  5. unusual pattern or collection of symptoms
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32
Q

tests and measures

A
  • conducted after history and systems review
  • range from brief to lengthy
  • generate data most often regarding impairments and functional limitations
  • order should be prioritized
  • ask yourself: “should this be compared bilaterally?”
  • –answer=ALWAYS
  • start uninvolved/less involved-baseline
33
Q

prioritize tests and measures: considerations

A
  • safety
  • comfort
  • goals
  • social needs
  • cognition
  • physiological needs
  • psychological needs
  • functional needs
  • financial needs
  • vocational needs
  • medical treatment priority
34
Q

PT musculoskeletal tests and measures

A
  • ROM
  • Muscle Performance
  • Joint Integrity and Mobility
  • Posture, body mechanics and motor function
  • gait, locomotion and balance
  • pain
  • sensory integrity
  • reflex integrity
  • athropometric characteristics
  • special tests
  • assistive and adaptive device
35
Q

ROM exam should include

A
  1. quantity of AROM and PROM
  2. Quality
    - smoothness, movement pattern
  3. Symptom provocation
    - does this reproduce your symtoms
36
Q

documentation of ROM

A
  1. type of motion assessed
  2. quantity of AROM and PROM
  3. quality
37
Q

AROM: quantity and quality

A
  • if limited/abnormal, ask yourself why?
    1. Active muscle dysfunction?
  • problem w/muscle “organic weakness”
  • reflex inhibition due to pain or effusion
  • tissue reactivity: inflammation, abnormal motor recruitment (guarding or splinting w/antagonists and subsititutions with synergists)
    2. passive motion restriction?
  • blocking ability to go forward, tightness
    3. joint stability?
  • will present w/limited AROM b/c uncomfortable
38
Q

PROM: quantity and quality

A
  • if PROM is limited, ask why?
  • ROM limited b/c instability w/opposing group
    1. passive insufficiency?
  • looking at muscles that cross two joints
    2. intrarticular obstruction
  • loose body
  • ROM may change each time
  • vs acl tear with limitation at same spot each time
    3. muscle guarding or splinting?
  • apprehension
  • pain from tissue reactivity
  • biomechanical load intolerance
39
Q

resisted isometric testing: 4 exam responses

A
  1. strong and painless
  2. strong and painful
  3. weak and painless
  4. weak and painful
40
Q

different end feels

A
  1. hard end feel-bone on bone
  2. soft end feel-soft tissue approximation
  3. firm end feel-shoulder flexion, springy rebound
  4. empty end feel- complaint of pain that prevents full endfeel
41
Q

ROM: pain provocation: compression load

A

compression load intolerance->Reactivity

  • articular cartilage subchondral bone
  • periosteum
  • bursa/fat pad
  • tendon and/or tendon sheath
  • meniscus or articular disk
  • neural tissue
42
Q

ROM: pain provocation: tensile load

A
  • capsule
  • ligament
  • tendon or muscle
  • neural tissue
43
Q

AROM and PROM findings

A
  • if AROm is full and pain free you may often choose not to perform PROM
  • if AROM
44
Q

Specific tests and measures: muscle performance

A

s

45
Q

strength

A

10 rep max, % of 10 rep max

46
Q

power

A

1 rep max

47
Q

endurance

A

longevity, duration

48
Q

contraction types

A

concentric
eccentric
isometric

49
Q

muscle performance examination: resisted isometric tests

A
  • myotomal, break patient
  • cyriax classifications
  • force to pain onset-dynanometer, objective measure
50
Q

MPE: strength/endurance tests

A
  • MMT
  • isotonic x RM testing
  • isokinetic testing
  • functional task testing
51
Q

How should the presence of pain during resistive testing guide our use of strength testing in the patient population

A

dont use strength testing if pain during brake testing

52
Q

resisted isometric testing (break)

A 
testing abilities of contractile unit
-innervation (myotome/peripheral nerve)
-muscle
-myotendinous junction
-tendon
-tendoperiosteal junction
examining gross strength in a static position
possible reactivity (pain production)
53
Q

examiner observations during resisted isometric movement

A
  • whether the contraction causes pain and, if it does, the pains intensity and quality
  • strength of contaction
  • type of contraction causing problem
54
Q

resisted isometric testing: procedure

A
  • test position is neutral and mid range joint position
  • joint should be kept still
  • instruct the patient to hold the test position while resisting the examiner’s break or make force
  • PT gradually increases force until a maximal muscle contraciton is achieved or patient cannot resist the force
  • hold 3-5 seconds at peak force
55
Q

cyriax’s isometric testing results

A

Grade 0: strong and painless
Grade 1: strong and painful: minor muscle/tendon involvement
Grade 2: weak and painful: more severe muscle/tendon lesion
Grade 3: weak and painless: complete muscle or tendon rupture or neurological problem. organic weakness

56
Q

isometric force to pain onset testing

A
  • test position is a neutral joint position
  • joint kept still
  • instruct the pt to hold the test position while resisting the break force
  • PT gradually increase force until onset of pain
  • -handheld dynamometer
  • -weights
  • -time
  • record force measure bilaterally
57
Q

proceed to MMT

A
  • once resisted isometric break testing has confirmed weakness within a nerve root, MMT should be performed to isolate specific muscles innervated by that root
  • important tool for determining the muscular cause of movement dysfunction
58
Q

joint integrity and mobility testing

A
  • examination of accessory motions
  • -component motion and joint play
  • testing performed by the PT
  • normally
59
Q

component motion

A

motion that accompanies active motion, but not under voluntary control (upward rotation of the scapula with clavicular rotation

60
Q

joint play

A

motion that occurs between the joint surfaces (arthrokinematics-roll, slide distraction, compression)

61
Q

loose pack postion

A

loosest postion for joint where you can get the most ROM

62
Q

mennels rules for joint play testing

A
  • pt should be relaxed and fully supported
  • examiner should be relaxed and should use firm but comfortable grasp
  • one joint should be examined at a time
  • the movement should be examined one a time
  • unaffected side should be tested first
  • one articular surface is stabilized while the other surface is moved
  • movements must be normal and not forced
  • movements should not cause undue discomfort
63
Q

posture, palpation, body mechanics and motor function

A 
begin palpation procedure with a visual examination
-skin and subcutaneous tissue in the affected area
-note any:
areas of localized edema or effusion
ecchymosis or hematoma
-abrasions or lacerations
-discoloration of skin and nail beds
-calluses, blisters, scars
-atrophy or hypertrophy
-alterations in contour
64
Q

palpate to examine

A
  • tissue temp
  • -increase temp: increase inflammation decrease sympathetic activity
  • -decrease: decrease vascularity, increase sympathetic activity
  • moisture and texture
  • -moist and smooth (inc. symp)
  • -scaly and dry (dec. symp)
  • -skin mobility via rolling: adhesions?
  • tenderness (inflammation, trigger sites, leave to end of exam if known
  • sensation
  • muscle status
  • -increased/decreased tone
  • -trigger sites
  • -continuity or defects
  • swelling
  • -edema: pitting or non-pitting
  • -effusion
  • pulse
  • bony alignment and relationships
  • mechanical signs
  • bilateral comparison
65
Q

palpation procedure

A
  • inform pt as to what is coming
  • have target and purpose in mind
  • confidently proceed
  • use no more pressure than necessary
  • start superficial then progress to deep
  • may choose to use the back of the hand to detect temp
  • tips of the fingers most sensitive and discriminating
66
Q

palpable tenderness grading

A

grade 1: pt complains of pain
grade 2: pt complains of pain and winces
grade 3: pt winces and withdraws the joint
grade 4: pt will not allow palpation of the joint

67
Q

sensory integrity testing

A
  • assessment of deep and superficial sensations
  • proprioception
  • kinesthesia
  • touch sensitivity: peripheral sensory
  • touch discrimination
  • bilateral comparison
68
Q

proprioception

A

static joint position sense

69
Q

kinesthesia

A

dynamic, passive awareness of movement

70
Q

touch sensitivity: peripheral sensory

A

light brush or wisp of cotton

  • temp
  • pressure
71
Q

touch discrimination

A

-2 point and sharp/dull

72
Q

reflex integrity

A
  • used to determine excitability of the nervous system and the integrity of the neuromuscular system
  • developmental reflexes (pediatrics)
  • pathological reflexes-not normally present (babinski, clonus, etc)
  • muscle stretch reflexes/deep tendon reflexes
73
Q

deep stretch reflexes (MSR)/Deep tendon reflexes (DTR)

A
  • pt and muscle must be relaxed
  • tendon placed on slight stretch
  • elicit: strike tendon with reflex hammer
  • repeat 5-6 times to note fading response-bilateral comparison
  • hyporeflexia: lower motor neuron
  • hyperreflexia: upper motor neuron
  • if needed, jendrassik maneuver to enhance DTR
  • -UE: adduct LE together
  • -LE: clench UE together
74
Q

anthropometric characteristics

A
  • describes human body characteristics including atrophy and edema
  • measures:
  • -height (ruler)
  • -weight (scales)
  • -body fat (caliper, electrical impedance)
  • -girth: flexible ruler, volumetric technique
  • bilateral comparison or normative comparison
75
Q

mesomorphic

A

athletic build

76
Q

endomorphic

A

round/curvy frame

77
Q

ectomorphic

A

very skinny, low body fat

78
Q

special tests

A
  • regional tests designed to confirm whether or not a specific condition is present
  • often many available per condition
  • often provacative
  • special tests are used in conjuction with other examination data to formulate a diagnosis
  • not the be all end all of pt
  • test validity is often questionable
  • -skill of examiner
  • -presence of multiple conditions
79
Q

special test uses

A
  • to confirm a tentative diagnosis
  • to make a differential diagnosis
  • to differentiate between structures
  • to understand unusual signs
  • to unravel difficult signs and symptoms

Musculoskeletal Lecture (4 decks)

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