Theory Flashcards
1
Q
What are the aims of Tx for Constipation?
A
1) Reduce stress
2) Decrease SNS firing
3) Decrease pain
4) Address contributing postural imbalances
5) Decrease hypertonicity and trigger points in lumbar spine muscles and glutes
6) Decrease congestion in the abdomen
7) Increase circulation to the abdomen
8) Decrease trigger points and hypertonicity in iliopsoas if present
9) Move fecal matter
10) Maintain ROM
2
Q
What order/direction do you move fecal matter during Constipation Tx?
A
- Apply slow, short fingertip kneading to colon from sigmoid colon - superiorly along descending colon, to splenic flexure - across transverse colon to hepatic flexure and inferiorly to cecum
- Same techniques are then applied proximal to distal colon
- ALWAYS apply clockwise direction
3
Q
What is the purpose of the Rebound test? When would you use it?
A
Purpose: Rule in/out appendicitis
Use: Someone has abdominal pain
4
Q
Causes of Constipation?
A
- Longer transit time than average of fecal movement through the intestine (average 24-48hrs)
- More water is absorbed from stool the longer it is present in the intestine, causes it to become more solid (unable to pass)
5
Q
Predisposing Factors (Causes) of Constipation?
A
- Poor diet (low fibre)
- Sedentary lifestyle
- Stress
- Resisting urge to defecate
- Postural imbalance
- Surgery
- Medications
- Pregnancy
- Poor muscle control
- GI conditions (IBS)
6
Q
Signs and Symptoms of Constipation?
A
1) Straining, and pain or discomfort may be experienced when passing stools
2) Infrequent bowel movements occur. 1/day to 3/week is considered within normal limits.
3) Hard stool, “rabbit” or “pellet” stools- may be interspersed with softer stools or diarrhea, referred to as IBS.
4) Abdominal pain, cramps or discomfort intermittently
5) Low back pain or discomfort can result. Stimulation of the rectum from the presence of fecal matter can cause pain referral to the sacrum
6) Bloating and flatulence
7) Hemorrhoids can result from straining due to large or hard stools
8) A bad taste in the mouth, bad breath (halitosis), nausea, and lack of appetite can result due to the slowing of gastric emptying
9) Headaches, nausea, irritability, and malaise seem to result reflexively from dissention of the rectal wall
7
Q
Pathway of fecal matter through the large intestine? Time frame it takes to transmit?
A
- Normal: average time is 24-28 hrs and the normal limits are 1/day to 3 times a week
- Starts at: Cecum -> Transverse Colon -> Splenic Flexure -> Descending Colon -> Sigmoid Colon -> Colon
8
Q
What is IBS?
A
Irritable bowel syndrome - a functional GI disorder characterized by a variable combination of chronic and recurrent intestinal symptoms not explained by structural or biochemical abnormalities.
9
Q
Home care for Constipation?
A
1) Epsom salts bath
2) Self massage / cool wash to abdomen
3) Refer to naturopath or nutritionist for diet counselling
4) Stretch / strengthen affected postural muscles
5) Diaphragmatic breathing
6) Place footstool in front of toilet to increase flexion of hips and help with the bearing down during defecation
10
Q
Postural changes that can occur during Pregnancy?
A
1) Ligamentous laxity
2) Anterior carriage of weight shifts the center of gravity upward and forward
3) Hyperlordosis & Kyphosis due to weight shifting
4) Anterior pelvic tilt external rotation of the hips and hyperextension of the knees and possible Pes planus. Ant Pelvic tilt - Gluteal muscles, piriformis, quadriceps and iliotibial band will shorten.
5) External rotation of the hips may cause lengthening of the adductors
6) Enlarged breast can cause shoulder to rotate anteriorly
7) Anterior head carriage - shorten the posterior cervical, upper trapezius, scalene and sternocleidomastoid muscles.
8) Compensatory posture of the upper back and winging of scapula - lengthening of the selecta characters, rhomboids, middle and lower trapezius.
9) Pronation of the feet
- lengthening of tibialis anterior muscles and medial head of gastrocnemius.
11
Q
Symptoms of Pregnancy
A
1) Nausea and vomiting
2) Frequent urination
3) Blood pressure often falls in early pregnancy
4) Breast changes
5) Musculoskeletal changes
6) Taste and smell altered
7) Mood swings
8) Edema primarily in the legs
9) Hypertension / preeclampsia
10) Supine hypotension
11) Shortness of breath
12) Back aches associated with Hyperlordosis or Hyperkyphosis
13) Abdominal pain
14) Diastasis symphysis pubis
15) Varicose veins
16) Hemorrhoids
17) Pigmentation such as butterfly mask
18) Stretch marks
19) Nosebleeds, gum bleeding, and nasal congestion
20) Headaches
21) Emotional changes
22) Gestational diabetes
23) Ketoacidosis
24) Compression syndromes
25) Sacroiliac sprain
26) Leg cramps
27) Pelvic discomfort
28) Fatigue/ insomnia and restlessness
12
Q
Techniques that are appropriate in 3rd trimester of Pregnancy
A
All techniques are appropriate for a client in their third trimester of pregnancy monitor for ominous signs and treat within the client’s pain tolerance.
13
Q
If pregnant client at your client has sudden rise in blood pressure, what would be the appropriate course of action?
A
Send them to their doctor. Do not treat this client.
14
Q
Aim of Tx in 3rd trimester of Pregnancy
A
1) Monitor blood pressure
2) Decrease sympathetic nervous system firing
3) Decrease physical discomfort and trigger points
4) Decrease edema
5) Decrease the breast discomfort
6) Decrease constipation
7) Treat conditions that arise (carpal tunnel, IT band tightness, low back pain)
8) Maintain circulation and tissue health
9) Provide emotional support, education, referral
monitor for ominous signs
15
Q
What is Preeclampsia?
A
- A cardiovascular crisis
- A- toxemia related condition, although no toxin causes preeclampsia
- It may present as early as 20th week of pregnancy
16
Q
What are the signs of Preeclampsia?
A
1) Spiking blood pressure
2) Edematous weight gain over 2 pounds a week
3) Proteinuria (Presence of protein in the urine)
* Any two of the three symptoms are indication of preeclampsia*
17
Q
What is Postpartum Depression?
A
Postpartum depression is going from extreme happiness to sadness without explanation.
18
Q
CI’s associated with pregnancy
A
1st Trimester:
1) Abdominal and sacral massage only have light strokes or not at all ( especially if risk of miscarriage is present)
2) Deep massage and fascial CI in low back (lumbar)
2nd/3rd Trimester:
1) Carefully positioned on back to avoid compression of aorta and inferior vena cava
1) Care taken over abdomen during entire pregnancy
2) After 4 months, general/gentle is usually enjoyable for baby and mother
3) Fascial should be assessed for any stabilizing structure of posture before using
4) Aggressive joint play avoided over entire body, due to joint laxity during and 6 months after delivery
5) Decrease pressure over varicose veins
6) Change in blood pressure, combined with preeclampsia symptoms
7) Diabetes - snacks, juice should be eaten prior to tx to maintain blood sugar
8) Heartburn 2 hours should elapse after a meal before tx
19
Q
Tx for client with Frozen Shoulder in (Acute) freezing stage?
A
1) Decrease pain with cool/cold hydrotherapy, reflex techniques, grade 1 joint play FDB
2) Eliminate metabolites and localized swelling with Swedish and manual drainage techniques
3) Reduce muscle spasms to compensating muscles of the shoulder, back and anterior chest with hydrotherapy and soothing, effleurage and petrissage
4) Maintain range of motion with low-grade joint play to affected joint and Joint play to joints above and below the GH joint. Mid-range passive movement
5) Address distal musculature with gentle muscle squeezing and stroking without increasing venous and lymphatic return that make congest the site
6) Treat opposite limb, back, anterior chest and neck for compensation
20
Q
Treatment for Frozen Shoulder (Subacute) stage?
A
EARLY:
1) Cold hydro
2) Vibrations
3) Shaving
4) Compensatory structure
LATE:
1) DMH
2) Low grade joint play into higher grades
3) Frictions
4) Triggerpoint
5) Adhesions
6) Gentle stretching (pendulum swings)
21
Q
Tx for Frozen Shoulder in chronic stage (Thawing)?
A
1) DMH
2) High grade joint play
3) Stretching
4) Strengthening
5) Frictioning
6) Triggerpoints
22
Q
Triggerpoint in which muscle can cause Frozen Shoulder?
A
Subscapularis
23
Q
Capsular pattern associated with GH joint? Significance to Frozen Shoulder?
A
1) restriction in movement due to increased fluid
2) low grade joint play only
3) may not always be capsular pattern, cuz only part of the capsule may be involved
4) joint mice may be present ( floating cartilage)
5) use end feel to assess normal ROM
24
Q
Homecare exercise for Frozen Shoulder?
A
1) Pendulum swings
2) Wall crawl
3) Wall-walking / washing
4) Wand exercises
5) Strengthening of back, shoulder, chest and neck muscles
6) Passive stretching of rotator cuff muscles, chest, neck muscles
7) Increase range of motion first then strengthen
25
Special tests that could be positive for Frozen Shoulder?
1) Apley's stratch
2) Frozen shoulder PR abduction test
3) Anterior & Lateral spinous challenge: reveal vertebral hypomobility
4) 1st rib mobilization, sternoclavicular joint play show hypomobility
26
Describe hyperextension (head on collision) injury in CS?
1) Reverse of rear-impact; torso accelerates backwards and the neck hyperflex is first, then hyperextends
2) A person may be able to see impending collision and brace for the impact
3) Seat belts, airbags, headrests, and front and crumple zones all help reduce injuries
27
Describe hyperflexion (rear end collision) injury in CS?
Phase 1 (60ms):
- Back seat pushes torso as vehicle moves forward
- Torso compressed into seat and carried forward along with vehicle
- Head stays fixed in place (inertia)
- Torso then moves upward (compressing CS)
- Cervical discs may be injured
Phase 2 (120ms):
- Vehicle/torso reach peak forward position
- Seat begins to recoil back
- Head/neck stay in place as torso moves forward (causing hyperextension of neck)
- Anterior neck muscles overstretched
- Facet joints, TMJ injured
```
Phase 3 (160ms):
-Head/neck at peak forward position, vehicle/torso slowing down
```
Phase 4 (280ms):
- Head/torso full deceleration
- Seatbelt restrains torso while head/neck continue to flex forward (hyperflexion)
- Greatest stress placed on muscles, discs, ligaments in lower CS/upper TS (injuring tissues)
- C5-C7 most affected
28
Which muscles commonly strained in hyperextension Whiplash?
Muscles of anterior neck:
- SCM
- Mylohyoid
- Omohyoid
- Supra/Infrahyoid
- Platysma
29
Techniques for Acute Stage Whiplash?
- Cold hydro
- MLD before any compensatory work to decrease edema
- Treat trunk, shoulder girdle, uninjured limbs to reduce H+ and increase drainage
- Muscles of respiration treated with apical breathing
- Effleurage and slow petrissage
- QTF 0-1, isometric agonist contraction, gentle vibrations and effleurage to antagonist
- GTO and O&I on affected muscle
- Isometric agonist contraction in higher grades if tolerated (don’t remove spasm)
- Other on-site work CI’d
- Stroking/squeezing on head, muscles of mastication and dital arm
30
Difficulty swallowing is associated with TP in which muscle with Whiplash?
TP in SCM, may also cause deafness, dizziness, headache, memory loss, TMJ pain, TOS and tinnitus
31
What are various factors that can influence whiplash when driving?
1) Head position: compressive stress on ipsilateral facet joints turned to the side, compress nerve roots
2) Seatbelt: contribute to neck injury, low back pain and bruising to chest
3) Headrest position: if too low may further extend CS
4) Seatback position: too far inclined, headrest can't reduce injury
5) Stature: shorter than 5 feet are 40% less likely to sustain neck injury, more likely to have cervical injury from shoulder harness
32
Various grades from Quebec task force for WAD?
Grade 0:
No complaint about neck
No physical signs of injury
Grade 1:
Neck has pain, stiffness or tenderness.
No physical signs are serious enough to cause spasm
Grade 2:
Neck has pain, stiffness or tenderness
Musculoskeletal signs of decreased ROM and point tender
Injury of muscle, tendon, ligament and joint capsule can cause spasm
Grade 3:
Neck pain, stiffness or tenderness
Neurological signs including decreased tendon reflex and weakness
Injury of muscle, injury to neurological system due to mechanical injury or inflammation
Grade 4:
Neck complaint and fracture or dislocation
33
Special test for Whiplash?
Vertebral Artery Test
Passively takes clients head into extension/side flexion
Dizziness indicates vertebral arteries are compressed
Compression Test
Client’s head rotated and head is pressed straight down
Pain radiates into arm indicated compressed nerve root
Distraction Test
Hand under client’s chin, other under occiput. Slowly lifting clients head
Pain relief indicates nerve root compression
Swallowing Test
SCM grasped at site of potential TP, client swallows.
Pain/difficulting swallowing can indicate TP’s in SCM or cervical pathologies
Strength Test
Test to assess motor weakness
Spurlings
Carefully presses head down in neutral, extended, extended/rotated to tested side
Pain radiating into arm toward side of bent head indicates nerve root pressure
1st Rib Mobility
Adson’s
Palpate radial pulse. Client rotates head toward test shoulder, extends head back while shoulder is laterally rotated and extended. Client takes deep breath
If radial pulse disappears positive for TOS
Wright’s
Palpate radial pulse. Client’s arm is hyperabducted. Tested seated, then supine. Take deep breath and rotate head and neck while arm is brought over the head
Disappearance of pulse or tingling numbness in upper limb indicates TOS
3 Knuckle Test (for TMJ)
Length Test
May reveal shortness due to scar tissue
34
Various types of Dislocation?
1) Posterior Dislocation
2) Anterior Dislocation
3) Inferior Dislocation
35
Special test for Dislocation?
1) AF apprehension test
2) ROM testing
3) Apley’s scratch test
4) AC shear test
36
What similarities does tx of dislocation have with severe sprain?
- Do not treat to affected area (Don't want to remove protective spasm)
37
Health history questions for dislocation?
1) Any medication being used, anti-inflammatories, etc
2) Any contributing conditions
3) History of recurrent dislocation
4) When did it occur
5) What was done at time of injury - what position were they in
6) Have they seen a Dr
7) Any pins, screw, surgery done to area
8) If pain is sharp indicates acute injury
38
What direction is most common for patella to dislocate?
Laterally
| - Injury involves external rotation of tibia and foot when knee is flexed
39
What happens to muscles surrounding joint after dislocation during healing? (Acute, Subacute, Chronic)
Acute:
Protective mm spasm present in mm crossing affected joint
Heat present over injured joint
Subacute:
Tone of the mm crossing joint changes from spasmodic in the early subacute stage to tightness and hypertonic in the late subacute.
TP’s are now present in these mm
Chronic:
Adhesions are local to joint capsule
Hypertonicity and TP are present local to injured joints and in compensator mm.
Disuse atrophy may be present
40
Steps to safely asses client's ROM, joint stability, strength after dislocation?
1) Main goal in assessing a dislocated joint before treatment is to determine if joint is stable or unstable
2) If the AF apprehension test is positive (unstable) no PR testing performed. Continue only with AR isometric testing
3) If any joint instability is present during any AF or PR tests - refer back to AR isometric test and do not continue with further PR testing
View chart in LP 21 pg. 9 *Easiest explanation*
41
Homecare for Dislocation?
1) Hydro
2) Self massage
3) Remex
4) Encourage activity
Acute: Maintain ROM
Early Subacute: Increase strength
Late Subacute: Increase strength
Chronic: Strengthen Muscle
42
Muscles associated with TMJ?
1) Medial Pterygoids: elevate Jaw
2) Lateral Pterygoids: pulls disco anteriorly to allow for jaw movement
3) Temporalis: elevate Jaw
4) Masseter: elevate Jaw
5) Supra & Infra Hyoid: depress Jaw (with Digastric)
43
Signs/Symptoms of TMJ?
Stage 1
-Disc slightly anterior and medial on mandibular condyle
-Inconsistent click (possible)
Mild/No pain
Stage 2
- Disc anterior and medial
- Reciprocal click present (early opening and late closing)
- Severe consistent pain
Stage 3
- Reciprocal consistent click (later on opening and earlier on closing)
- Most painful stage
Stage 4
- Click rare (disc no longer relocates)
- No pain
44
What would cause mandible to deviate to right when opening the mouth? *NOT SURE IF THIS IS RIGHT ANSWER*
1) Lateral deviation may be due to TP’s in Masseter, Temporalis and Post. Digastric on side the mandible deviates towards (in this case the right side)
2) Lateral deviation may also be due to TP’s in Lateral Pterygoid on side it moves away from (in this case the left side)
3) Also may be indicative of Capsular Restriction? (pg. 9 TMJ LP)
45
What is capsular pattern of restriction for TMJ?
- This would indicate that there is a C-Shaped wobble
- Capsular Source - mandible deviated to side that is restricted
- Restriction to the right side in Capsular
46
Contributing factors for TMJ?
1. Predisposition: can be intrinsic (genetic development of mm, ligaments and bones) OR extrinsic (trauma to the neck, face, or jaw)
2. Tissue alteration: can occur to the dental and neuromuscular structures.
3. Stress: results in increased tone of the muscles of mastication due to jaw clenching, bruxism, or habits such as gum chewing.
4. Forward head posture, incorrect swallowing patterns, mouth breathing
47
Normal AF ROM for TMJ
Depression: 35-50 mm
Lateral deviation: 8-10mm
Protrusion: 5mm
Retrusion:3-4mm
48
TMJ is secondary concern to what type of WAD?
Rear impact, phase two (120 milliseconds)
49
Explain palpation of muscles of mastication
Masseter
Between cheek and molars w/ clients teeth gently clenched
Isolate muscle - clench teeth
Medial Pterygoid
Finger on the last molar, slid around to the medial surface of the molar and inferiorly past gum towards the floor of mouth. Finger against inner surface of mandible, finger is slid posteriorly to medial pterygoid
Isolate muscle - resist elevation (closing)
Lateral Pterygoid
Finger between cheek and molars, fingernail against last upper molars. Finger slid superiorly and posteriorly between the maxilla and coronoid process into hollow at roof of cheek
Isolate muscle - resist depression (opening)
Mylohyoid
Finger between lower teeth and tongue. Beginning at incisors, finger slid down the inner surface of mandible to floor of the mouth, posteriorly to last molar where mylohyoid ends
Isolate muscle - resist depression (opening)
50
3 components present for TMJ to occur?
1) Predisposition
Intrinsic (Genetic development of bones, muscles
Extrinsic (Trauma to neck, face or jaw)
2) Tissue Alteration
Can be skeletal, muscular or dental (tooth loss, hypermobility, spasm, poor posture)
3) Stress
Increased mm tone, due to jaw clenching, chewing gum, etc
51
Indications of breast massage?
- Congestion, Edema, Lymphedema
- Painful Breast
- Pregnancy, Breast Feeding
- Drainage issues
- PMS
- Breast trauma
- Scar formation
- Post breast cancer discomfort
- Post surgery
- Education regarding self-examination
- Requested by client
- Client seeks assistance in breast monitoring
- Client has goal to become more comfortable with their breasts
52
CI's of breast massage?
- Mastitis (active infection or post surgery)
- Local massage to undiagnosed lump
- Local massage to breast abscess
- Forceful attempt to reduce implant related contracture
- Direct pressure on ruptured implant
- Client unable to clarify wishes, or establish comfortable boundaries
- Therapist cannot establish professional environment
- Client/Therapist cannot establish open communication
- Client doesn’t give or withdraws consent
53
Ominous signs with breast?
1) Nipple retraction (normal after 35, but rapid retraction may be sign of cancer)
2) Nipple discharge that is crystal clear, gray/green or bloody
3) Hard, non-tender lumps
4) Cancerous lumps are usually not painful (pain usually indicates later stage of cancer)
54
Anatomical boundaries of breast tissue?
Upper: Lower edge of clavicle
Lower: 1” below breast contour, overlying upper fibers of rectus abdominis
Medial: Sternal midline
Lateral: Ant. edge of Latissimus Dorsi with some tissue extending to axilla
55
Injury to Longus Coli is associated with what condition? What stage of healing is commonly a issue?
Whiplash, longus coli is in usually in chronic spasm in the chronic stage of healing
56
Right thoracic scoliosis, convex right and concave left. What direction would movement be restricted?
Restriction on convex side - Right side flexion
```
Convexity is based on position of vertebral body NOT SP's. SP's point to concavity.
For example (left curve= right shoulder down, right hip up) - result in hypertonicity of right muscles and restriction of movement in left flexion
```
57
Which muscles are short/tight in Hyperkyphosis?
Shoulder protraction: pectoralis major, pectoralis minor, subclavius, serratus anterior and anterior intercostals
Internal rotation of the humerus: subscapularis
Depression of scapula: latissimus dorsi
Anterior head carriage: levator scapulae, upper trapezius, sternocleidomastoid, scalenes and suboccipitals
58
What muscles are weak/lengthened in Hyperkyphosis?
Shoulder protraction: rhomboids, middle trapezius, thoracic erector spinae
Anterior head carriage: longus colli, longus cervicis, longus capitis, suprahyoids, infrahyoids.
59
Hyperlordosis - Erector Spinae short or lengthened?
Lumbar is short and tight
60
Hyperlordosis - QL is short or lengthened?
Short and tight
61
Hyperlordosis - Multifius is short or lengthened?
Short and tight
62
Hyperlordosis - Glute Max is short or lengthened?
Stretched and weak
63
Hyperlordosis - Rectus Abdominus is short or lengthened?
Stretched and weak
64
Hyperlordosis - Iliopsoas is short or lengthened?
Short and tight
65
Hyperlordosis - Rectus Femoris is short or lengthened?
Short and tight
66
Hyperlordosis - Hamstrings are short or lengthened?
Stretched and weak
67
What would be medical emergency with compartment syndrome?
- Acute is a medical emergency.
- Bleeding and swelling within the compartment can cause an increase in intra-compartmental pressure and may compress nerves and/or blood supply
68
Contributing factors for patellofemoral syndrome?
1) Abnormal Biomechanics
2) Small High Riding Patella
3) Tight Lateral Structures (Vastus lateralis, ITB, TFL)
4) Tight Anterior/Posterior Structures (Hamstrings, Gastroc, Rectus Fem)
5) Weakness (Vastus Med, Glute Med)
6) Knee Injuries
7) Arthroscopic Procedures
8) Repeated Knee Stress and Overuse
69
AF/PR/AR ROM and Special testing for patellofemoral?
AF ROM:
Excessive lateral movement of patella during first 45 degrees of flexion
PR ROM:
Palpate for crepitus
AR ROM:
Weak glute medius
Length Test:
Hamstrings, Gastrocnemius are shortened
Q Angle:
Greater than 18 degrees when client is standing
Waldron’s:
McConnell’s:
Femur laterally rotated, and isometric contraction at 120, 90, 60, 30, 0 for 10 sec intervals. Pain produced during any stage the leg is passively returned to full extension
Test for patellofemoral syndrome
Positive sign is if pain is decreased
Clarke’s:
Hand supports client’s patella, and is pushed down while client contracts quads
Pain under patella indicated patellofemoral dysfunction
Patellar Apprehension Test:
Knee is extended, and patella is moved medially and laterally
If there is apprehension on client’s face it indicative positive for patellar dysfunction or dislocation
70
Triggers for migraines?
Stress, hunger, medication, weather change, visual stimuli, auditory stimuli, olfactory stimuli, sleeping patterns, hormones, allergies, food additives
71
List 2 types of Headaches?
1) Primary Headaches
Headache IS the condition, such as tension or migraine
2) Secondary Headaches
Result of underlying pathology (ie. head trauma)
72
List other headache of muscular origin?
1) Cervicogenic
2) Spinally Mediated
3) Chronic Daily
73
List 2 types of migraines
1) Vascular Model
| 2) Neurogenic Theory
74
2 main categories of Migraines
Migraine with Aura
| Migraine without Aura
75
List 5 other types of Headaches/Migraines
1) Mixed Transformational
2) Cluster
3) Drug-Associated
4) Chronic Paroxysmal
5) Trauma-Related
76
Typical head posture with Torticollis?
- Head and neck side bend towards the affected side
- Face turns away from affected side
- Shoulder of affected side is raised
- Head may be in extension if Levator Scapula is involved
- May be in flexion if SCM is affected
77
What side should pregnant woman be positioned during massage?
Laying on left side
- This is important because the inferior vena cava is on the right side
- Or while in supine, client has right hip hiked to take pressure from the baby off the inferior vena cava
78
Describe Grade 0 QTF in whiplash
- No complaint about neck
| - No physical signs of injury
79
Describe Grade 1 QTF in whiplash
- Neck has pain, stiffness or tenderness.
| - No physical signs are serious enough to cause spasm
80
Describe Grade 2 QTF in whiplash
- Neck has pain, stiffness or tenderness
- Musculoskeletal signs of decreased ROM and point tender
- Injury of muscle, tendon, ligament and joint capsule can cause spasm
81
Describe Grade 3 QTF in whiplash
- Neck pain, stiffness or tenderness
- Neurological signs including decreased tendon reflex and weakness
- Injury of muscle, injury to neurological system due to mechanical injury or inflammation
82
Describe Grade 4 QTF in whiplash
Neck complaint and fracture or dislocation
83
What similarities does tx for dislocation have with severe sprain?
- Not to reduce protective mm spasming around the dislocation or sprain?
84
What are the relevant health history questions for a client with dislocation?
- What is the clients overall health history? Is the client on any medication for unrelated conditions that indicate treatment modifications?
- Does the client have any contributing conditions or pathologies that predispose the person to ligament injuries. such as congenital ligamentous laxity, rheumatoid arthritis, hemiplegia or cerebral palsy?
- Has there been a history of recurrent dislocations or subluxation of that joint? This indicates that the joint is unstable.
- In terms of the presenting complaint, when did the injury occur?
- Does the client know the mechanism of injury. for example, falling on an outstretched hand. the person may describe the feeling of a bone ”pop out of place” or hearing a snapping or popping noise.
- What was done at the time of injury? Was first aid applied?
- Did the clients see any other Healthcare practitioner for this injury, such as a physician, physiotherapist, chiropractor or sports therapist? If so, what treatment was given? Is the client still receiving this treatment?
- Was the joint immobilized or was the joint capsule surgically repaired? Are pins, wires, screws or other appliances present? If the joint was immobilized, how long was it for? with immobilisation, disuse atrophy and adhesions may be present
- Is the client using a sling, other support, or crutches for the affected joint? This is expected with an acute or sub-acute dislocation
- Is the client taking any medication for the dislocation, such as analgesics or anti-inflammatories? This includes self medication such as aspirin or other over-the-counter products
- What symptoms is the client currently experiencing? does the client have pain now? Where exactly is the pain? Is the pain sharp or diffuse? Sharp, hot pain indicates an acute injury, while an ache is associated with a chronic injury.
- What aggravates or relieve the pain?
- Is there any edema or bruising local or distal to the injury?
- Were there any complications, such as nerve or blood vessel damage or fracture?
- What activities are difficult or painful to complete? Are any activities impossible to complete? For example, the client may report an inability to place the joint in the position in which the injury occurred. This may be due to the clients apprehension or joint instability. If the capsule was surgically repaired, a reduced range of motion is desired for joint stability.
- What are the clients activities of daily living? Does the clients occupation or recreational activity Place stress on the joint?
85
What direction is most common for the patella to dislocate?
- Lateral Direction
| - Injury involves external rotation of tibia and foot when the knee is flexed
86
Describe what happens to muscles surrounding a joint after a dislocation during each stage of healing. (Acute, Subacute, chronic)
1. Acute
- Protective mm spasm present in mm crossing affected joint
- Heat present over injured joint
2. Subacute
- Tone of the mm crossing joint changes from spasmodic in the early subacute stage to tightness and hypertonic in the late subacute.
- TP’s are now present in these mm
3. Chronic
- Adhesions are local to joint capsule
- Hypertonicity and TP are present local to injured joints and in compensator mm.
- Disuse atrophy may be present
87
Describe the steps necessary to safely and effectively assess a client's range of motion, joint stability, and strength following a dislocation.
- Main goal in assessing a dislocated joint before treatment is to determine if the joint is stable or unstable
- If the AF apprehension test is positive (unstable) no PR testing is performed. Continue only with AR isometric testing
- If any joint instability is present during any AF or PR tests - refer back to AR isometric test and do not continue with further PR testing
- View chart in LP 21 pg. 9 *Easiest explanation*
88
List all appropriate home care strategies for a client with dislocation. List stages of healing where applicable.
```
Hydro
Self-massage
Remex
Encourage activity
Acute: Maintain ROM
Early Subacute: Increase strength
Late Subacute: Increase strength
Chronic: Strengthen Muscle
```
89
List all muscles associated with the temporomandibular joint and their role in mastication?
Medial Pterygoids: Elevate Jaw
Lateral Pterygoids: Pulls disco anteriorly to allow for jaw movement
Temporalis: Elevate Jaw
Masseter: Elevate Jaw
Supra & Infra Hyoids: Depress Jaw (with Digastric)
90
What are the signs and symptoms of TMJ dysfunction associated with different stages of healing?
```
Stage 1
- Disc slightly anterior and medial on mandibular condyle
- Inconsistent click (possible)
- Mild/No pain
Stage 2
- Disc anterior and medial
- Reciprocal click present (early opening and late closing)
- Severe consistent pain
Stage 3
- Reciprocal consistent click (later on opening and earlier on closing)
- Most painful stage
Stage 4
- Click rare (disc no longer relocates)
- No pain
```
91
What situation / circumstance would cause the mandible to deviate to the right when opening the mouth?
- Lateral deviation may be due to TP’s in Masseter, Temporalis and Post. Digastric on side the mandible deviates towards (in this case the right side)
- Later deviation may also be due to TP’s in Lateral Pterygoid on side it moves away from (in this case the left side)
- Also may be indicative of Capsular Restriction? (pg. 9 TMJ LP)
92
What is the capsular pattern of restriction for the TMJ?
- This would indicate that there is a C-Shaped wobble
- Capsular Source - mandible deviated to side that is restricted
- Restriction to the right side in Capsular
93
What are possible contributing factors for TMJ dysfunction?
1. Predisposition: can be intrinsic (genetic development of mm, ligaments and bones) OR extrinsic (trauma to the neck, face, or jaw)
2. Tissue alteration: can occur to the dental and neuromuscular structures.
3. Stress: results in increased tone of the muscles of mastication due to jaw clenching, bruxism, or habits such as gum chewing.
Others:
Forward head posture
Incorrect swallowing patterns, most breathing and incorrect respiration
94
What are the normal ranges of active free range of motion of the TMJ?
Depression: 35-50 mm
Lateral deviation: 8-10mm
Protrusion: 5mm
Retrusion:3-4mm
95
TMJ dysfunction can be a secondary concern to what type of WAD?
Rear impact, phase two (120 milliseconds)???
96
Review how to intraorally palpate the muscles of mastication
Masseter
Between cheek and molars w/ clients teeth gently clenched
Isolate muscle - clench teeth
Medial Pterygoid
Finger on the last molar, slid around to the medial surface of the molar and inferiorly past gum towards the floor of mouth. Finger against inner surface of mandible, finger is slid posteriorly to medial pterygoid
Isolate muscle - resist elevation (closing)
Lateral Pterygoid
Finger between cheek and molars, fingernail against last upper molars. Finger slid superiorly and posteriorly between the maxilla and coronoid process into hollow at roof of cheek
Isolate muscle - resist depression (opening)
Mylohyoid
Finger between lower teeth and tongue. Beginning at incisors, finger slid down the inner surface of mandible to floor of the mouth, posteriorly to last molar where mylohyoid ends
Isolate muscle - resist depression (opening)
97
What are the three components that must be present for TMJ dysfunction to occur?
Joint noises, popping/clicking - may be present in tissue alteration and stress
It’s possible to have one or two of these without having TMJ dysfunction
Predisposition:
-Intrinsic (Genetic development of bones, muscles
-Extrinsic (Trauma to neck, face or jaw)
Tissue Alteration:
-Can be skeletal, muscular or dental (tooth loss, hypermobility, spasm, poor posture)
Stress:
-Increased mm tone, due to jaw clenching, chewing gum, etc
98
List all indications we have discussed for breast massage
```
Congestion, Edema, Lymphedema
Painful Breast
Pregnancy, Breast Feeding
Drainage issues
PMS
Breast trauma
Scar formation
Post breast cancer discomfort
Post surgery
Education regarding self-examination
Requested by client
Client seeks assistance in breast monitoring
Client has goal to become more comfortable with their breasts
```
99
List all contraindications we have discussed for breast massage
Mastitis (active infection or post surgery)
Local massage to undiagnosed lump
Local massage to breast abscess
Forceful attempt to reduce implant related contracture
Direct pressure on ruptured implant
Client unable to clarify wishes, or establish comfortable boundaries
Therapist cannot establish professional environment
Client/Therapist cannot establish open communication
Client doesn’t give or withdraws consent
100
What are ominous signs associated with breasts?
Nipple retraction (normal after 35, but rapid retraction may be sign of cancer)
Nipple discharge that is crystal clear, gray/green or bloody
Hard, non-tender lumps
Cancerous lumps are usually not painful (pain usually indicates later stage of cancer)
101
What are the anatomical boundaries of the breast tissue?
Upper: Lower edge of clavicle
Lower: 1” below breast contour, overlying upper fibres of rectus abdominis
Medial: Sternal midline
Lateral: Ant. edge of Latissimus Dorsi with some tissue extending to axilla
102
Injury to Longus Coli is associated with what condition? What stage of healing is this muscle more commonly an issue?
Whiplash, longus colli is in usually in chronic spasm in the chronic stage of healing.
103
Please do not forget that scoliosis is named for the convexity. For example, with right thoracic scoliosis, the convexity is on the right and the concavity is on the left. Which directions would the movement be restricted in this circumstance?
```
Restriction on convex side - Right side flexion
Convexity is based on the position of the vertebral body NOT SP's. SP's point to concavity.
For example (left curve= right shoulder down, right hip up) - result in hypertonicity of right muscles and restriction of movement in left flexion
```
104
With hyperkyphosis which muscles are short/tight and which are weak/lengthened?
Contractured and/or hypertonic muscles are:
Shoulder protraction: pectoralis major, pectoralis minor, subclavius, serratus anterior and anterior intercostals
Internal rotation of the humerus: subscapularis
Depression of scapula: latissimus dorsi
Anterior head carriage: levator scapulae, upper trapezius, sternocleidomastoid, scalenes and suboccipitals
Weakened muscles are:
Shoulder protraction: rhomboids, middle trapezius, thoracic erector spinae
Anterior head carriage: longus colli, longus cervicis, longus capitis, suprahyoids, infrahyoids.
105
With a client with classic hyperlordosis, please list whether the following muscles would be tight/shortened,weak/lengthened, or uninvolved.
```
Erector Spinae:
Lumbar is short and tight
Quadratus lumborum
Short and tight
Multifidus
??? Short and tight??
gluteus maximus
Stretched and weak
rectus abdominus
Short and tight
Iliopsoas
Short and tight
rectus femoris
Short and tight
Hamstrings muscle group
Stretched and weak
```
106
What constitutes a medical emergency with compartment syndrome?
Acute is a medical emergency.
Bleeding and swelling within the compartment can cause an increase in intra-compartmental pressure and may compress nerves and/or blood supply
107
What are the common contributing factors for a client with patellofemoral syndrome?
```
Abnormal Biomechanics
Small High Riding Patella
Tight Lateral Structures (Vastus lateralis, ITB, TFL)
Tight Anterior/Posterior Structures (Hamstrings, Gastroc, Rectus Fem)
Weakness (Vastus Med, Glute Med)
Knee Injuries
Arthroscopic Procedures
Repeated Knee Stress and Overuse
```
108
List all relevant assessment techniques (AF/PR/AR ROM, Special testing, Etc.. .) For a client with patellofemoral syndrome. How would each assessment technique present?
AF ROM:
Excessive lateral movement of patella during first 45 degrees of flexion
PR ROM:
Palpate for crepitus
AR ROM:
Weak glute medius
Length Test:
Hamstrings, Gastrocnemius are shortened
Q Angle:
Greater than 18 degrees when client is standing
Waldron’s:
McConnell’s:
Femur laterally rotated, and isometric contraction at 120, 90, 60, 30, 0 for 10 sec intervals. Pain produced during any stage the leg is passively returned to full extension
Test for patellofemoral syndrome
Positive sign is if pain is decreased
Clarke’s:
Hand supports client’s patella, and is pushed down while client contracts quads
Pain under patella indicated patellofemoral dysfunction
Patellar Apprehension Test:
Knee is extended, and patella is moved medially and laterally
If there is apprehension on client’s face it indicative positive for patellar dysfunction or dislocation
109
What are the triggers for migraines?
Stress, hunger, medication, weather change, visual stimuli, auditory stimuli, olfactory stimuli, sleeping patterns, hormones, allergies, food additives
110
What are the types of headaches and migraines?
```
-2 Types of Headaches
Primary Headaches
Headache IS the condition, such as tension or migraine
Secondary Headaches
Result of underlying pathology (ie. head trauma)
-Other Headaches of Muscular Origins
Cervicogenic
Spinally Mediated
Chronic Daily
-2 Types of Migraines
Vascular Model
Neurogenic Theory
-2 Main Categories of Migraines
Migraine with Aura
Migraine without Aura
-Other Types of Headaches/Migranes (there are too many this is annoying)
Mixed Transformational
Cluster
Drug-Associated
Chronic Paroxysmal
Trauma-Related
```
111
What is the typical head positioning for a client with torticollis?
Head and neck side bend towards the affected side
Face turns away from affected side
Shoulder of affected side is raised
Head may be in extension if Levator Scapula is involved
May be in flexion if SCM is affected
112
Which side should a pregnant woman be positioned on while receiving a massage?
Laying on left side
This is important because the inferior vena cava is on the right side
Or while in supine, client has right hip hiked to take pressure from the baby off the inferior vena cava
113
Define Whiplash
Acceleration-Deceleration injury of head/neck
114
Define constipation?
Slow difficult or infrequent movement of feces through bowl, and considered a symptom rather than condition
115
What is Postpartum blues?
Experiencing extreme joy, sadness, fear, anger or anxiety in mild form (7 out of 10 mothers feel this)
116
What is Postpartum Depression?
Strong feelings of sadness, anxiety or hopelessness. Counselling usually required
117
Which OA test would you use to rule in Facet irritation of Cervical spine?
Kemps/Quadrants Test
118
What health history question is most important in dislocation?
C: Can the client explain the mechanism of injury (how it happened?)
119
Can you give a relaxation breast massage to a male if requested?
No, you can’t give a male a relaxation massage only female (they have no need for it as they have no breast tissue)
120
Which of the following are not appropriate to Whiplash injury in the Early Subacute stage?
C: Hold/relax technique to improve ROM to cervical spine
121
What is Eclampsia?
- Severe spike in blood pressure
- Eclampsia is a serious complication of pregnancy characterized by life threatening acute tonic – seizures in a pregnant woman. Eclampsia essentially occurs in those women who already have had preeclampsia and which possibly was not treated on time.
- 1 in 200 women who have had preeclampsia, eventually also develop eclampsia
122
What are the 4 Trimesters and the weeks of each?
1st Trimester (0-12 weeks)
2nd Trimester: (13-26 weeks)
3rd Trimester: (27-40 weeks)
4th Trimester: Postpartum after birth
123
What is Gestational Diabetes?
- Development of diabetes during pregnancy caused by increase in demand for insulin during fetal development, and increased levels of glucose in the blood of GI
- Higher risk of developing gestational diabetes in those with history of stillbirth/miscarraige
- Possible to development overt diabetes mellitus 5-10 years after birth
- Risk of G. Diabetes on child increased in premature delivery and fetal deformities
124
This is the most painful movement in Frozen Shoulder
Abduction/External Rotation
125
Most Painful Period of Frozen Shoulder?
Subacute (Frozen Stage)
126
Know how to perform Painful Arc Test:
```
Determine where the pain is originating (AC or GH joint)
0 Degree: Painless
45-60 to 120: GH painful arc
120-170: Painless
170-180: AC painful arc
```
127
What is CMNL Standard 15?
Perform breast massage:
| - Breast massage is requested and client has consented to breast massage
128
CMNL Standard 15: Quality Standard?
1) Avoid nipple/areola
2) Breast tissue is uncovered only when its being treated
3) Massage isn't performed or is modified if CI for treatment exists
129
CMTNL Standard 15: Safety?
1) Vigorous work isn't performed on implants
| 2) Consent has been obtained with Health/Standard #7
130
What is CMTNL Standard 16?
Massage to structures of the Chest wall
| - Given client has requested massage to chest wall and consent as been obtained
131
What is CMTNL Standard 16: Standard/Quality?
Chest/breast is uncovered only with prior and voluntary consent according to Health/Standard #12
132
What is CMTNL Standard 16: Safety?
Structures of chest wall are not treated or is modified if CI is present
133
Clinical Indicators in Standard #16?
1) Post-mastectomy
2) Scarring to tissue of chest wall
3) Relief of muscle pain
4) Rehabilitation from cancer treatment
5) Chronic respiratory conditions
6) Postural rebalancing
134
CMTNL Statement 4?
Chest wall, gluteal, inner thigh are sensitive areas and need special consent.
- Client must obtain consent for treatment to these areas
- Professionalism must be obtained by therapist at all times
- Communication and trust with client is very important
135
What is the impact of hyoid muscles on function of the jaw?
Supra/Infrahyoid depress the jaw
136
What does Lateral pterygoid do in Mastication?
pulls meniscus ant allowing condyle to pivot/open jaw
137
Action of Masseter, temporalis, med pterygoid?
Elevates the jaw
138
Observations that are associated with assessment of clients with Temporomandibular joint dysfunction?
Ant head carriage could be present, clenched jaw, HT+, neck and shoulders could be compensated.
139
Trigger Point: Temporalis?
Side of head, above the ear, maxilla to forehead
140
Trigger Point: Masseter?
cheek, mandible, forehead or ear
141
TP for Lat. Pterygoid?
Check to TMJ
142
TP for Med. Pterygoid?
Post mandible to TMJ
143
CI's for TMJ ?
1) No compression of carotid artery/sinuses, mandible superiorly
2) Massage over both SCM mm at same time
3) Deep work over styloid process of temporal bone
4) Frictions if anti-inflammatories
5) Latex gloves if allergy during intra-oral
6) Heavy/deep pressure intra-oral
7) If history of abuse.
144
CI's to Whiplash?
1) Certain testing during acute stage
2) If vertebral artery test positive
3) Avoid removing full spasm/Passive stretch of spasm
4) Extreme stretches/mobilizing hypermobile vertebrae
Joint play for spine shouldn’t be painful
5) Avoid aggressive techniques, compression of carotid artery/sinuses when treating ant neck
6) Techniques on both SCM at same time
7) Frictions if anti-inflammatories/blood thinners
145
Define Dislocation?
Complete dissociation of articulating surfaces of joint, can occur in any joint
146
Define Subluxation?
When articulating surface of joint remain in partial contact with each other
147
What is the most common dislocation?
GH joint dislocation (excessive abduction and ext rotation of humerus
148
Define Frozen Shoulder?
painful, significant restriction of active and passive ROM at the shoulder. Most frequently in abduction and external rotation
149
Define Adhesive Capsulitis?
inflammation of GH capsule and synovium leading to adhesion formation of the axillary fold of the capsule
150
Define Constipation?
Slow difficult or infrequent movement of feces through bowl, and considered a symptom rather than condition
151
CI's of Constipation?
1) No heat on abdomen if client has history of increased BP/cardiovascular problems, Inflammatory bowel disease (in flare up)
2) No abdominal massage if client has diarrhea at time
152
Signs/Symptoms in 1st trimester of Pregnancy
Nausea/vomiting, fatigue, frequent urination, constipation, BP-falls, breast changes, Musculoskeletal changes, Relaxing produced, taste/smell altered, mood swings,
153
Signs/Symptoms in 2nd trimester of Pregnancy
```
Edema (legs)
HP+/pre-eclampsia,
Shortness of breath
Supine HT-
Backache,
Ab pain/diastasis recti, diastasis symphysis
Varicose veins
Hemorrhoids
Pigmentation, stretch marks, nosebleeds/gum bleeding/nasal congestion, headache, emotional changes
```
154
Signs/Symptoms in 3rd trimester of Pregnancy
Gestational diabetes, Ketoacidosis, Edema (legs, hands, fingers) Compression syndromes, backache, SI sprain, leg cramps, pelvic discomfort, costal margin pain, Frequent Urination/incontinence, fatigue, insomnia/restlessness, emotion improve
155
Signs/Symptoms in 4th trimester of Pregnancy
Physical changes
P{st-surgical recovery
Breast sore/cracking
Emotion (Postpartum blues/depression)
156
Circulatory supply and drainage of the breast?
1) Branches of subclavian artery responsible for supplying breast with blood
2) Venous return originates from venous plexus deep to areola and drains into internal mammary vein running lateral to sternum and axillary vein in axilla
3) Skin surface of breast/areola richly supplied with tiny, valve less lymph channels running through breast in loose CT. Lymph drains from superficial to deep, meaning direction of drainage techniques is directed towards areola to allow drainage into sub areolar plexus
157
Techniques for Early Subacute Stage Whiplash?
- Contrast hydro
- Proximal MLD
- Trunk/shoulder girdle muscles treated to reduce H+
- GTO to tendons in SCM, Scalenes, U. Traps, Lev. Scap, Pos. Cervical mm
- Agonist contraction and O&I useful
- Treat TP’s that refer to head and neck gently
- QTF 0-1: Onsite work of thumb/fingertip kneading
- QTF 2+: Onsite work of light stroking/vibrations
- Hematoma present CI’d onsite work
- PR pain free, mid-range ROM in C/S
158
Techniques for Late Subacute Whiplash?
- Cold/hot contrast hydro
- Reduce H+ and TP’s in neck and shoulders
- GTO to suboccipital
- TP’s in SCM
- Reduce H+ and TP’s in infra/suprahyoid, Ant/Post thoracic region
- Reduce adhesions in affected muscles with myofascial release, skin rolling, stripping and frictions
- Joint play to hypomobile vertebrae
- Careful mid-full range PR ROM to C/S
159
Techniques for Chronic Whiplash?
- DMH
- Reduce H+ and TP’s in HNS
- Stripping, fascial techniques and frictions
- Pain free PR ROM
- Joint play in hypomobile cervical vertebrae, shoulder and thorax
- Long axis traction of C/S
160
How long can the Freezing (Acute) stage last for Frozen Shoudler?
2-9 months
| Stiffness sets in 2-3 weeks
161
How long does the Frozen (Subacute) stage last in Frozen Shoulder?
4-12 months
162
How long does thawing (chronic) stage last with Frozen Shoulder?
Up to 2 years
