Week 1: Introduction to treatment of the musculoskeletal system (Masterclass)

Question 1

Healing time: Tendon

Answer 1

2-12 weeks

Question 2

Healing time: Muscle

Answer 2

3 weeks - 3 months

Question 3

Healing time: Bone

Answer 3

6-8 weeks

Question 4

Healing time: Ligament

Answer 4

6-12 weeks

Question 5

Healing time: Fibrocartilage (meniscus, TFCC, TMJ)

Answer 5

8-12 weeks

Question 6

Healing time: Articular cartilage (inside all joints)

Answer 6

3-6 months

Question 7

Healing time: Nerve

Answer 7

2-5mm/day (several months to over a year)

Question 8

Healing time: skin

Answer 8

3 days to 2 weeks

Question 9

What does the biopsychosocial model include from a treatment perspective?

Answer 9

• Patient values
• Research evidence
• Therapist clinical expertise

Question 10

How does exercise work… What is mechanotransduction?

Answer 10

Mechnotransduction: Biological process by which mechanical load is received and converted into a cellular response leading to structural change of the tissue.

Question 11

How does exercise work….What is mechanotherapy?

Answer 11

• How therapeutic exercise is used to promote beneficial tissue adaptations e.g. repair/remodeling

Question 12

Outline stage 1 of the exercise response…

Answer 12

Stage 1: Mechanocoupling – the loading trigger
- The physical load causes physical perturbation to cells that make up a tissue
- E.g. every step the Achilles tendon receives tensile loads. Cells in the tendon recognise this load

Question 13

What is the envelope of function?

Answer 13

• A representation of the tissues ability to deal with loading in comparison to frequency
• Our envelope = all activities of our day to day life
• Activities that cause pain fall outside of this envelope of function

Question 14

In the envelope of function what is the zone of supraphysiologic overload?

Answer 14

More load than the tissue can handle. The zone of supraphysiological overload zone will disrupt homeostasis but it will not instantly cause structural failure

Question 15

In the envelope of function was is the zone of subphysiologic underload?

Answer 15

If you only perform activities in the bottom with low load and low frequency you will experience deconditioning

Question 16

In the envelope of function how does structural failure occur?

Answer 16

Prolonged overload in the supraphysiologic zone may eventually lead to structural failure

Question 17

Outline stage 2 of the exercise response…

Answer 17

Stage 2: Cell to cell communication
- Cells distribute the message that the tendon has been loaded

Question 18

Outline stage 3 of the exercise response…

Answer 18

Effector cell response
- Activate production of new proteins
- E.g. in tendon there is an upregulation of insulin-like growth factor (IGF-1) which is associated with cellular proliferation and matrix remodeling
- Increased tendon stiffness and CSA*
- To maximize these effects in tendons high intensity muscle contractions (e.g. 80% max and interventions longer than 12 weeks required for optimal adaptation)

Question 19

What was the initial explanation for how manual therapy worked… why was this incorrect?

Answer 19

Initial thoughts that manual therapy (e.g. pushing on joints) led to changes in the length of connective tissues ie increases ROM by making it looser, such as the joint capsule/ligaments and muscles

This is biomechanically not correct - the forces we apply aren’t strong enough to provide permanent changes in patients soft tissue length

Question 20

How does manual therapy work?

Answer 20

1. Complex neurophysiological response from the PNS & CNS
2. Mechanical stimulation (eg pushing on joints) triggers afferent neurones located in skin/joint/muscle
3. This stimulation can have several responses - pain inhibition, neuromuscular inhibition or facilitation

Question 21

Manual therapy is appropriate if:

Answer 21

Passive movement limited by some combination of pain and stiffness

Note:
- If targeting Pain… treatment should < Pain
- If targeting stiffness… treatment should < stiffness

Question 22

What is the name of the grading system for manual therapy?

Answer 22

Maitland

Question 23

What is a grade I amplitude in manual therapy?

Answer 23

Small amplitude movement at the beginning of the available range of movement (small oscillation)

Question 24

What is a grade II amplitude in manual therapy?

Answer 24

Large amplitude movement at within the available range of movement (pass mid-range)

Question 25

What is a grade III amplitude in manual therapy?

Answer 25

Large amplitude movement that reaches the end range of movement (to end of range)

Question 26

What is a grade IV amplitude in manual therapy?

Answer 26

Small amplitude movement at the very end range of movement

Question 27

What is a grade V amplitude in manual therapy?

Answer 27

Manipulation

Question 28

In what instance would you perform a grade I/II?
How many sets/seconds?

Answer 28

Painful and irritable
1-3 sets of 30-45 seconds.

Question 29

In what instance would you perform a grade III, IV or V? How many sets/seconds?

Answer 29

Stiffness (and/or pain), not irritable
3-5 sets of 45-60 seconds

Question 30

What are some absolute contraindications to manual therapy?

Answer 30

• Neurological deterioration
• Blood clotting disorder
• Osteoporosis
• Acute radiculopathy
• Children/adolescents with open epiphyseal plates
• Directly over a wound

Question 31

What are some relative contraindications to manual therapy?

Answer 31

• Fractures
• Pregnancy (last trimester)
• Signs of coronal or vertebral artery dysfunction
• Joint fusions
• Active inflammatory condition