HOC / HOK - Theme 10 Flashcards
(111 cards)
1
Q
Describe the structure of a physiotherapeutic methodical approach.
A
- Direct access or Admission via General Practitioner
- Registration
3 a. Discovering the ‘Request for Help’
b. Screening (Worrisome/Non-worrisome)
c. Inform and advise - Initial hypothesis
- Anamnesis (RPS form)
- Adjusted hypothesis.
- Examination
- Definitive hypothesis
- Treatment plan
- Treatment
- Evaluation
- Conclusion
2
Q
What is the difference between a screening and diagnosing?
A
Screening: is a process to establish whether a patient can continue through the physiotherapeutic process or whether they need to be referred back to a GP, this is done by answering a series of questions to see whether there are ‘red-flags’, which indicate serious / potentially sinister pathologies.
Diagnosing: is the process of identifying the nature and cause of a certain phenomenon.
3
Q
What is the concept of an ‘initial hypothesis’ and PIPs/NPIPs.
A
Initial hypothesis: is established by use of hypothetico-deductive reasoning, this starts by gaining clues/insight from the moment a patient presents to you.
PIPs: these are ‘patient identified problem(s)’, either in a symptom AND/OR functional limitation/disability level.
NPIPs: this is essentially a problem list generated by the clinician. This is an ongoing process of evaluation as the subjective examination and physical examination is taking place.
4
Q
Describe the ‘General principles’ described in the Movement contiuum model by Cott.
A
- Movement is essential to life.
- Movement occurs on a continuum from the microscopic level to the level of the individual in society.
- Movement levels on the continuum are influenced by physical, psychological, social and environmental factors.
5
Q
Describe the ‘Physical Therapy principles’ described in the Movement continuum model by Cott.
A
- Movement levels on the continuum are interdependent.
- At each level on the continuum there is a maximum achievable movement potential (MAMP) which is influenced by the MAMP at the other levels of the continuum and physical, social, psychological and environmental factors.
- Within the limits set by the MAMP, each human being has a preferred movement capability (PMC), and a current movement capacity (CMC) which in usual circumstances are the same.
- Pathological and developmental factors have the potential to change the MAMP and/or to create a differential between the PMC and the CMC
- The focus of physical therapy is to minimise the potential and/or existing PMC/CMC differential.
- The practice of physical therapy involves therapeutic movement, modalities, therapeutic use of self, education and technology and environmental modifications.
6
Q
What is the general gist of the Movement continuum model by Cott.
A
This theory consists of eight principles of movement, three of which are shared with other movement sciences and five of which are specific to physiotherapy. These general principles are that movement is essential to human life, movement occurs on a continuum from the microscopic level to the level of the individual in society and movement levels on the continuum are influenced by physical, psychological, social and environmental factors.
https://www.researchgate.net/publication/284671257_The_movement_continuum_theory_of_physical_therapy
7
Q
What are the contents of a physiotherapeutic diagnosis (Basis for the indication, the essence of the health problem, the prognosis and the treatment plan)?
A
- Supplementary anamnesis.
- Supplementary examination.
- Anamnesis.
–> Leads to adjusted hypothesis.
8
Q
Describe the concept “tangential surface”
A
The plane opposite to the direction of the normal.
9
Q
Describe the concept “normal”
A
The direction of traction.
10
Q
Describe the concept “capsular pattern”
A
Order of movement limitations in a joint typical to inflammation of the entire joint capsule (arthritis).
Please note: the order is important!
11
Q
Describe the concept “closed pack position”
A
Maximal fitting ball and socket.
Capsular ligament system maximally contracted
12
Q
Describe the concept “maximal loose pack position”
A
Ligaments and capsule are in the maximally relaxed position.
This allows for great mobility
which is
important for examinations and treating the joint (non-specific traction and translation techniques)
13
Q
Describe the Concave/Convex rule.
A
The direction in which sliding occurs depends on whether the moving surface is concave or convex.
Concave = hollowed or rounded inward
Convex = curved or rounded outward
If the moving joint surface is CONVEX, sliding is in the OPPOSITE direction of the angular movement of the bone.
If the moving joint surface is CONCAVE, sliding is in the SAME direction as the angular movement of the bone.
14
Q
Describe “open chain movement”
A
When the distal end is not fixed. i.e. kicking a ball (The foot is not fixed on anything).
15
Q
Describe “closed chain movement”
A
When the distal end is fixed. i.e. a push up (hands are fixed on the floor), or standing up from a chair (feet are fixed on the floor).
16
Q
Name the following aspects of the art. humeri;
- Ball/socket
- Capsular pattern
- Normal/traction direction
A
Ball: Caput humeri
Socket: Cavitas glenoidale
CP: Exorotation> abduction > endorotation
Normal:Lateral/ventral/ slightly cranial
17
Q
Name the following aspects of the SC joint;
- Ball/socket
- Capsular pattern
- Normal/traction direction
A
Ball: (depends on the movement).
- Protraction/Retraction - Incisura clavicular sternale
- Elevation/Depression - Extremities sternale clavicular
Socket: (depends on the movement).
- Protraction/Retraction - Extremities sternale clavicular
- Elevation/Depression - Incisura clavicular sternale
CP: Max. ROM and pain
Normal: ±lateral, slightly cranial (from sternum)
18
Q
Name the following aspects of the AC joint;
- Ball/socket
- Capsular pattern
- Normal/traction direction
A
Ball:
Socket:
CP: Max. ROM and pain
Normal: Lateral/ caudal/dorsal
19
Q
Name the ligaments and inhibitions of these ligaments for the art. humeri.
A
Lig. glenohumeral superius: Limits external rotation and inferior translation of humeral head.
Lig. glenohumeral medium: Limits external rotation and anterior translation of humeral head.
Lig. glenohumeral inferius:
- Anterior portion limits external rotation and superior and anterior translation of the humeral head.
- Posterior portion: Limits internal rotation and anterior translation.
Lig. coracohumerale:
- Anterior portion limits extension while the posterior portion limits flexion.
- Both divisions limit inferior and posterior translation of the humeral head.
- Helps to support the weight of the resting arm against gravity.
Lig. transversum humeri: Serves to keep the tendon of the long head of the biceps in the bicipital groove.
20
Q
Name the ligaments and inhibitions of these ligaments for the SC joint.
A
Lig. sternoclaviculare posterius: Limits protraction.
Lig. sternoclaviculare anterius: Limitis retraction.
Lig. costoclaviculare: Limits elevation, protraction and retraction.
Lig. interclaviculare: Resists excessive depression or downward glide of the clavicle
21
Q
Name the ligaments and inhibitions of these ligaments for the AC joint.
A
Lig. coracoacromiale: Prevents upwards dislocation of the glenohumerale joint.
Lig. acromioclaviculare: Ensures stability of the AC joint.
Lig. coracoclavicualre;
- lig. trapezoideum: Limits posterior movement between the scapula and clavicle.
- lig. conoideum: Keeps the coracoid process of the scapula and the clavicle in close apposition.
22
Q
Name the following aspects of the art. Humeri joint;
- CPP
- MLPP
A
CPP: max Abd + exorotation + horizontal extension
MLPP: 60 degrees Abd / 60 degrees anteflexion / forearm 30 degrees from horizontal plane
23
Q
Name the following aspects of the SC joint;
- CPP
- MLPP
A
NONE
24
Q
Name the following aspects of the AC joint;
- CPP
- MLPP
A
NONE
25
Explain Primary impingement.
Primary impingement is due to structural changes that mechanically narrow the subacromial space; these include bony narrowing on the cranial side, bony malposition after a fracture of the greater tubercle, or an increase in the volume of the subacromial soft tissues – due, e.g., to subacromial bursitis or calcific tendinitis – on the caudal side.
26
Explain secondary impingement.
Secondary impingement results from a functional disturbance of centring of the humeral head, such as muscular imbalance, leading to an abnormal displacement of the centre of rotation in elevation and thereby to soft tissue entrapment.
27
Name different pathologies that could cause impingement complaints.
- Bicep-SLAP pathology
- GIRD
- Scapular dyskinesis
- Instability
- Rotator cuff pathology
(according to Cools et al 2008)
28
Name the symptomatology of a shoulder impingement.
- Painful arc.
- Pain during overhead movements.
- Pain in the deltoid muscle area (top and outer side of your shoulder).
- Pain or aching at night, which can affect your sleep.
- Weakness in your arm.
29
Explain what an impingement is.
Impingement is when soft tissue(s) are trapped / compressed. This can be a result of bony narrowing or osteophyte formation, bony malposition after a fracture, or increase in the volume of subacromial soft tissue.
30
Explain the aetiology (causes) of impingement complaints of the shoulder.
Primary external impingement: related to structural changes, either congenital or acquired, that mechanically narrow subacromial space such as; shape of the acromion process of the scapula or shoulder blade may play an important role in recovery and treatment from primary impingement.
Pain at night when lying on that shoulder. Since osteophytes are a common reason it’s normal in 50+ers. But malposition after a fracture is common as well.
Secondary external impingement: related to abnormal scapulothoracic kinematics, strength balance alteration resulting in functional disturbance in the centering of the humeral head, leading to an abnormal displacement of the center of rotation when the arm is elevated. Generally caused by weakness of the RC muscle (functional instability) combined with a GHJ capsule and ligaments that are too loose (micro-instability).
Pain at secondary impingement generally occurs at the coracoacromial space during anterior translation of the humeral head. Typically occurs in younger individuals with pain is located in the anterior or anterolateral aspect of the shoulder. The symptoms are usually activity-specific and involve overhand activities (though the OH goes for primary as well ofc).
Internal impingement: is probably the most common cause of posterior shoulder pain in the throwing or overhead athlete. Caused by impingement of the articular surface (intra-articular) of the RC (posterior edge of the supraspinatus and the anterior edge of the infraspinatus) against the posterior-superior-glenoid and glenoid labrum. Mainly seen with repetitive overhead activities, this positioning becomes pathologic during excessive external rotation, anterior capsular instability, scapular muscle imbalances, and/or upon repetitive overload of the RC musculature. These deficiencies result in poor scapulohumeral control.
31
Describe the physiological recovery processes after a connective tissue trauma. - INFLAMMATION PHASE
Inflammation: 0-5 days
```
The body’s natural response to tissue damage
Characteristics:
- Rubor: redness
- Dolor: pain
- Tumor: swelling
- Calor: heat
- Functio laesa: Restricted function
```
Inflammatory mediators:
- Bradykinin
- Histamine
- Prostaglandin
- Substance P
32
Describe the physiological recovery processes after a connective tissue trauma. - PROLIFERATION PHASE
Proliferation: 5-21 days
- Production of new functional connective tissue is the main objective.
- Intensive collagen production
- Stimulating local blood circulation (massage/ultrasound)
- ‘Keep the moving’
33
Describe the physiological recovery processes after a connective tissue trauma. - REMODELLING PHASE
Remodelling: 21-365 days
- Collagen becomes more stable and thicker as its reconstructed from type 3 to type 1.
- Increased production of base substance
Cross-linking
34
Explain what a frozen shoulder is...
Characterised by initially painful and later progressively restricted active and passive GH joint ROM with spontaneous complete or nearly-complete recovery over a varied period of time.
This inflammatory condition causes fibrosis of the GH joint capsule, accompanied by gradually progressive stiffness and significant restriction of ROM (typically external rotation).
35
Describe the different stages of a frozen shoulder.
Freezing: gradual onset of shoulder pain at rest with sharp pain at extremes of motion, and pain at night with sleep interruption which may last anywhere from 2-9 months
Frozen: pain starts to subside, progressive loss of GH motion in capsular pattern. Pain is apparent only at extremes of movement. This phase may occur at around 4 months and last until about 12 months
Thawing: Spontaneous, progressive improvement in functional ROM which can last anywhere from 5-24 months. Despite this, some studies suggest that it’s a self limiting condition, and may last up to three years.
Though other studies have shown that up to 40% of patients may have persistent symptoms and restriction of movement beyond three years.
It is estimated that 15% may have persistent pain and long term disability. Effective treatments which shorten the duration of the symptoms and disability will have a significant value on reducing the morbidity.
36
Describe different stages of an AC dislocation.
These injuries often result from falling on the shoulder or an outstretched arm. According to Tossy they can be classified into three types;
Tossy I - The ligg. acromioclaviculare and coracoclaviculare are stretched but still intact.
Tossy II - The lig. acromioclaviculare is ruptured with subluxation of the joint.
Tossy III - Ligaments are all disrupted, with complete dislocation of the art. acromioclavicularis.
Rockwood added three more types that occur less frequently;
Rockwood IV - Dislocation of the clavicle shifts dorsally, due to the pars clavicularis of the m. deltoideus being pulled off the clavicula.
Rockwood V - Dislocation of the lateral end of the clavicle is increases in the cranial direction, due to the mm. deltoideus and trapezius being pulled off the clacviclua.
Rockwood IV - The lateral end of the clavicula underneath the acromium or proc. coracoideus is dislocated (Very rare).
Use mnemonic BUD... Backwards, Upwards, Down.
37
Name the characteristics of nonspecific complaints of the lower back.
Non-specific low back pain is defined as low back pain for which no specific cause can be identified. This is the case in about 90% of all patients with low back pain.
The most obvious symptom in these patients is pain in the lumbosacral region. The pain may also radiate to the gluteal region and the upper leg. It may be increased when the patient adopts a particular position, makes certain movements or
lifts or moves heavy objects. The patient has no general symptoms of disease, such as fever or weight loss. The pain may be continuous or occur in episodes.
38
Name the characteristics of nonspecific complaints of the neck.
Non-specific neck pain is an unpleasant sensory and emotional experience that is associated with actual or potential tissue damage in the neck region (from the superior nuchal line to the scapular spine), potentially accompanied by pain in the head, shoulder, and/or arm. Neck pain usually decreases by 45%, accompanied by a decrease in the limitations in activities and/or participation, within 6 weeks of pain onset.
39
Name the characteristics of a cervical radicular syndrome.
Neurological deficits will present themselves because of impinged cervical radix, in the form of numbness, altered reflexes, or weakness. May radiate anywhere from the neck into the shoulder, arm, hand, or fingers.
Symptoms
• sensory symptoms in the arm, such as paresthesia, numbness, reduced sense of touch
• restricted cervical range of motion, defined as rotation <60 degrees or limited and painful rotation
• reduced muscle strength or muscle control
• radiating pain in the arm
Signs
• reduced tendon reflexes, muscle weakness, or sensory disorders
40
Recognise and identify the WAD categorisation from the guideline.
(Not likely to come up since the Whiplash guideline has been replaced)
WAD 0 - no complaints, no subjective or objective abnormalities
WAD 1 - Pain, stiff and sensitive area, but no objective abnormalities
WAD 2 - Neck complaints and other complaints of the postural and locomotor system (e.g. limited mobility, pressure point sensitivity)
WAD 3 - Neck complaints and neurological failure (e.g. limited or no tendon reflexes, muscle weakness and sensory disorders)
WAD 4 - Neck complaints and fractures or dislocations
41
Name the important prognostic factors from the guideline for whiplash.
(Not likely to come up since the Whiplash guideline has been replaced)
Prognostic factors in NEW guideline are: hypersensitivity, history of musculoskeletal disorders, previous episodes of neck pain, regular cycling, catastrophizing, depression, anxiety, need to socialize, advance age, PTSD at onset, passive coping, psychosocial stress, poor psychological health, high workload, low impact of own work.
42
Name the red flags of the CS.
Fracture - advanced age, trauma in medical history, use of corticosteroids, osteoporosis
Cervical arterial dysfunction - cerebrovascular symptoms such as dizziness, double vision, nausea, vomiting, weakness of the limbs, and papillary changes
Damage to spinal cord or cervical myopathy - neurological symptoms, including widespread neurological signs in both arms and/or legs, such as sensory disorders, loss of muscle strength in extremities, bowel and bladder dysfunction
Infection (including urinary tract infection or skin infection) - symptoms and signs of infection (e.g. fever, night sweats), risk factors for infection (e.g. underlying pathological process, in the case of immunosuppressants, an open wound, intravenous drug use, exposure to infectious diseases)
Malignant tumors - cancer in medical history, no improvement in symptoms after 4 weeks of treatment, unexplained weight loss, age >50 years, trouble swallowing, headaches, vomiting.
Systemic diseases (herpes zoster, spondylitis ankylosis, inflammatory arthritis, rheumatoid arthritis) - headache, fever, unilateral skin rash, burning pain, itching.
43
Name the different types of neck complaints/headache
```
Primary Headaches:
Migraine
Tension-Type Headache (TTH)
Cluster Headache
Other Primary Headaches
```
```
Secondary Headaches:
Headache as a result of whiplash
Medication-dependent headache
Cervicogenic headache
Temporomandibular headache
```
44
Name the signs and symptoms corresponding to cervicogenic headache (CH).
The main symptoms of a cervicogenic headache are a combination of;
- Unilateral pain
- Ipsilateral diffuse shoulder, and arm pain.
- ROM in the neck is reduced,
- Pain is relieved with anaesthetic blockades.
- Lasts hours up to weeks.
45
Name the functional anatomy of the high-cervical area.
| Spinal segments and ligaments
- Atlas
- Axis
- Ligg. alaria (connects dens to occiput - guides rotaion)
- Lig. apicis dentis (connects dens to foramen magnum)
- Lig. longitudinal posterior (called membrana tectoria at this level)
- Lig. transversum atlantis (arches across the atlas ring)
- Ligamentum cruciforme atlantis (transversum atlantis along with longitudinal bands/fasciculi above and below)
46
What is the joint between the Atlas and Axis called?
art. atlanto-axialis
47
Which tests would you use to test for upper cervical instability/cervical ligaments?
- Sharp purser test
- Short cervical flexion test
- Lateral slide-ability test
48
Identify the screening process and the different scenarios.
- Red flags (familiar pattern)
- Familiar pattern with unfamiliar course
- Familiar pattern with unfamiliar symptom
- Unfamiliar pattern
49
Test to confirm Cervicogenic headache?
- Cervical flexion rotation test
| - Test of Hall
50
The student is able to name the consequences of spondylosis in the long term (spondylolysis, spondylolisthesis, spondylodesis)
Spondylolysis is when a crack forms in the bony ring on the back of the spinal column. Mostly it’s a surmenage in children and young people who do back bending sports. Healing can lead to spondylolisthesis (a disk slipping). In order to stop the slippage, the disc can be fused to the other vertebrae surgically. This is called spondylodesis.
51
Name the characteristics of lumbosacral radicular syndrome
The lumbosacral radicular syndrome, a form of specific low back pain characterised by radicular pain in one leg, which may or may not be associated with neurological deficits.
Signs suggesting a lumbosacral radicular syndrome include:
• radicular pain radiating to the leg, and
• leg pain that is more prominent than low back pain.
52
What tests would you use for diagnosing Lumbosacral radicular syndrome?
* Positive ‘straight leg raising test’ (Lasègue’s sign)
* muscle weakness
* fingertip-floor distance > 25 cm when bending forward.
53
Describe the structure of the SI joint.
The Sacroiliac joint (simply called the SI joint) is the joint connection between the spine and the pelvis.
- Made up of the sacrum and the two in-nominates of the pelvis.
- Each innominate is formed by the fusion of the three bones of the pelvis: the ilium, ischium, and pubic bone.
- The sacroiliac joints are essential for effective load transfer between the spine and the lower extremities.
- It functions both as a shock absorber for the spine above and converts torque from the lower extremities into the rest of the body.
- The sacrum, pelvis and spine-, are functionally interrelated through muscles, fascia and ligamentous interconnections.
54
Describe the structure of the vertebral joints.
Two corpora with a disc between = Symphysis intervertebralis (anterior intervertebral joint).
2/5th of the cervical Symphysis intervertebralis is disci
⅓ for lumbar Symphysis intervertebralis is disci
and ⅕ for thoracic Symphysis intervertebralis is disci
Facet joints you call zygapophysialis (the posterior intervertebral joint) this is no symphysis but a proper, synovial joint.
55
Describe the structure of the costovertebral joints .
The costovertebral joints are;
- art. capitis costae (connects to corpus vertebrae)
- art. costotransversaria (connects to transverse proc)
Joining of ribs to the vertebrae occurs at two places;
- Head - Two convex facets from the head attach to two adjacent vertebrae. This forms a synovial planar (gliding) joint, which is strengthened by the ligament of the head and the intercapital ligament.
- Tubercle of the rib - Articulation of the tubercle is to the transverse process of the adjacent vertebrae. This articulation is reinforced by the dorsal costotransverse ligament
56
Describe the movement possibilities of the SI joint.
Nutation occurs:
when the sacrum absorbs shock; it moves down, forward, and rotates to the opposite side.
as the sacrum moves anteriorly and inferiorly, the coccyx moves posteriorly relative to the ilium.
This motion is opposed by the wedge shape of the sacrum, the ridges and depression of the articular surfaces, the friction coefficient of the joint surface, and the integrity of the posterior, interosseous, and sacrotuberous ligaments that are also supported by muscles that insert into the ligaments.
Counternutation:
the sacrum moves up, backward, and rotates to the same side that absorbs the force. This motion is opposed by the posterior sacroiliac ligament that is supported by the multifidus.
57
Describe the movement possibilities of the vertebral joints.
Nr 1, Cervical
The facet joints are flat on transversal. Can therefore rotate. Other movements come from the anterior joint of the spine.
Nr 2, Thoracic
These are good with latero-flexion. Because they are flat on frontal with each other.
NR 3, Lumbar
These are sagittal axis flat on each other - flexion extension
58
Describe the movement possibilities of the costovertebral joints .
The movements on these joints are called ‘pump-handle’ or ‘bucket-handle’ movements, and are limited to a small degree of gliding and rotation of the rib head.
The function of these movements is to enable lifting of the ribs upwards and outwards during breathing.
The end result is the increase of the lateral diameter of the thorax and subsequent expansion of the lung parenchyma as the air is being inhaled.
59
Describe the ligaments of the SI joint.
- Anterior Sacroiliac: an antero-inferior thickening of the fibrous capsule that is weak and thin when compared to the other ligaments of the joint. It connects the third sacral ligament to the lateral side of the pre-auricular sulcus and is better developed closer to the arcuate line and the PSIS. This ligament is injured most often and is a common source of pain because of its thinness.
- Interosseus Sacroiliac: forms the major connection between the sacrum and the innominate and is a strong, short ligament deep to the posterior sacroiliac ligament. It resists anterior and inferior movement of the sacrum.
- Posterior (Dorsal) Sacroiliac: connects the PSIS with the lateral crest of the third and fourth segments of the sacrum and is very strong and tough. Nutation, which is anterior motion of the sacrum, slackens the ligament, and counter-nutation, which is posterior motion will make the ligament taut. It can be palpated directly below the PSIS and can often be a source of pain.
- Sacrotuberous: consists of three large fibrous bands and is blended with the posterior (dorsal) sacroiliac ligament. It stabilises against nutation of the sacrum and counteracts against posterior and superior migration of the sacrum during weight bearing.
- Sacrospinous: triangular shaped and thinner than the sacrotuberous ligament and goes from the ischial spine to the lateral parts of the sacrum and coccyx and then to the ischial spine laterally. Along with the sacrotuberous ligament, it opposes forward tilting of the sacrum on the in-nominates during weight bearing
60
Describe the ligaments of the vertebral joints.
Two ligaments strengthen the vertebral body joints: the anterior and posterior longitudinal ligaments, which run the full length of the vertebral column. The anterior longitudinal ligament is thick and prevents hyperextension of the vertebral column. The posterior longitudinal ligament is weaker and prevents hyperflexion.
The joints between the articular facets, called facet joints, allow for some gliding motions between the vertebrae. They are strengthened by several ligaments:
- Ligamentum flavum: extends between lamina of adjacent vertebrae.
- Interspinous and supraspinous: join the spinous processes of adjacent vertebrae.
- Interspinous ligaments attach between processes, and the supraspinous ligaments attach to the tips.
- Intertransverse ligaments – extends between transverse processes.
61
Describe the ligaments of the costovertebral joints .
Four ligaments;
lig. costotransversarium laterale: attaches the lateral facet to the tip of the transverse process of the vertebral body.
lig. constotransversarium superius: attaches the neck of the rib to the underside of the transverse process of the vertebra above
lig. costotransversarium: attaches the back of the neck of the rib to the front of the transverse process
The three ligaments above stabilise the art. costeotransversaria because the proc. transversus do not have articulair facets.
lig. capitus costae radiatum: formed by three bands which connect the rib head to the vertebral bodies
62
Describe the structure and function of the disc of the intervertebral joint.
Nucleus Pulposus: A gel-like structure that sits at the center of the intervertebral disc and accounts for much of the strength and flexibility of the spine. It is made of 66% to 86% water with the remainder consisting of primarily type II collagen (it may also contain type VI, IX, and XI) and proteoglycans.
Annulus Fibrosis: Consists of “lamellae” or concentric layers of collagen fibres. The fibre orientation of each layer of lamellae alternate and therefore allow effective resistance of multidirectional movements. The AF contains an inner and an outer portion. They differ primarily in their collagen composition. While both are primarily collagen, the outer annulus contains mostly type I collagen, while the inner has predominantly type II. The inner annulus also contains more proteoglycans than the inner.
Vertebral end-plate: An upper and a lower cartilaginous endplate (each about 0.6– 1 mm thick) cover the superior and inferior aspects of the disc. The endplate permits diffusion and provides the main source of nutrition for the disc. The hyaline endplate is also the last part of the disc to wear through during severe disc degeneration
IVDs allow the spine to be flexible without sacrificing a great deal of strength. They also provide a shock-absorbing effect within the spine and prevent the vertebrae from grinding together.
63
Name the aetiology of osteoporosis
Primary osteoporosis is defined as loss of bone tissue associated with the normal process of aging, without any other identifiable cause. Primary osteoporosis may be due to an increased rate of bone resorption, rather than to a reduced bone formation rate, or to an abnormality in the mechanism linking bone formation and bone resorption. Primary osteoporosis is subdivided into postmenopausal osteoporosis and age-related osteoporosis. • Postmenopausal osteoporosis affects women aged 51–61 years, who show a clearly increased rate of loss of trabecular bone
tissue. This loss of bone tissue can lead to vertebral fractures. • Age-related osteoporosis affects both men and women over the age of 65 years. The disorder is characterized by the loss of trabecular as well as cortical bone tissue, which may lead to hip fractures and vertebral collapse.
Secondary osteoporosis is defined as loss of bone tissue with an identifiable cause. Examples of disorders that greatly increase the risk of osteoporosis include: inflammatory intestinal diseases,
celiac disease, osteogenesis imperfecta, anorexia nervosa, hypogonadism, malabsorption syndrome, primary hyperparathyroidism, gastric resection, Cushing’s syndrome and chronic rheumatoid arthritis. The use of corticosteroids also causes severe bone loss, especially in the first year. Other medicines that carry a risk of osteoporosis or osteopenia include antiepileptics, fenprocoumon (an anticoagulant) and goserelin (which inhibits hormone production in the hypothalamus). (KGNF guideline)
64
Name the pathogenesis of osteoporosis.
Failure to achieve peak bone mass and excessive bone resorption and/or decreased bone formation during remodelling. All these processes are likely to contribute to osteoporosis. (Sunita, Sandhu, Hampson, 2011)
65
Name the signs and symptoms of osteoporosis.
- Back pain: Episodic, acute low thoracic/high lumbar pain.
- Compression fracture of the spine
- Bone fractures (much more easily broken)
- Decrease in height
- Kyphosis
- Dowager’s hump (is a forward bending of the spine. slouching their shoulders and rounding their back, creates a permanent hump on the upper back).
- Decreased activity tolerance
- Early satiety
66
Name the yellow flags for non-specific low back pain
Well, since yellow flags are psychosocial. The PS prognostic factors mentioned in the KGNF guideline:
- Psychological and psychosocial stress
- Pain-related fears / avoidance behavior
- Somatization
- Depressive complaints
67
Identify and divide the back muscles through the direction of their muscle fibres.
- Lateral system:
- Inter-transverse: going from transverse to transverse process (Unilateral: lateroflexion / Bilateral: stabilises).
- Transverse: Most caudal origins going to transverse
and ribs, most cranial insertion be mastoid
process (Unilateral: lateroflexion, homolateral
rotation / Bilateral: extends)
- Spinal: spinal to spinal process (extends)
- Spinotransverse: spinal to transverse process (and even to mastoid process) (UNILAT: homolat rot, lateroflex HOMOLAT: extends)
Transversospinal - transverse to spinal process (BILAT: extends UNILAT: heterolat rot. and lateroflex)
For clarity: they run from caudal to cranial in the above description
68
Describe the function of the muscle corset of the trunk in relation to stability.
The muscle corset torso is a collaboration between: Thoracic diaphragm, Abdominal muscles, Pelvic floor, Back muscles.
A deficit or imbalance of this can lead to the following signs:
- Poor propriocepsis and reduced lumbar control (hesitating/pivoting)
- Reduced strength/endurance in local muscles at the level of the unstable segmental area
- Aberrant movement (abnormal course of movement)
- Pain in static postures which are maintained for long periods of time
- Gower’s sign: the patient ‘walks’ his hands back to neutral position
- Movement too large (1 or 2 segments) during flexion-extension
- Reduced willingness to move or fear of moving
- Hyper mobility (during posterior/anterior (P-A) spring test)
- Increased muscle tension/defensive tension
- Poor posture and postural changes such as lateral shift and change of lordosis
- Frequent audible cracking/popping/clicking sounds -during a movement
- Hypo-mobility of contiguous segments
69
Is able to name the three regulatory systems according to the stabilising system.
Panjabi spinal stability system
- Passive: Ligaments, capsule
- Active: Muscles
- Neuronal: Feed forward of muscle activation
70
Is able to explain the concepts of instability.
Clinical instability is defined as a significant decrease in the capacity of the stabilising system of the spine to maintain the intervertebral neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain.
71
Is able to explain the concepts of the neutral zone.
The neutral zone is a region of intervertebral motion around the neutral posture where little resistance is offered by the passive spinal column.
The neutral zone appears to be a clinically important measure of spinal stability function. It may increase with injury to the spinal column or with weakness of the muscles, which in turn may result in spinal instability or a low-back problem. It may decrease, and may be brought within the physiological limits, by osteophyte formation, surgical fixation/fusion, and muscle strengthening. The spinal stabilising system adjusts so
that the neutral zone remains within certain physiological thresholds to avoid clinical instability.
"neutral zones within the physiological limits so that there is no neurological dysfunction, no major deformity, and no incapacitating pain.”
72
Is able to explain the concepts of motor control.
There is only a moderate relationship between patho-anatomical findings (segmental instability based on increased translation possibility for a specific segment), the severity of the pain and the extent of the limitations.
This sub group is distinguished by a changed pattern of motor contraction.
73
Know the clinical prediction rules for the LS
The value of clinical prediction rules for patients with low back pain has not yet been sufficiently proven. The KGNF therefore does not recommend the use of such rules in therapy practice.
Hicks et al's lumbar stabilization rule contains two groups: a “Success” group and an “Improvement” group. The two groups are different in the magnitude of the change in their outcome score and in the variables used to predict group assignment.
The Success group changed by better than 50% on the Oswestry Disablement Scale (ODI). The Improvement group changed from 6% to 49% on the ODI. Any change less than 6% was considered a treatment failure and alternative treatments were suggested.
```
Success stabilization group:
Success Rule predictor variables
Age less than 40 years old
SLR greater than 91 degrees
Aberrant motion present
Positive prone instability test
```
Improvement stabilization group:
Improvement Rule predictor variables
FABQ physical activity scale greater than 9 points
Aberrant movements absent
No lumbar hypermobility with prone spring testing
Negative prone instability test
74
Name and describe the three phases of stability training.
```
Cognitive phase
• Demonstrate often
• Patient copies therapist
• Many errors allowed
• Adequate feedback important: Knowledge of Performance and Result
• Trial and error
```
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Associative phase
• Learning through procedures
• Does not have to be flawless
• Patient capable of identifying own mistakes
• Lots of variation in exercises
• Feedback Knowledge or Results
```
Characteristics:
• Attention available for other processes
• Accuracy, timing and speed increase
• Accurate feedback important: Knowledge of Performance and Result
75
Lower back complaints can be divided into non-specific and specific lower back complaints.
Explain the difference between the two and give some examples?
Non-specific lower back complaints are complaints of the lower back without a clear cause found for example in X-rays, blood tests, etc.
Specific lower back complaints can be proven. Examples of specific lower back complaints are a hernia nuclei pulposi (HNP) or vertebral fracture.
76
Specific neck complaints are provable through imaging tests.
What are some examples of specific neck complaints?
Examples of specific neck complaints are: cervical radicular syndrome, cervical myelopathy, neck complaints as a result of rheumatoid arthritis.
77
What is the name of the categorisation of neck and back complaints into specific and non-specific complaints?
Triage.
78
Explain the categories of the Triage, inc. percentages of sufferers.
Back complaints ->
- Non-specific back complaints (90%).
- Specific back complaints (10%).
- Radiculopathy (8%).
79
What signs and symptoms suggest a Lumbar Radiculopathy?
- Unilateral pain in the leg > backache.
- Pain usually radiates to the foot/toes.
- Not only discogenic cause (pain originating from a damaged vertebral disc, particularly due to degenerative disc disease).
- Paraesthesia, sensibility disorder.
- Neuromeningeal stimulus
- reduced straight leg raising, slump.
- Reduced motor, sensory or reflex function
- matching one segment.
80
Explain how pressure on a disc causes radicular syndrome?
If the nucleus pulpous pushes through the annulus fibrosis (herniation), it can compress the nerve root.
81
What are the Red flags for Lower back pain?
There is consensus about the following red flags:
• Onset of the low back pain after age 50 years, continuous
pain regardless of posture or movement, nocturnal pain,
general malaise, history of malignancy, unexplained
weight loss, elevated erythrocyte sedimentation rate (ESR)
→ malignity?
• Recent fracture (< 2 years ago), previous vertebral fracture,
age over 60 years, low body weight (< 60 kg/ BMI < 20
kg/m2), older person with hip fracture, prolonged use of
corticosteroids, local percussion pain, tenderness and
axial pressure pain in the spinal column, marked height
reduction, increased thoracic kyphosis → osteoporotic
vertebral fracture?
• Onset of low back pain before age 20 years, male sex,
iridocyclitis, history of unexplained peripheral arthritis
or inflammatory bowel disease, pain mostly nocturnal,
morning stiffness > 1 hour, less pain when lying down
or exercising, good response to NSAIDs, elevated ESR
→ ankylosing spondylitis?
• Severe low back pain after trauma → vertebral fracture?
• Onset of low back pain before age 20 years, palpable
misalignment of the processi spinosi at the L4-L5 level
→ severe spondylolisthesis?
82
name the measuring instruments for LBP
NRS-pain, PSC, QBPDS
83
How long is the ABNORMAL COURSE CUT-OFF for Lower back pain.
No progress after 3w.
84
Describe the treatment for LBP
TREATMENT:
1: under 3 sessions, reassure activity is good, max 2 day bed rest.
2: inform+advice (same), exercise program, joint mobilisation/manipulation, massage/thermal for pain reduction, talk to GP if patient on sick leave after >4w.
3: same but more focus on advice/info, recommend contacting GP, talk to GP, sick leave and activity program - matching, terminate if no progress after 3-6 weeks.
85
Name the profiles of LBP
PROFILES:
1. non-specific w normal course
2. non-specific w abnormal course
3. non-specific abnormal because of PS factors.
86
4 categories of negative prognostic factors (LBP).
1. back pain related factors (severe limitations of activities, radiating pain, widespread pain)
2. personal factors (older age, poor general health status)
3. psychosocial factors (psychological and psychosocial stress, pain-related fears/avoidance behaviour, somatisation, depressive complaints)
4. occupational factors: unsatisfactory colleague relations, physically heavy tasks
87
Testing for radiculopathy LBP?
SLR, CSLR, slump.
88
Testing to determine affected plexus in radiculopathy LBP?
Neri, Bragard
89
Testing for fracture in LBP?
Percussion test for fracture
90
Globally distinguish between different surgery techniques and corresponding rehabilitation treatment protocols of hip implants.
With total hip you have cemented and un-cemented. Cemented provides early full weight bearing whereas you generally are careful with full weight bearing with un-cemented hips. The latter provides for later revision however and hence suitable for younger patients.
Patients should be aware that during the first six weeks after hip resurfacing surgery, they will need to follow certain precautions to protect the hip and avoid complications. These include avoiding hip flexion beyond 90º, crossing the legs, turning the operative leg inward past a neutral position, and lifting more than 30 pounds.
The main operation techniques, anterior approach surgery is minimally invasive and allows for fast recovery (full weight-bearing exercises according to tolerance, are made possible in the first postoperative days). Un-cemented will delay loading.
The following is a suggested protocol in the absence of complications.
Day 1: Post-Surgery
- Education and advice
- Education of muscular relaxation
- Revision of precautions and contraindications (provided that patient had a pre-operative session with the physiotherapist, otherwise full education will be done as mentioned in pre-operative section).
Bed exercises:
- Circulation drills
- Upper limb exercises to stimulate the cardiac function
- Maintenance of the non-operated leg: attention should be paid to the range of motion in order to preserve controlled mobilisation on the operated hip
- Isometric quadriceps (progressing to concentric VMO) and gluteal contractions
- Active-assisted (progressing to active) heel slides, hip abduction/adduction
- Bed mobilisation using unilateral bridging on the unaffected leg
- Transfer to sit over edge of bed
- Sit to stand with mobility assistive device (preferably a device giving more support like a walking frame or rollator)
- Gait re-education with mobility assistive device as tolerated (weight bearing status as determined by surgeon)
- Sitting out in chair for maximum 1 hour
- Positioning when transferred back to bed
Day 2: Post-Surgery
- Bed exercises as described above, progressing repetitions and decreasing assistance given to patient
- Progression of distance mobilised and/or mobility assistive device
- Incorporate balance exercises if needed
- Sitting in chair
Day 3: Post-Surgery
- Bed exercises as described above, progressing repetitions and decreasing assistance given to patient
- Progression of distance mobilised and/or mobility assistive device
- Stair climbing (at least 3, or as per home requirements)
- Sitting in chair
- Revision of precautions, contraindications and functional adaptions
- Give 6 week progressive resistive strengthening home exercise to patient; this can include stationary cycling, as long as the patient stays within the precautions (especially posterior approach surgery)
- Discharge from hospital
- Accelerated Protocol
- Combination of days 2 & 3 to discharge patient day 2 post surgery.
- Only selected patients
6 Weeks Post Surgery
Patients are normally followed up by orthopaedic surgeon
Surgeon determines if the patient is allowed the following:
Full range of motion at the hip
Full weight bearing without mobility assistive device
Driving
After 6 Weeks
Gain of initial ROM, stabilization, and proprioception
Endurance
Flexibility
Balance
Speed, precision, neurological coordination
Functional exercises
91
Knowledge of primary deforming osteoarthritis of the hip
Specific for hip osteoarthritis:
In hip osteoarthritis, the clinical picture is formed by: age
45 years or older, pain complaints longer than three months and especially when loading, sitting does not aggravate the pain, pain in the groin or thigh and sometimes in the buttock or low back, decreased internal rotation, external rotation, extension and flexion, a bony end feeling, loss of strength of the hip abductors, starting pain and / or stiffness in movement and pain on palpation over the inguinal ligament.
92
Name the differences between primary gonarthrosis and secondary gonarthrosis.
Primary osteoarthritis - is articular degeneration without any apparent underlying cause.
Secondary osteoarthritis - is the consequence of either an abnormal concentration of force across the joint as with post-traumatic causes or abnormal articular cartilage, such as rheumatoid arthritis (RA).
93
Name the different possibilities for the surgical treatment of gonarthrosis.
Arthroscopy for osteophyte removal
Osteotomy of the tibia head
Knee joint replacement surgery
94
Describe the form and function of the menisci.
The half moons on the tibial plateau.
| Shock absorption, increasing contact, stability, dividing synovia, increase ROM.
95
Name the innervation of the muscles of the upper leg.
Adductor magnus:
Deep part: obturatorius (L2-L4)
Superficial part: N. tibialis (L4)
Pelvic trochanteric group: direct branches of the sacral plexus.
Psoas major: Direct branches of lumbar plexus.
Iliacus, Sartorius, Quads, Pectineus: femoral nerve
Bicep femoris
Brevi: fibular nerve.
Longus: tibial nerve
Semitendinosus and membranosus: tibial nerve
Glut maximus: inferior gluteal nerve
Glut med/min+TFL: superior gluteal nerve
Adductor Brevis, Gracilis, Adductor Longus: obturatorius nerve.
96
Describe in which way the arch of the foot is contracted and which muscles are involved.
The arch is divided into the medial and lateral longitudinal arch as well as the transverse arch. Which are the ways the foot is contracted.
The muscles involved: Short foot muscles: m. abductor hallucis + m. flexor hallucis brevis + m. flexor digitorum brevis + m. quadratus plantae + m. abductor digiti minimi. and tendons of m. tibialis anterior, m. tibialis posterior and m. peroneus longus.
97
Describe the directions in which the meniscus moves during different movements of the knee.
.
98
Explain the terms tendinitis, tendinosis and tendinopathy.
Tendinitis is inflammation or irritation of a tendon.
Tendinosis is a degeneration of the tendon's collagen in response to chronic overuse
Tendinopathy is a degeneration of the collagen protein that forms the tendon
99
Name the different causes that could impede tendon recovery (risk factors).
- Unloading
- Excessive load
- Individual factors.
100
Name the prognostic factors from the KNGF Guideline Meniscectomy
Unfavourable prognostic factors
1 No participation in sports
2 Bad Preparation on sports
3 Previous knee operations ( in history) 4 Complicated lesion/injury
5 Pre –operative pain
6 Extensive amount of surgically removed tissue 7 Financial compensation employer
8 Place of resection
Favourable prognostic factors
1 Participation in sports
2 Good preparation on sports
3 No previous knee operation ( in history) 4 Uncomplicated lesion/injury
101
The parameters of the strength endurance.
Strength Endurance:
• Muscular overload should take place, And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter)
• Series: 3-6
• Repetitions: 20 to maximum 40
• Series break: 30 seconds to 1 minute
• Exercise speed: 2-0-2 (depends on the exercise, speed will remain low).
102
The parameters of the Hypertrophy
```
Hypertrophy
• Muscular overload should take place
And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter)
• Series: 3-6
• Repetitions: 6,12
• Series break: minimum 1 minute
• Exercise speed: 1–0-1 (depends on the exercise, speed will remain moderate)
```
103
The parameters of the Submaximum
Sub maximum
• Muscular overload should take place
And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter)
• Series: 2-4
• Repetitions: 3-6
• Series break: Minimum 2 minutes for complete recovery of phosphate pool
• Exercise speed: 1-0-1 or 1-0-2 (depends on the exercise, speed will remain moderate)
104
The parameters of the Maximum
Maximum
• Muscular overload should take place
And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter)
• Series: 2-4
• Repetitions: 1-3
• Series break: Minimum 2 minutes for complete recovery of phosphate pool
• Exercise speed: 1-0-1 or 1-0-2 (depends on the exercise, speed will remain moderate)
105
The parameters of the supramaxium
Supra Maximum
• Muscular overload should take place
And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter)
• Series: 2-4
• Repetitions: 1-3
• Series break: Minimum 2 minutes for complete recovery of phosphate pool
• Exercise speed: 1-0-1 or 1-0-2 (depends on the exercise, speed will remain moderate)
• Assistance during concentric phase of the exercise
106
The parameters of the Explosivness
Explosiveness
• (Neuro) muscular overload should take place. Practicality is now dependent on the
concentric speed. When the speed decreases during the concentric phase, the overload will
be visible.
And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter)
• Series: 3-4
• Repetitions: 6-12 hh
• Series break: Minimum 2 minutes for complete recovery of phosphate pool
• Exercise speed: maximum concentric – hold 1 second – 1-2 seconds eccentric
107
The parameters of the Speed
Speed
• (Neuro) muscular overload should take place. Practicality is now dependent on the total
speed. When the speed decreases, the overload will be visible.
And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter).
• Series: 3-4
• Repetitions: 8-10 repetitions in 8-10 seconds
• Series break: Minimum 2 minutes for complete recovery of phosphate pool
• Exercise speed: max- 0 - max (maximum speed both concentric and eccentric without fixed
moment.
108
The parameters of the Plyometric
Plyometric
• (Neuro) muscular overload should take place. Practicality is now dependent on the delivered
capacity. When the speed decreases during the exercise, the overload will be visible.
And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter)
• Effort: +/- 10% extra
• Series: 3-4 series
• Repetitions: 6-12 repetitions > working towards function
• Series break: minimum 2 minutes for complete recovery of phosphate pool
• Exercise: from eccentric activity straight into maximum concentric
109
The parameters of the Sport-specific
• (Neuro) muscular overload should take place. Practicality is now dependent on the delivered
capacity. When the speed decreases during the exercise, the overload will be visible.
And/or
• The exercise is no longer technically feasible (1 correction is allowed, the exercise is stopped
thereafter)
• Effort: +/- 10% extra
• Series: 3-4 > working towards function
• Repetitions: 6-12 repetitions > working towards function
• Series break: minimum 2 minutes for complete recovery of phosphate pool. Working
towards sports function
• Exercise speed: function specific
The category 'sports specific' also includes agility training and complex training.
110
Describe the diagnostic and the therapeutic treatment process, as described in the KNGF guideline ankle injuries.
First of all, the name of the guideline is a bit misleading, since it goes for both of these conditions:
```
1. Acute ankle sprain
Expect return to sport within 12 weeks and walk after 2 weeks. If not, assess:
Relevant pathologies impeding recovery
Crazy inflammation
Unexplained pain
Patients behaviour incl. pain
Re-injury
Pre-existent ankle instability
```
2. Functional instability (the chronic kind of ankle sprain)
Persistent giving away, but pain from load-bearing and swelling might be less prominent. Reasons why someone might develop this are:
Laxity of ligaments (mechanical instability)
Abnormal propriocepsis
Low muscular strength (active stability)
Slow muscle activation time
Chronic synovitis
Bad dorsal flexion
Bad coping/anxiety
Red flags
Acute: Ottawa ankle rules (fracture) NOT A RED FLAG, BUT YOU DO SEND TO GP FOR X-RAY.
Instability: Sinus tarsi (syndrome) and persistent synovitis (arthritis)
How to treat
Well if it’s one of the three red flags it’s back to the GP.
If it’s functional stability with new tissue damage you treat it like acute.
TRAUMA
Phase 1 (0-3 days) inflammatory
Goals: Reduce pain and swelling. Promote partial load bearing and improve circulation.
Procedures: Informing & advising (price), move to stimulate circulation, apply bandage.
```
Phase 2 (4-11 days) Proliferation
Goals: Restoring function and activities, build up to load bearing.
Procedures: Info advice (crutches), taping
```
Phase 3 (11-21) Early remodelling
Goals: muscle strength, ROM, active stability,
Procedures: inform about preventive measures incl. look at footwear, exercise therapy for strength, ROM, balance, walking (symmetrical gait), running, stairs.
```
Phase 4 (21-6 weeks) Late remodelling
Goals: Increase load-bearing capacity, walking and stair climbing, work, domestic and sports activities.
Procedures: coordination skills, dual tasks, give homework.
```
Phase 5 (6-8-12 weeks) Sports specific:
Goals: sports specific
Procedures: sports specific
FUNCTIONAL INSTABILITY
Goals: greatest possible restoration of patients functions and activities
Procedures: Inform/advice, exercise, evaluate, prevent new ankle injuries, conclude and report.
111
Describe the most common knee injuries and knows the corresponding physiotherapeutic diagnostic tests.
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Iliotibial pain syndrome (observation, palpation, history taking)
jumpers knee (observation, palpation, history taking)
MCL tear (valgus stress test)
Meniscus tear (mcmurry, Apley's, Joint Line Tenderness and Thessaly)
Osgood schlatter (palpation)
Patellofemoral instability (patellar apprehension test)
PFPS/runner's knee/chondromalacia (observation, palpation, history taking)
Sinding larsen (roentgen)
```
