PY1104 - Intro to Musculoskeletal Physiotherapy Flashcards
(93 cards)
1
Q
WEEK 1
A
MSK subjective assessment
2
Q
What is the subjective assessment
A
The initial assessment where we talk to our patients and gather information
Discussions with other clinicians, family or carers
Reading referrals or notes to gather initial information
3
Q
What are the aims of the subjective assessment
A
Build rapport with your patient
Gather information to enable us to plan our objective assessment
Establish differential diagnoses
Establish the main problems and patient’s goals / expectations.
Evaluate patient awareness, knowledge and insight.
Establish baseline subjective markers
4
Q
What is included in an MSK subjective assessment
A
History of present condition
Past medical history
Drug history
Social history
Patient goals / aims / expectations
Differential diagnoses
5
Q
What is involved in HPC
A
Timeline, Mechanism of injury, treatment/ investigations to date
How might an improving Vs worsening presentation change your potential diagnosis or further assessment?
How might a clear mechanism help your diagnosis?
What might a major mechanism suggest vs a minor mechanism?
What information or mechanism would make you stop and think?
How might previous intervention information help your assessment? How might it hinder it?
6
Q
what are non-verbal pain cues
A
- Facial expressions, grit teeth, frown, grimace, bite lip, blink, tears, tightly close eyes
- Making a fist, extending legs or fingers, curl toes
- Talking a lot or Quiet
- Deep breathing or Measured breathing
- Colour changes – pale or flushed
- Withdraw from touch
7
Q
other words to describe pain
A
Sharp, aching, shooting, dull, prickling, tight, cramping, hot, burning, heavy, gnawing sickening, splitting, stabbing, throbbing, sore, tiring, exhausting, gripping, angry, stinging….
8
Q
What is involved in PMH
A
Previous operations, accidents or significant illnesses
(THREADS)
Relevant current medical conditions
Specific ‘red flag conditions’
9
Q
What is involved in Drug history
A
Current medication
Significant past medication
Specific ‘red flag’ medication
10
Q
what is involved in social history
A
Occupation.
Relevant social or family situation
Hobbies and interests
11
Q
HPC - Signs and symptoms
A
What are the main symptoms
Are there any other symptoms that the patient might report?
How can we record these in a clear, detailed way?
12
Q
How are signs and symptoms recorded
A
Symptoms are recorded on a body chart.
Symptoms should be numbered if there is more than one eg P1, P2 for different areas of pain.
The relationship of these to each other should be established as well as the exact location and behaviour of the symptoms.
13
Q
what is pain defined as
A
'’An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.” (IASP definition)
14
Q
how can pain location be recorded
A
body chart, is it dull or a sharp pain, are there more than one pain locations, is it deep or superficial, are the different pains linked together
15
Q
what things do we need to know surrounding the pain tendancies
A
aggravating factors, Easing factors, 24hr pattern, night pain
16
Q
what are special questions
A
Questions which help diagnosis eg
Any P&N/numbness?
Any swelling?
Any feelings of instability / locking / giving way?
Any audible pops / clicking?
17
Q
what are red flags questions
A
Questions which indicate more serious pathology eg
Cauda equina symptoms
PMH THREADS questions
18
Q
what is SIN
A
Severity - L/M/H
Irritability - L/M/H
Nature - Nociceptive, Neuropathic or neurogenic
19
Q
what is irritabaility
A
Irritability = a disorder’s susceptibility to become painful, how painful it becomes and the length of time this pain takes to subside.
It is usually rated as low, moderate or high.
20
Q
what is Nociceptive pain
A
Pain derived from tissues by mechanical or chemical processes.
Most likely to be associated with an acute injury, with damaged and healing tissues and postural pain.
21
Q
what is neuropathic/genic pain
A
Pain derived from the nerve itself or its connective tissue by mechanical or chemical stimulation.
Has characteristic qualities typical of nerve irritation and involvement including the sensation and behaviour of the pain.
22
Q
What is Nociplastic pain
A
Pain derived from a hyperactive and hypersensitised nervous system where the stimulus would not normally trigger a pain response and can be strongly linked to stress and emotion.
Can exist a feedforward response where thoughts and feelings can elicit a pain response.
23
Q
what are examples of Nociceptive pain
A
Dull, aching, sharp pain, mechanical inflammatory pattern, clear stimulus: response (aggs+eases), pain localised to area of injury
24
Q
what are examples of neuropathic pain
A
burning/ electric shocks, tingling/prickling/cold, allodynia/prolonged hyeranalgesic state, dermatomal/peripheral innovation field, random, spot pain along a nerve, paraesthesia
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what are examples of nociplastic pain
diffuse pain location, non-mechanical patter, increased emotional response and triggers, history of failed treatments, unclear stimulus: response, non-anatomical palpation pain
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WEEK 2
Ankle assessment and Objective Ax
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WEEK 2 pt1
(Ankle + objective Ax notes)
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what is are examples of arthrogenic structures
Joint, Bones, Ligaments
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what are examples of a myogenic structure
Muscles + tendons
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what are examples of a Neurogenic/ Neuropathic structure
Referred from Lumbar spine, Peripheral nerves, Morton's neuroma
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How many grades for ligament sprains are there
normal then 1-3
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how many grades of muscle strains are there
normal then 1-3
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what are red flags
Clinical features which help us IDENTIFY and REFER patients with concerning signs & symptoms that could relate to potentially serious or previously undiagnosed conditions
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How many parts are there to an MSK objective Ax
9 - Preparation, Observation, Clearing Joints, AROM/PROM, palpation, Ottawa rules, Special tests, Muscle tests, Functional testing, Outcome measures
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what should you observe during the observation phase of the objective Ax
Gait (while walking in/ more formal), Posture (whole body/ lower limb, foot posture), Functional (squat, lunge, SLS), Deformities (lumps/bumps, toe deformities), Skin (any wounds redness/ callus) swelling
36
what is clearing joints
Joints above or below, or with the potential to refer to the affected area should be ‘cleared’
* Full AROM in all directions (helps to rule out other joints, helps to identify deficits which may be contributing to the patients symptoms)
* If they have full pain free ROM the clinician can apply overpressure ( do not apply overpressure if AROM is restricted/ painful or condition is highly irritable
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AROM/PROM for ankle joints
* Talocrural and Subtalar Joints (DF, PF, Inversion, Eversion)
* MTPJs and IPJs (Flexion, Extension)
* Weight Bearing lunge test
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ankle palpation bony landmarks
- Anterior tibia, Anterior talo-crural joint, Medial and lateral malleoli, fibula, metatarsals including base of 5th metatarsal, Navicular, Cuboid
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ankle palpation - muscles and soft tissues
ankle dorsiflexors (tib ant, ED, EDL), Peroneal tendons, Tibialis posterior, Gastrocnemius, Achilles tendon, Plantar Fascia
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ankle palpation - Ligaments
lateral ligament complex (ATFL, CFL, PTFL), Deltoid ligament, Anterior inferior tibia-fibula ligament
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what are the ottawa ankle rules
The Ottawa Ankle Rules are a set of clinical criteria used by healthcare professionals to determine the necessity of obtaining X-ray images in ankle injuries. They are designed to identify fractures accurately and avoid unnecessary imaging, reducing costs and radiation exposure
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what is a special test
Specific tests specific to a certain joint which aid our clinical reasoning
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special tests of the ankle
* Calf squeeze test / Thompson – Achilles rupture
* Anterior draw & Talar Tilt – lateral ligaments (ATFL/CFL)
* External rotation stress test & cotton test– High ankle sprain
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what are the muscle tests you can use during a MSK objective Ax
Oxford Grading, Isometric muscle testing, Functional testing, Muscle Length Testing
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what are the functional tests you can do on the ankle
* Balance tests (SLS, SLS eyes closed, balance error scoring system, star excursion test, Y balance test)
* Jump tests (Distance, Height)
* Hop tests (Single, triple hop test, crossover hop test)
* Other (Calf endurance test, Single leg squat, Lunges)
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what is clinical reasoning
Subjective Ax + Objective Ax = Clinical Reasoning
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what does clinical reasoning involve
* Hypothesis/DD
* Problem list
* Goals
* Treatment plan
* Rx/ Ongoing evaluation
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WEEK 2 pt2
MSK Objective Ax
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what are the three pain natures
Nociceptive, Neurogenic, Nociplastic
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what is the order of an objective Ax
Observation, AROM, clearing joints, PROM, Muscle tests, palpation, special tests to area, Functional testing, neuro tests, outcome measures
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how do you clear joints
Verbally check for other areas of pain (eg common referral areas) AROM and PROM with over pressure of joint above and below
52
what does SOAP stand for
Subjective - feedback from last session, treatment and exercises. Changes in symptoms, % improvement, subjective markers.
Objective – Repeated objective markers and measures. Planned tests from last session.
Treatment – what you did and the outcome of treatment.
Analysis – your ongoing thoughts, analysis on progress / changes in subjective and objective markers. Changes to diagnosis / hypothesis. Thought on main drive of the symptoms and where treatment focus needs to be – linked to subjective and objective findings.
Plan – Plan for next session or coming few sessions
53
what is the key mechanisms behind an ATFL tear
* Inversion mechanism of injury
* Most common ankle injury
* Graded 1-3
* Lateral ankle pain
* Associated swelling and bruising
* Can be associated with CFL and PTFL injuries.
54
what are the key mechanisms of an AITFL tear
* Corkscrew injury with dorsiflexion / eversion of the foot and knee adduction
* Higher force MOI eg landing from a jump
* Pain higher in ankle and anterior ankle
* Can be associated with other ligament injuries.
* More severe injuries often treated with a boot initially.
55
what are the Webber ankle fracture classification
* Webber A – fibula fracture below the level of the syndesmosis
* Webber B – fibula fracture at the level of the syndesmosis
* Webber C - fibula fracture above the level of the syndesmosis.
56
what is the Salter Harris classification
(1) S- separated growth plate
(2) A- above growth plate
(3) L- Below growth plate
(4) T- through growth plate
(5) ER- erasure of growth plate
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WEEK 3 pt1
Common pathologies of the knee
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what is an insidious/ overuse pathology
any disease that comes on slowly and does not have obvious symptoms at first
e.g OA/RA, PFPS, patella tendinopathy, adductor tendinopathy
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what is a traumatic pathology
a sudden and acute knee pathology
e.g meniscal tears, fractures, ACL/ MCL rupture/ tear, LCL tear, PCL tear/ rupture
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what is a post-operative knee pathology
a pathology that develops post surgery/ operation
e.g ACL repair, meniscal repair, TKR, arthroscopy, other ligament repair
61
what are the main pathological features of osteoarthritis
1) Joint space narrowing
2) Osteophyte formation
3) Sclerosis of the bone
4) Meniscal and articular cartilage degeneration
5) Exposure of subchondral bone
6) Muscle weakness
62
what problems will patients with OA present?
1) Pain on walking and weightbearing activities.
2) Weakness and feelings on instability.
3) Inability to continue with normal or previous activities.
4) Stiffness in the morning and after rest signs on inflammation.
63
what will be the findings on the assessment of OA (sub+obj)
1) Insidious onset, gradually worsening though episodic. Symptoms of pain, stiffness, weakness, giving way, hot knee, clicking. Functional limitations like a reduced ability to walk, kneel, squat.
2) Observed swelling or bigger knee, reduced AROM, reduced PROM, weakness in quads and hamstrings, joint line palpation pain.
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what are the stages of knee OA
1 - Doubtful
2 - Mild
3 - Moderate
4- Severe
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Patella pain syndrome
* One of the most common presentations seen in outpatient departments.
* Pain can be retropatella or around the patella and is often aggravated with stairs, squatting and prolonged flexion (movie goers knee)
66
what are the contributing factors to PFPS
Patella Alta (high), Patella Baja (low), Quads Weakness, Reduced quads flexibility, Reduced Gastroc flexibility, Hip abductor weakness, Increased knee valgus on landing, Overload, Gluteal weakness, Trochlea morphology, Osteochondral defects
67
what is Patella tendinopathy
* Point tenderness over the proximal tendon on its attachment to the distal pole of the patella.
* Load related patella tendon pain which follows the normal tendinopathy pattern.
* Pain is aggravated by loading the tendon and quads activation.
68
what are examples of traumatic pathologies
* Fractures
* Meniscal tears
* Ligament tears and ruptures – LCL, MCL, PCL and ACL
69
knee fractures + examples
Knee fractures are rare and usually result from high force sports trauma, falls or RTAs.
* Patella – usually a direct trauma or deceleration injury
* Tibial plateau – usually a fall or high trauma event
* Fibula head – usually lateral impact
Most knee fractures will need surgical fixation and immobilisation.
70
what are the Ottawa rules of the knee
a knee x-ray of the knee is only required when patients have these findings:
1- age 55 or older
2- isolated tenderness of patella
3- Tenderness at head of Fibula
4- Inability to flex to 90 degrees
5- Inability to bear weight both immediately and in the emergency department (4 steps)
71
ACL injuries
* ACL ruptures are most frequently non-contact sports related injuries.
* MOI is usually a cutting, twisting, or landing action where with foot is planted on the ground and the knee pivots into adduction and medial rotation.
* Can be audible ‘pop’ on rupture.
* Intra-articular swelling within few hours and a positive sweep test seen on examination.
* The Anterior draw test and Lachman’s test are often used to aid diagnosis.
72
PCL injuries
* The PCL is strong and prevents posterior translation of the tibia.
* Injury is usually through hyperextension or a forceful AP translation of the tibia while in flexion.
* Symptoms are often quite vague so they can go undetected.
* They are graded 1-3.
* G1 – partial tear
* G2 - complete tear
* G3 – complete tear with associated injuries eg PLC tear.
* The PCL is reported to be the strongest of the knee ligaments and twice as strong as the ACL. The role of the PCL is to prevent posterior tibial translation and increase rotational stability in the knee. Unlike the ACL it does not sit withing the joint, therefor will not elicit the same degree of swelling on injury.
* The posterior cruciate ligament prevents posterior tibial translation and is therefor injured when the tibia is forced posteriorly on the femur, usually in knee flexion for example when landing on a step or hard object following, a direct blow to the anterior tibia (eg a tackle), a fall into full flexion with the foot in plantarflexion or with a hyperextension injury.
* As the PCL is extraarticular there is no hemarthrosis and symptoms are classically vague with the knee feeling slightly unstable and just ‘not right’. Because of the difficulty in diagnosis they can be missed and present several weeks after the injury. The garding system is slightly different to normal ligament grading: A grade 1 is a partial tear, a grade 2 a complete tear and a grade 3 a complete tear with other associated injuries. With complete tears there will be a posterior tibial sag seen when both feet are parallel and knees flexed in supine, as shown on the next slide.
73
post operative knee problems
* Ligament repair
* Meniscal repair
* Total knee replacement - TKR
* Knee arthroscopy
* They will all have a post op protocol which can vary from consultant to consultant.
* Aims are initially to regain range and reduce swelling, then strengthen and return to function.
High level and sports specific rehabilitation might be appropriate
74
red flag pathologies and findings
* Septic OA
* Wound infection
* Compartment syndrome
* Bone tumours
* Blocked movement
* Gross instability
* Non-mechanical pain
* Calf redness/heat/pain
These are all very rare however they can be picked up within a Physiotherapy assessment.
Make sure you know what each of these are and how the conditions may present.
75
WEEK 3 pt2
Red flags and special questions + LSPJ
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what is a masquerader
a condition which is not what it seems or presents as another condition
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what is a red flag
a possible indicator of serious pathology
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what is the definition of a serious pathology
clinical concern of potential condition which needs urgent or prompt medical assessment.
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what is a red herring
a misleading biomedical or psychosocial factor that can lead to incorrect clinical reasoning
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red flags: determining a level of concern
* Red flags are signs and symptoms that raise suspicion of serious pathology.
* Patients which invoke a high index of suspicion, or a high level of clinical concern must be referred on for further investigations.
* Patients with a lower index of suspicion need to be ‘safety netted’ and monitored closely through treatment.
* ‘Safety netting’ refers to giving the patient the appropriate advice and education on what to do if their symptoms worsen or start to include red flags.
* Patients with no concerning features can be treated and monitored less closely.
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what levels of concern are there
no concerning features
few concerning features
some concerning features (urgent)
some concerning features (emergency)
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what are examples of red flag pathologies
Fracture
Infection
Malignancy
Visceral
Cauda Equine Syndrome
Cervical spine artery dysfunction, cervical instability, cervical myelopathy
83
what are rheumatological conditions
* Rheumatological diseases are usually caused by problems in the immune system, inflammation, or the gradual deterioration joints, muscles and bones.
* More than one joint affected
* Family history of RA or other rheumatological condition
* Family history of RA or other rheumatological condition
* Early morning stiffness which lasts more than 30 minutes
* Fatigue
* Swollen joints
* Joints feel better after light activity
* Uveitis, psoriasis
84
examples of rheumatic diseases
* Rheumatoid arthritis
* Osteoarthritis
* Axial spondyloarthritis (e.g. ankylosing spondylitis)
* Gout
* Psoriatic arthritis
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what is the Axial Spondyloarthritis referral criteria
* LBP starting before the age of 45, has lasted for longer than 3 months and 4 or more of the following are present:
* LBP started before the age of 35
* Waking during the second half of the night due to symptoms
* Buttock pain
* Improvement with movement
* Improvement within 48 hours of taking NSAID’s
* A first degree relative with spondyloarthritis
* Current or past arthritis
* Current or past enthesitis
* Current or past psoriasis
86
what is Axial Spondyloarthritis
Axial spondyloarthritis (axSpA) is a form of arthritis that mostly causes pain and swelling in the spine and the joints that connect the bottom of the spine to the pelvis (sacroiliac joint). Other joints can be affected as well. It is a systemic disease, which means it may affect other body parts and organs. AxSpA tends to run in families.
There are two types of axSpA:
Ankylosing spondylitis, or AS, also known as radiographic axSpA, because the damage it can cause to the sacroiliac joints and spine can be seen on X-rays.
Nonradiographic axSpA (nr-axSpA) causes damage that may not be visible in X-rays but it may show up on magnetic resonance images (MRIs)
87
What is Osteoperosis
A condition when bone strength weakens and is susceptible to fracture. It usually affects hip, wrist or spine
Reduced bone mineral density
Most common bone disease in humans
Affects women more than men
1 in 2 women > 50 will break a bone mainly as a result of poor bone health
1 in 5 men > 50 will break a bone mainly as a result of poor bone health
Most common site for osteoporotic fractures: spine, wrist, hip, pelvis
88
risk factors of osteoporosis
Female
> 50
Low body weight
Previous fracture or height loss
Smoking
High intake of alcohol
Amenorrhea
Early menopause (before 45)
Inflammatory conditions (e.g. RA, Crohn’s)
Conditions affecting hormone producing glands
Family history of osteoporosis
Long term use of medications which affect bone strength e.g. prednisolone
Poor diet lacking calcium, vitamin D, fruit and vegetables
Too much protein, sodium and caffeine
Malabsorption problems
Vitamin D deficiency
Inactive lifestyle
89
what is septic arthritis
is an inflammation of a joint that's caused by infection. Typically, septic arthritis affects one large joint in the body, such as the knee or hip. Less frequently, septic arthritis can affect multiple joints.
90
septic arthritis facts
Septic arthritis can develop when an infection, such as a skin infection or urinary tract infection, spreads through your bloodstream to a joint.
Less commonly, a puncture wound, drug injection, or surgery in or near a joint — including joint replacement surgery — can give the germs entry into the joint space.
Commonly affects knee, but can also affect wrists, ankles, hips, symphysis pubis.
Painful, red, swollen joint with reduced range of motion. May be accompanied by feeling systemically unwell and a fever
Risk factors include Inflammatory joint disease, diabetes, IV drug use, alcoholism, immunosuppression, malignancy, recent trauma or surgery
Prompt medical intervention is needed to treat and prevent joint damage
91
what is osetomylitis
Osteomyelitis is an infection in a bone.
It can affect one or more parts of a bone. Infections can reach a bone through the bloodstream or from nearby infected tissue.
Infections also can begin in the bone if an injury opens the bone to germs.
In children the growing ends of long bones are the most common site
In adults the spine is the most common site
Infection of fracture fixation devices is also possible
Patients present with fever, and pain at the infection site.
Abx +/- surgical drainage
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