Passive Care - Exam 3 (Final)

Inflammatory phase (acute phase)

immediate - a few days

essential

purpose: defend against foreign intruders, removing damaged tissue/debris, immobilize area

Joint effusion

contained by joint capsule

feels like a water balloon

moves when palpated then returns

Edema

fluid in interstitial space

pressure on tissue w/finger = dent/pit remains

measurement of edema w/circumference is reasonable accurate and correlates well w/CT scans

Acute treatment - PRICES

protect, rest, ice, compress, elevate, support

Acute care

protect

rest - protects from further injury and inflammation, conserves energy needed for healing

ice

Compression

decreases edema and bleeding

mechanical support

external compression

internal compression

External compression

wrap distal to proximal

adding horseshoe (U) or J shaped felt pad held in place with elastic wrap increases compression

throbbing = too tight

Purposes for external compression

pushes fluid toward heart (therapeutic and prophylactic for DVT and VTE)

pushes arterial blood into extremity (ischemia, intermittent claudication)

Internal compression (lymph vessels and veins)

muscle contractions

ROM, pumping ankles, alphabet, isometrics

Intermittent compression

acute or chronic edema

mechanical device (pneumatic) - inflates to compress part

can be combined with cooling

Intermittent sequential graded compression

Most Common

3 parts - distal, intermediate, proximal

inflated for minutes then deflated (repeated for hours per day)

Elevation

gravity augments lymph flow

elevation above heart level significantly reduced edema in 20 min

dependent position increases edema

PRICE Support

nutritional - vitamins, anti-inflammatory diet

education - acute injury, ADLs, spine sparing, chiropractic

referral for emotional support - psychology

bracing, taping, crutches, canes

Taping and bracing (little research)

effective for acute support

athletic tape (white tape) stretches in 20-30min

bracing may inhibit muscle action

Ambulatory Aids

support or assist when pt is unable to walk or bear weight on one extremity

localized rest to lower extremity

still maintain partial weight bearing

Fitting cruches

low heeled shoes, stand w/tall posture, feet close together

crutch tip = 6” lateral to shoes, 2” in front of shoe

arm brace = 1-2” below axillae

hand brace = elbow flexed 30 deg

Crutch palsy

pressure on axillary nerves and vessels

temporary or permanent numbness

Walking w/crutches

nonweight bearing = tripod gait

partial weightbearing = tripod or 4pt gait

always use upright spinal posture

discourage pt from resting on underarm braces

Tripod gait (non-weightbearing)

affected foot fully elevated

crutch tips move 12-15in ahead of feet

lean forward and straighten elbows + pull underarm brace firmly against torso

swing both legs btw crutches, step onto unaffected foot

Tripod gait for partial weight bearing (four point gait)

affected leg and crutches move forward together (partial weight placed on affected leg)

swing through w/body and unaffected limb

Swing-to gait

bring foot to crutches

easier, less coordination

Swing-through gait

foot lands in front of crutches

faster, more coordination

Up and down stairs w/crutches

Handrail gait (preferred, safer) - both crutches under 1 arm away from railing on affected side

• UP - unaffected leg steps first, crutches and affected leg follow

• DOWN - crutches down first, affected leg down, unaffected leg down

Tripod gait - if no handrail/curbs

• UP - unaffected leg steps first, crutches and affected leg follow

• DOWN - crutches and affected leg down first, unaffected leg follows

Fitting a cane

wearing low-heeling street shoes

cane length = superior aspect of greater trochanter of femur

cane used on OPPOSITE side of involvement and moves WITH involved side

Scoliosis braces

TLSO - thoraco lumbo sacral orthosis

CTLSO - cervico thoraco lumbo sacral orthosis

Boston brace/ Under arm brace (TLSO)

for thoracolumbar scoliosis

fitted to child’s body and is custom molded to individual

worn under clothing for at least 23hr a day

Milkwaukee brace (CTLSO)

for thoracic scoliosis

similar to Boston brace but includes neck ring

worn for at least 23hr a day

Charleston Bending brace

night time brace (only used during sleeping hours)

molded to pt while they are in side flexion to give added pressure

Bracing for spinal fractures

Jewett brace, TLSO, Extension (hyperextension), Voight-Bahler

Trochanteric/Sacroiliac Belts

support and compression of SI joints and pelvis (force closure)

causes gapping of SI joints if worn over trochanters

pregnant and PPD females w/SI joint pain

Lumbar supports

weak evidence that they benefit reducing the risk of re-injury

give the impression that an individual can lift more

should be worn temporarily

pt w/HTN and high HR = cardiac risk

Knee braces

feel more stable (doesn’t improve stability objectively)

slows hamstring reflexes (elastic taping improved this)

protects from lateral blows

Neoprene sleeves keep muscles and joint warm (no injury prevention)

Cho-Pat

Knee = Osgood Schlatter’s

Elbow = epicondylitis

Tape/Pre-wrap strap

Walking boot

fracture, severe sprain, post surgical

full immobilization with weight bearing

Ankle stirrup

allows flexion/extension but no inversion/eversion

Orthopedic (fracture) shoe

fractured toe

rigid sole

protect from re-injury/aggravation

Plantar fasciitis

thermoskin plantar FXT night splint

passive night splint

strassbrurg sock

Cervical pillows (little research)

positive results on pain

mixed results on disability

Philadelophia collar

rigid, prevents motion, stabilization, slight distraction

Soft cervical collar

“reminder”

limit cervical motion (doesn’t limit rotation)

following sprain/strain injuries

Wrist braces

cock up splint, neutral, or flexion (depends on “spoon”)

used for sprains and carpal tunnel

Kinesio tape

tx of muscular disorders and lymphedema reduction

taping over/around muscle to assist/support or prevent over-contraction

acutely = helps prevent overuse and facilitates lymph flow

patellar malalignment, osgood-schlatters, lymphatic drainage (URI), plantar fascia + gastroc tightness

Manual therapies

massage

various release and digital compression techniques

instrument assisted soft tissue techniques (Graston, FAKTR, Trigger point)

Massage

rubbing, kneading, stroking superficial parts of body w/hand or instrument

purpose = modifying nutrition, restoring power of movement, breaking up adhesions

Physiologic effects (hands on therapy) of massage

increased blood flow, dilation of lymphatics, removal of lactic acid

sedation and muscle relaxation

increase dispersion of waste products from increased circulation

loosens adhesions and softens scars

Indications of massage

superficial adhesions, circulatory stasis, congestion

edema and joint swelling and stiffness

myalagia/trigger points

tension headahces and postexertion fatigue

Contraindications of massage

arteriosclerosis, thrombosis/embolism, sever varicosities

acute phlebitis, cellulitis, synovitis

abscesses and skin infections

acute inflammatory conditions

Effleurage

long stroking motions (superficial and deep)

applied w/palm of hand or flats of fingers

parallel w/orientation of fibers of targeted muscle tissue

Petrissage

kneading muscle w/one or both hands

pulling tissue up with fingers and hand (squeezing, pinching, rolling)

Tapotement or Percussion

series of rapid blows

rhythmic mechanical motion over tissue

• tapping w/tip of fingers

• hacking w/ulnar border of hand (chopping)

• slapping w/fingers

• cupping w/hands

Manual vibration (distal to proximal)

shaking/trembling of underlying tissue

keep hand in contact w/skin and muscle

quick back and forth motion

perpendicular to orientation of targeted muscle fibers

Mechanical vibration

deep, rapid, short duration percussion

use mechanical vibratory device (G5, Genie rub, Thumper)

devices have gently contoured surface or attachments

variable speed

Effects of frequency of mechanical vibration

High - analgesia, decrease trigger points, pre-exercise warm up, relax spasticity, superficial circulatory stimulation

Low - decrease congestion, edema, stasis, milk tissue, postural drainage

Treatment times of vibratory massage

Localized treatments - 0-10 min

Trigger points - 6-8 min

Muscle relaxation - 0-10 min

Postural drainage - 0-15 min

General body relaxation - 5 min

Cross-Friction Massage

used over ligaments, tendons, muscles

small treatment area

used to - loosen scar tissue and adhesions, aid in absorption of local edema/effusion, mobilize ligaments/tendons/scars, restore mobility and extensibility

Cross-Friction technique

hand/finger position depends on area (stays in contact)

place tissue on slight stretch

massage directly over lesion or pain

perpendicular to orientation of tissue fibers and sweep full width of tissue

Tx time = 7-10 min (or until numb)

Trigger point therapy

focus of hyperirritability in muscle or fascia which produces local and referred pain

Rope sign and Twitch response are not elicited in normal muscle tissue

Rope sign

taught band of fibers which can be snapped like a rope causing hyper-excitability in surrounding musculature (twitch response)

Treatment of Trigger points

Nimmo Technique

Trigger point therapy

• Ichemic compression - digital pressure applied for 1min or series of 7-10sec

• Stripping - sliding along tissue w/increasing pressure, pause over trigger point

• Spray and Stretch (Trevell) - vapocoolant spray combined w/stretching

Myofascial release

applying pressure to tendons, ligaments, fascia, nerves while actively/passively moving the tissue

Active Release Technique (ART)

restore strength, flexibility, motion and function to soft tissues

release entrapped nerves, circulatory structures, lymphatics

concentrates on tissue (texture, tension, movement, function)

over 700 specific protocols

Rolfing Structural Integration

goal is to balance the body within a gravitational field (alter pt’s posture and structure)

deep massage without lubricant

Instrument assisted soft tissue mobilization

allow deeper pressure (less stress on hands/thumbs)

trigger point therapy (T-bar)

FAKTR and Graston (localized inflammation reaction to speed healing, break up scar tissue, loosen adhesions)

FAKTR-PM (functional and kinetic treatment w/rehab)

Functional - treat during function, not just static

Kinetic - assess and use entire kinetic chain

Treatment - variety of soft-tissue techniques

Rehab - incorporate resistance + proprioceptive ex

Provocation - reproduce pain + treat

Motion - treat w/motion if more painful

Indications for Instrument assisted soft tissue mobilization

Tendinopathies (tennis elbow, RC, achilles tendinopathy, patella tedinopathy)

Fascial syndromes (ITB syndrome, trigger finger)

Entrapment syndromes (CTS, TOS)

Ligament pain (MCL sprain, ankle sprain, AC ligament sprain)

scar tissue/adehsions

edema

FAKTR treatment

treatment in position of provocation (single plane, coupled)

treat in motion of provocation (single plane, coupled)

treat w/resistance (static, motion, concentric/eccentric)

treat w/functional positions (any kinetic chain activity, w or w/o resistance)

treat w/any of above with added proprioception (oscillation/vibration, unstable surfaces)

SASTM

sound assisted soft tissue mobilization

Traction

drawing or pulling apart of a body segment

spinal traction (traction forces applied to cervical and lumbar spine via various mechanical systems

Types - manual, positional, mechanical, inversion

Positional traction

knee to chest

side lying on a roll to open an IVF

Inversion traction

not recommended

contraindications - heart disease, HTN, glaucoma, sinus infections, asthma, migraines, detached retina

Indications for spinal traction

neck and low back disorders

disc protrusion/herniation

nerve root impingement

joint hypomobility

arthritis conditions of facet joints

Contraindications to traction

infection, inflammation, tumor

fracture/dislocation, severe disc herniation

VBI, spinal stenosis, aortic aneurysm

abdominal hernia, HTN, pregnancy

Risks for traction

pain exacerbation

hx of spinal surgery

spondylolysis and spondylolisthesis

HTN and respiratory disorders

dentures and TMD

Static vs Intermittent Traction

static - constant pull

intermittent - may be more tolerable, periodic max and min, relax phase shorter

Total tx time = 10-30min

Mechanical traction

cervicals - over the door pulley system, 10-30% body weight

lumbars - 2 harness (pelvic and thoracic), pt position w/hips and knees flexed

flexion-distraction - cox technique

Pain

unpleasant sensory and emotional experience associated with actual/potential tissue damage

affects entire organism, altering physical and psychological processes

Categories of pain

Nociceptive (somatic or visceral)

Neuropathic (peripheral or central)

Psychogenic

Carcinogenic

Response to injury

Kubler-Ross death and dying model

• 5 stages = denial, anger, bargaining, depression, acceptance

Cognitive Appraisal model

response to injury depends on understanding of injury

response doesn’t neatly divide into stages in a particular order

response to injury can be influenced by actions and message of doctor

ability to cope is influenced by family, friends, co-workers, stress level, knowledge

Chiropractors reduce pain by

removing subluxations - restoring joint motion, alignment, nervous function

EPAs - therapeutic exercise, reduce symptoms to allow functional recovery

MC use of therapeutic modalities is to

reduce pain levels

Peripheral sensory receptors

special - sight, taste, smell, hearing, balance

visceral - hunger, nausea, distension, visceral pain

superficial - mechanoreceptors and thermoreceptors

deep - proprioceptors and nociceptors

Transduction

process of changing energy of nociception into electrical action potential in the neuron

• nociceptors normally have a high threshold

Superficial sensory receptors - Mechanoreceptors

Meissner’s + Pacinian corpuscles = pressure and touch

Merkle cells + Ruffini endings = skin stretch and pressure

Superficial sensory receptors - Thermoreceptors

Cold receptors and Hot receptors = temp and temp changes

Deep sensory receptors - Proprioceptors

Golgi tendon organs = change in muscle length and tension

Pacinian corpsucles = change in joint position + vibration

Ruffini endings = joint end range and possible heat

Deep sensory receptors - Nociceptors

free nerve endings = pain

Peripheral transmission

first order afferent (peripheral nerve fiber)

cell body in DRG and synapse in spinal cord

First order peripheral nerve is typed according to structural and functional characteristics

diameter of nerve (velocity of transmission)

degree of myelination (velocity of transmission

function of nerve (type of information carried by nerve

A-beta fibers (myelinated)

hair follicles, Meissners, Pacinian, Merkle, Ruffini

in skin

touch, vibration, hair deflection

A-delta fibers (thinly myelinated)

warm and cold receptors, hair follicles, free nerve endings (pricking/pinching/crushing)

in skin

touch, pressure, temperature, pain

What is the smallest peripheral nerves associated with pain

C fibers

C fibers (unmyelinated)

efferent postganglionic fibers of sympathetic NS, mechanoreceptors, nociceptors, thermoreceptors

in muscle and skin

touch, pressure, temperature, pain

Central transmission

first order neuron synapses in dorsal horn of SC

cell body of second order neuron (T cell) found in dorsal horn

cell body of third order neurons found in thalamus (VPL and VPM)

VPL of thalamus

ascending pain fibers from body synapse

VPM of thalamus

fibers from head and face synapse

Thalamus

modulates input and transmits to somatosensory cortex

relays to the limbic system (emotion, autonomic, endocrine)

Modulation phase

any activity after the cortex has received input

excitatory or inhibitatory role

hypothalamus, pituitary, reticular formation, Raphe nucleus

Network of messages and activation of brain centers may exacerbate the painful event and lead to

windup

Peripheral pain modulation

targeted at desensitizing of peripheral nociceptors (increases threshold)

may decrease effects of chemical mediators in inflammatory process

ice