BASIC PRINCIPLES OF MUSCULOSKELETAL PHYSIOTHERAPY

Lectures 1-5

Stages of healing: INITIAL TRAUMA

tensile strength of soft tissue following injury

tensile strength = max stress a material can withstand before breaking

Initial injury:

1. Immediate drop in tensile strength

2. Primary damage to myofibrils, fascia and blood vessels

3. Local bleeding (vasoconstriction follows quickly)

4. Inflammatory response (swelling and anoxia)

5. Secondary tissue swelling → goal of physio = limit further healing

healing ability and time frame depends on age, vascularity of tissue, intensity of exercise, fitness, general health

Stages of healing: INFLAMMATORY PHASE

• 1-4 days until phase complete

• Lag, acute or granulation phase

AIMS:

• seal wound

• phagocytosis

• initiate fibroblastic activity

• neurovascularisation

• establish fibrin network

Events:

• Inflammatory cells enter site (ia torn b.v.) → clean up wound

• Bleeding stimulates release of leucocytes + macrophages

• histamine released → vasodilation

• bradykinins → increase vascular permeability

• prostaglandins -. prolong vasodilation

• SWELLING

Chronic inflammation

• Repeated trauma

• Persistent irritation by chemical irritants

• Prolonged swelling

• Inadequate/inappropriate physiological response

• Increase tensile force to quickl

Stages of healing: Fibroblastic/ proliferation phase

• starts at 3-5 days → lasts 2-12 weeks

AIMS:

• Epitheliasation

• Wound contraction

• Collagen Production

Process:

• Collagen production (stimulated by fibroblasts)

• More collagen = stronger scar. Collagen III laid down first followed by collagen I which is stronger.

• Intermolecular bonds responsible for scar strength

• GAG lubricates and fills space

FIbroblastic / Proliferation stage: Immobilisation vs. mobilisation

Effects of immobilisation on healing:

• longer immobilisation = bigger scar

• Mobilisation is the mechanical stress needed to adhere the regenerating ends of the muscle to the lateral extracellular matrix

Stages of healing: REMODELING PHASE

• starts day 21 → 6-12 months

AIMS:

• strengthen scar w/o increasing inflammation

• restore normal strength, endurance + coordination

Process only starts when lysis = synthesis

• Inflammation → collagenase → increases lysis

• collagen contracts to bring regenerating ends of muscle tg

Phase complete = when functional scar formed

• scar must be: right length, non-adherent to other tissue, in line with healthy tissue, able to withstand force

Clinical implications of healing phases

INFLAMMATORY PHASE

• Initially:

  • reduce impact of injury/ from site of injury (e.g. field)

  • immobilisation/support → crutches or brace

  • Protect injury site: fibrin network

• Avoid anti-inflammatories

• Ultra sound disintegrates macrophages (non thermal)

• Reduce swelling (Peace and Love)

• No deep soft tissue work

FIBROBLASTIC/ PROLIFERATION PHASE

• movement + tension to optimize strength + reorganisation of tissue

  • motility exercises + stability & strengthening programs

  • SSTM

REMODELING PHASE

• add load + ensure length for optimal function

  • tension increased, strengthening programs increased, heating

SUBJECTIVE INTERVIEW

Goals of subjective exam

to determine:

• level of functioning (ICF)

• source of symptoms

• pathobiological mechanisms (stage of healing/ type of disorder)

• precautions and contraindications

• predisposing/contributing factors

• insight about management

1st session with patient overview

• introduction (welcome and inform)

• interview

• physical exam

• preliminary treatment and reassessment

• reflection

Subjective examination

5 parts:

• main problem (kind of disorder)

  • includes: pain, stiffness, sensation of instability, weakness, loss of function

• body chart

  • diagram/reference depicting areas of pain

  What to note:

  • area of symptoms

  • nature/quality of pain

  • depth of pain

  • severity/intensity of pain ?/10

  • constant/intermittent

  • abnormal sensation

  • relationship of symptoms/areas

  • clear unaffected areas with a tick

• behaviour of symptoms

• history

• special questions

Interpreting pain/symptoms 1

Interpreting pain/ symptoms 2

Nature/ quality of symptoms and correlation to body structures

Abnormal sensation

• anaesthesia (no sensation)

• paraeathesia (abnormal sensation (“pins & needles”)

• hypoaesthesia / hyperaesthesia (decreased / increased sensation to touch)

• analgesia (no sensation of pain)

• hypoalgesia / hyperalgesia (decreased / increased sensation of pain)

• allodynia (pain due to a stimulus that does not normally provoke pain)

Summary of body chart

• Area pain – structure

• Nature of Pain- structure

• VAS ( intensity of pain)

• Superficial or deep – structure

• Constant versus Intermittent – Inflammatory versus Mechanical

• Abnormal Sensations – structure and pain mechanisms

• Relationship between areas

Interpreting pain/symptoms 3

Behaviour of symptoms

• the symptoms that the patient feels & their changes in site & intensity need to be related to daily activities & positions, including periods of rest

• can indicate:

  • how the symptoms affect the patient’s daily life

  • the severity of symptoms

  • insight into the overall level of disability

  • precautions & contraindications

  • treatment objectives

Aggravating + easing factors

Aggravating factors:

• what aggravates the pain

• quality (slow, fast, rapid, etc.) of movement/ position

• quantity (how much/often) of movement/position

• can activity/position be continued despite pain

Easing factors:

• what/how makes main subside → do symptoms completely subside

• how long does it take to ease

• can activity/position be resumed once pain subsides

SIN (Severity, Irritability + Nature)

if patient presents 2/3, consider a SIN patient

Severity (VAS):

• pain response /10

• 0-3 = low, 4-7 = medium, 8-10 = high

Irritability:

• how quickly patients pain is provoked/ how long it lasts or to subside

• degree + quality of increased symptoms

Nature:

• how pain is generated (mechanical = movement, inflammatory = constant and worsening, neuropathic = burning/tingling, etc.)

• Pattern of pain

  • Constant vs intermittent

  • Local vs spreading

  • Superficial vs deep

24-hour behaviour (including sleep)

Morning symptoms:

• pain on waking (instabilities)

• pain getting out of bed → eases quickly = mechanical

• pain getting out of bed → lasts unusually long (2-3) = inflammatory

• ischaemic disorders (caused by reduced blood supply to tissues, leading to pain, dysfunction, and possible tissue damage due to lack of oxygen.) → require repeated movement to relieve symptoms

Evening/ night symptoms:

• pain that subsides with rest = mechanical

• pain getting into bed = inflammatory

• pain that disturbs sleep = inflammatory → may indicate serious pathology

• note effects of patients home environment and behaviour

Pain during day

• may vary depends on activity

pain diary can be useful → record symptoms over 7 days (useful if symptoms not regular)

Present history

Previous history

• no. of previous episodes

• aggravating + easing factors

• previous treatment + effectiveness of treatment

• current episode compared to previous episodes

• changes in frequency of episodes

• level of impairment, activity loss between episodes

• how pain/level of disability has developed over the years

Social history

• get to know your patient

• understand activities & participation

• interests, hobbies, sport

• psychosocial influences

Interpreting history

Contraindications to treatment

• significant trauma

• severe, unremitting night pain (cant go back to sleep)

• unexplained / sudden weight loss or weight gain

• malaise / unexplained fatigue / tiredness

• fever

• night sweats

• medication

  • steroid use

  • intravenous drug use

• cord signs

  • bilateral pins & needles in hands or feet

  • gait disturbances

• cauda equina syndrome (a medical emergency caused by severe compression of nerve roots at the base of the spinal cord, often due to a massive herniated disc, tumor, or fracture)

  • saddle anaesthesia/paraesthesia (loss of sensation when in the saddled sitting postion)

  • loss of anal sphincter tone or faecal incontinence (problems with bladder/bowel)

  • urinary retention

• special investigations

• dizziness** → possible suggest involvement with vertebral artery

• cardiac symptoms

• cancer + malignancy

Precautions

• SIN

• pathobiological processes

  • stage of healing, tissue mechanisms, pathological processes

  • stage + stability of disability

• patient at risk of developing long term disability die to pain

• psychosocial risk factors

How to identify precautions during examination

• observe: body language + posture and movements, non verbal expressions

• assess: discrepancy between pain + percieved disability, attitude of patient,

• ABCDEFW

  • attitude (pain means harm, must stop before activity, expect pain with work, can’t control it, rehab is passive.)

  • behaviour (too much rest, less activity, skipping exercise, more substances.)

  • compensatory issues (money reasons to stay off work (past claims, disability grants, lack of incentive to return).)

  • diagnostic (doctors reinforce disability, give passive care, conflicting explanations, scary language, and advice to stop work/activities.)

  • emotion (fear of pain with activity, low mood/loss of joy, anxiety about body sensations, stress/lack of control, feeling useless.)

  • family (overprotective/solicitous spouse, family discouraging return to activity/work, and lack of supportive person to talk to.)

  • work (heavy physical demands, rigid schedules, belief work is harmful, no gradual return plan, and employer disinterest.)

Interpreting red and yellow flags

Provisional hypothesis

• based on subjective interview, what is wrong with patient??

• story you start developing

Planning physical exam

• plan sequence

• any special tests?

• any positions to avoid?

• is referral needed/indicated??

OBJECTIVE EXAMINATION

objective examination musts

• ensure patient comfort + safety

• be comprehensive + standardised

• appropriate for patient + patient disorder

Components of objective examination

• Observation

• functional demonstration of functional tests

• Clearing tests of joints above and below

• Active movements

• Passive Movements

• Isometric muscle tests

• Special tests- to isolate and test for specific structures and their involvement

• Neurological tests ( Conduction and/ or Neurodynamic testing)*

• Muscle strength tests*

• Flexibility tests ( Muscle length) *

• Palpation

• Check case records & radiographs

• hypothesis planning

• treatment planning

• Warnings, instructions & recommendations to patient

Observation in objective exam - purpose + structure

Purpose:

• obtain info about functional deficits with regards to

  • posture, alignment, joint positions, local tissues

• any unusual pain behaviours noted

Informal observation:

• observe way patient moves/posture

• get feel for: attitude, willingness, quality of mvmnt + any unusual pain behaviour

Formal observation:

• posture (lat., post., ant.) → abnormalities that may/may not contribute to patients symptoms

  • change in skin (texture, colour, hairloss, swelling), muscle tone/atrophy & body alignment

• gait: willingness to walk, pain, compensatory movements→ deformities

Objective exam test procedures

• correct posture & starting position

• determine symptoms at rest before EACH test

• ensure correct movement & accuracy of testing

• test unaffected side first; then test affected side

• clearly determine patient’s response to test

• SPECIFIC

• accurate recording & documentation essential

• remember - goal is to reproduce patient’s symptoms & to establish comparable sign

Functional demonstration

Patient’s demonstration of movement/function associated with disorder

active mvmnts in WB allows assessment of:

• muscle balance

• muscle control

• neuromuscular function

• co-ordination of movement

Clearing/screening tests of other joints

• joints (& structures that refer symptoms) above + below symptomatic area to be tested

Active movements - objective assessment

assess contractile + non-contractile structures

determine:

• willingness to move

• document ROM + limiting factors (LF)

• pattern of mvmnt

• indicate pain response (VAS)

• co-ordination of mvmnt

• reproduction of symptoms

• principle of overpressure (an active movement cannot be classified as normal unless unless relatively firm overpressure can be applied painlessly)

Passive movements - objective assessment

assesses non-contractile structures + stretch contractile structures

determine:

• pain amount, resistance + spasm thru ROM

• end feel (w/ overpressure)

• document ROM, LF, end feel, pain response

• physiological & accessory movements

Passive movement end feels

Passive movements - capsular & non-capsular patterns

Capsular patterns:

• Definition: Predictable decrease in passive movement around a joint.

• Indicates: Lesion of the capsule or synovial membrane (common in arthritis).

• Features:

  • Restriction in multiple directions, each to varying degrees.

  • Each joint has a typical pattern of limitation (useful for diagnosis).

  • listen in descending order of limitation

• Causes: Degeneration, inflammation, trauma.

Non-capsular patterns:

• Definition: Restriction of passive movement not following a predictable capsular pattern.

• Indicates: Lesion in extra-articular structures (ligaments, tendons, fascia, muscles).

• Features:

  • Decreased ROM in a single movement.

  • Or restriction that does not match the capsular pattern.

• Cause: Obstruction or limitation from surrounding soft tissues rather than the joint capsule itself.

Isometric tests

assess contractile structures

• indicates muscle weakness + pain

• document muscle weakness + pain response

• isometric testing does NOT allow for grading of muscle strength

Neurological tests - integrity, neurodynamic, other

Nerve conduction (integrity)tests

• muscle tests (myotomes)

• sensation (dermatomes)

• reflexes

Neurodynamic tests

• assesses mechano-sensitivity of nerves

Other neurological tests

• CNS (babinski, etc.)

Special tests

• stress or instability tests to isolate structures (Ligaments)

• Also specific tests for menisci, capsular structures etc

• Can include

  • palpation of vascular pulses

  • compression during active or passive tests - to determine the presence of intra-articular pathology

• cardiorespiratory tests

Muscle tests

• Concentric + eccentric tests (strength)

• muscle control

• muscle length (flexibility)

• muscle bulk

• isokinetic testing

Palpation

provides info about:

• temp, swelling

• sweating

• muscle tone

• bony abnormalities or misalignments

• soft tissue thickening, tightness

End of objective interview

• reflect on findings of objective examination

• explain findings of the subjective & objective examination to the patient

• give a brief outline of management plan, including some preliminary goal setting

• warn the patient of a possible exacerbation of symptoms within 24-48 hours after the initial session

  • ask patient to monitor behaviour of symptoms

• Must have a comparable sign *– i.e. an objective measure that reproduces the patients symptoms and which you can use to monitor effectiveness of treatment

• Hypothesis – based on findings which confirms one of your provisional hypothesis and identifies:

  • structure/s involved in symptom development; stage of disorder and patho-mechanics

  • cause and contributing factors

Developing hypothesis from exam

• sources of symptoms

• precautions + contraindications

• contributing factors (intrinsic + extrinsic)

• level of disability

• management (treatments/interventions)

• prognosis