PT 606 FINAL

job of the bursae

prevent rubbing between supraspinatus and superior acromion

- reduce friction

- non-contractile tissue

Causes of adhesions

Collagen loses its elasticity and ability to glide due to adhering to surrounding structures

- not mobilized in a timely manner and cause adhesions in a nearby structure

Contracture

adhesive tissue shortening, long-term, ADAPTIVE, permanently shortened

- hypOmobility

Synvitis

inflammation of a joint

Hemarthrosis

bleeding within a joint

Contusion

capillary rupture, bleeding due to direct blow

- present in soft tissue

- SEVERE tissue compression

Ganglion

fluid-filled cyst; along a tendon

NON-contractile

capsule, ligaments, bursa, labrum

Contractile

muscle and muscle-tendon unit

Capsular pattern

predictable loss of ROM; proportional

NON-capsular pattern

no pattern, no predictable loss

Contents of the subacromial space

Supraspinatus tendon

Infraspiantus tendon

Teres minor tendon

subscapularis tendon

biceps tendon

transverse humeral ligament

subacromial burse

Primary impingement

> 35 years old

structural, anatomical

Fault or abnormality

Example of primary impingement

- altered acromial shape

- thick coraci-acromial ligament

- inflammation/thickening of tendons

- inflamed RC tendons

Secondary impingement

late teens- 20s

vigorous overhead activities

biomechanical, muscular weakness, altered muscle timing, postural impairment

Example of secondary impingement

-rotator cuff weakness

-scapular muscle weakness

- altered force couples

- postural impairment

- posterior capsule tightness

- excessive thoracic flexion

Prognostic factors that impact healing (negative)

Age >70

Tear size

Fatty deposits

low bone mineral density

high physical activity

Comborbid factors impacting healing

CVD, smoking, diabetes

Circulation of lymph

secrete fluid into the interstitial space (Start)

Once fluid enters the lymphatic vessels, it is known as _____

lymphatic fluid or lymph

Composition of lymph

rich in

- protein

- white blood cells

- fat

- metabolites

- waste products

________% of fluid from the arteries into the interstitium is reabsorbed by the venous system, the remaining _____% returns via the lymphatic system

90% is reabsorbed by the venous system

10% returns via the lymphatic system

Lymph moves both ways or just one way?

ONE WAY! from the interstitial spaces to the subclavian veins at the base of the neck

The pathway of lymph

lymphatic capillaries --> collectors --> lymph nodes --> trunks --> lymphatic ducts -->subclavian vein

What does lymphatic flow rely on?

Intrinsic muscle contractions (within the vessel walls)

- occurs at a rate of 6-10 times per minute

what increases lymphatic flow

heat, exercise, inflammation

Circulation of lymph

Arterial blood -->

supplies nutrients and O2

-->

tissues and organs -->

excess fluid + waste + protein + fats -->

interstitium --> lymph vessels --> lymph --> veins

Functions of lymph

maintains healthy connective tissue

removes fluid, foreign particles, proteins, and fats from tissue (return to blood stream)

protects the body from infection and disease

Lymphedema

abnormal accumulation of protein-rich fluid in the interstitial tissues (leading to swelling)

- most common in the extremities

Lymphedema occurs when ______ exceeds ______

when lymphatic load (LL) exceeds the transport capacity (TC)

lymph time volume

the amount of lymph transported per unit of time

transport capacity (TC)

the maximum lymph time volume

Pathology of lymphedema

impaired lymphatic system = buildup of protein molecules in the interstitium = too large to pass = physiological changes in the tissue (overtime) = fibrosis and continuous pull of water into the interstitum

Dynamic insufficiency

when a healthy lymphatic system is overladed

dynamic insufficiency examples

sprained ankle, DVT, cardiac edema resulting in low protein edema

Mechanical insufficiency

when the lymphatic system is diseased, resulting in a high-protein edema

primary lymphedema

hereditary, congenital

- too few or abnormal lymph vessels

Secondary lymphedema

caused by damage, inflammation, or blockage of lymph vessels

- surgery

- infections

- tumors

- radiation

- filariasis

stages of lymphedema

Subclinical (stage 0)

Stage I

Stage II

Stage III

Subclinical, stage 0 (lymph)

feeling of heaviness in the limb without visible swelling

Stage I (lymph)

pitting edema is present, high water content, swelling reduced with elevation; it is reversible

Stage II (lymph)

non-pitting edema is present, not reduced by elevation, with moderate to severe clinical fibrosis

Stage III

Elephantiasis, skin changes, and lobules are present

Venous edema

hemosiderin staining, fibrosed/brawning subcutaneous tissue, pitting, atrophic skin, malleolar ulcerations

Cardiac edema

swelling greatest distally, sudden weight gain, bilateral nad symmatrical pitting, decrease with elevation

lipedema

occurs in women, bilateral symmetrical swelling from iliac crest to ankles

(Dorsum of foot NEVER involved; little to no pitting, painful to palpation and bruises easily)

Diagnosis of lymphedema

Lymphography

Doppler ultrasound

CT

MRI

- must rule out DVT, malignancy, cardiac issues

Compression garments

custom made garments (similar to short-stretch bandages)

- worn during the day

- recommended 20 hours per day

Classes of compression garments

Class I: 20-30 mmHg

Class II: 30-40 mmHg

Class III: 40-50 mmHg

Class IV: 50-60 mmHg

Complex Decongestive Therapy (CDT)

Phase I = reductive phase

Phase II = maintenance phase

Pneumatic compression

- inflates from distal to proximal (wave of pressure to move fluid)

- 80-110 mmHg for 4-8 hours

pros and cons of pneumatic compression

P

- used for patients unable to attend treatment or bandage, minimal fibrotic changes, use is controversial

C:

- can cause fibrotic bands, does not address truncal edema, can cause genital edema, patient is inactive

Contraindications for CDT

General

- acute infection

- cardiac edema

- malignant disease

Compression

- arterial disease

- CHF

- HTN

- Diabetes

- sensory neuropathy

MLD

- pregnancy

- recent surgery

- cardiac arrhythmias

- Congestive heart failure

General precautions for lymphedema

- avoid extreme hot (climates, showers, baths, saunas)

- no BP cuffs on affected side

- mani/pedi at salon

- insect bites, needle punctures, cuts, deep massage

Decongestive exercise

walking/cycling

arm ergometer

the limb must be wrapped

Sensitivity

ability of the test to obtain a positive test when the target condition is present (true positive)

Sensitivity calculation

Sensitivity = A / A+C

(LEFT column)

Specificity

ability of the test to obtain a negative test when the condition is absent (true negative)

Specificity calculation

D / B + D

(right column)

Specificity/sensitivity table

Left column = sensitivity

Right column = specificity

PPV =

A/A+B

(true positive / true positive + false positive)

NPV =

D/C+D

(true negative / true negative + false negative)

Prevalence calculation

A+C/A+B+C+D

Likelihood ratios

Large +LR = ruling in the condition (+LR>1)

Small -LR= ruling out the condition (-LR<1)

Close to 0 = no diagnostic value (LR=1)

"SPIN"

Spin = specificity = rule IN

"SNOUT"

Snout = sensitivity = rule out

AROM

stresses contractile and non-contractile tissues

PROM

stresses non-contractile tissue

Resisted ISO

assess the neuromuscular system

joint play

stresses non-contractile tissue

Weak and painful

Contractile

Strong and painful

minor contractile

Weak and painless

neurological impairment, complete contractile tissue rupture

Pain with repitition

vascular insufficiency

Strong and painless

Normal

"itis"

inflammation

"opathy"

degenerative

Arthrokinematics

Roll

Glide/Slide

Spin

Convex on Concave

Gliding/sliding in the OPPOSITE direction as the movement of the bone

Concave on convex

sliding/sliding in the SAME direction as the angular movement of the bone

Glide/slide

applied parallel to the treatment plane

- unweight joint (grade I distraction) prior

Distraction technique

applied perpendicular to treatment plant

GH joint Arthrokinematics

CONVEX humeral head

CONCAVE glenoid fossa

GH resting position

55 ABD

30 Horiz. ADD

Slight ER

GH posterior glide

IR

Flexion

Horizontal ADD

GH anterior glide

ER

Extension

Horizontal ABD

GH inferior glide

ABD

flex

GH Distraction

all motions, entire joint capsule

Contraindication/precautions for joint mobilization

-unstable/hypermobile

-recent fracture

- open epiphyseal plates

- joint effusion

- weakened skin

- weak bone

- local infection

- inability to relax

Joint mob assessment

Quality (crepitus, edema)

Quantity (hypomobile, hypermobile, normal)

Symptoms (pain, stiff, apprehension)

End feel (firm, hard, empty)

treatment grades

Resistance free range

tissue resistance range

R1

R2

Anatomical limit

resistance free range

no tissue resistance

tissue resistance range

the range where there is limtation to movement for the articular surface

R1

initial tissue resistance (take up slack)

R2

tissue resistance

Anatomical limit

articular end point

pain dominant

loose packed position

grades I and II

Sustained or oscillatory

stiffness dominant

end ROM (before pain)

Grades III or IV (oscil)

Grades II or III (sustained)

effects of joint mobilization intervention

- promotes synovial fluid movement

- mechanical stretch/distension

- stimulates mechanoreceptors

- incr. blood composition

- change in alpha motor neuron activity

- change in automatic response

Static/passive stability

NON-contractile tissue

- ligaments, joint capsule, labrum