Introduction to Ortho

hypothetical deduction

decision-making models of PT; develop a hypothesis during the exam and refute/accept it during the process of examination

heuristic

decision-making models of PT; pattern recognition and the ability to lump findings into coherent groups

mixed model

decision-making models of PT; elements of hypothetical-deduction and heuristic models

threshold approach

the accumulation of information to specified level that triggers a clinician to make a decision; ex - referral to ER for urinary retention to rule out cauda equina syndrome

pathognomonic diagnosis

involves decision based on a finding that is so characteristic of a disease or an outcome that the decision is made on the spot; prompts immediate action

moderators

factors that affect clinical outcomes; influence the "effect size" that the tx has on the outcome; when stratified at baseline, help define groups that will respond to a certain tx

mediators

factors that affect clinical outcomes; alter the means by which tx affects outcomes; factors that may change with the tx and then influence the outcomes

clinical reasoning

reflective process of inquiry and analysis carried out in collaboration with the patient, their context, and their clinical problems in order to guide EBP

deductive reasoning

develop and test clinical hypotheses to confirm/negate them

inductive reasoning

coming to an understanding of the patient's perspective

diagnostic reasoning

clinical reasoning strategies; deductive - identification and validation of activity/participation restrictions, physical impairments, pathology of body structures, pain mechanisms, and the broad scope of relevant contributing factors

narrative reasoning

clinical reasoning strategies; inductive - establishing and validating an understanding of the "person" wo is the Pt; includes understanding of their story, illness experience, context, beliefs, and culture

intervention procedures reasoning

clinical reasoning strategies; deductive and/or inductive - choice and administration of interventions; reasoning related to choice of re-examination strategy for determining progress and outcomes

interactive reasoning

clinical reasoning strategies; deductive and/or inductive - strategic choices of approach and manner of interacting with patients; results in establishing rapport

collaborative reasoning

clinical reasoning strategies; deductive and/or inductive - negotiation of a working relationship, including distribution of "power" in decision making; fostering a consensual approach in interpretation of examination data, setting, and prioritization of mutually agreed upon goals and choice of intervention strategy

reasoning about patient education

clinical reasoning strategies; deductive and/or inductive - thinking directed towards approaches and strategies for educating patients; includes effective assessment of whether or not intended learning has occurred

predictive reasoning

clinical reasoning strategies; deductive and/or inductive - process of developing a prognosis; includes exploration and consideration of various choices about management and implication of those choices

ethical reasoning

clinical reasoning strategies; deductive and/or inductive - recognition and resolution of ethical and pragmatic dilemmas in daily practice; results in doing the right thing

over-focus on early/superficial recognition

clinical reasoning errors; acceptance of an assessment based on superficial similarity to familiar case

premature anchoring

clinical reasoning errors; fixation on first impressions (unaltered with new or conflicting information)

premature closure

clinical reasoning errors; acceptance of a dx without adequate consideration of likely alternatives

framing effect

clinical reasoning errors; a decision influenced by perception of relative risk, whether risk is presented in a positive or negative light, and/or based on a tendency to avoid versus seek risk

commission bias

clinical reasoning errors; deciding to do something regardless of evidence that would contradict the decision

extrapolation error

clinical reasoning errors; inappropriately choosing to do something that was done in a dissimilar situation or group

confirmation bias

clinical reasoning errors; a tendency to look for, notice, and remember only the information that fits with pre-existing expectations

outcome bias

clinical reasoning errors; a tendency for an overreliance on outcome information to indicate accuracy or quality of the clinical reasoning that determined the choice of intervention

examination

the gathering of information in order to identify/define the patient's problem(s); ongoing process

evaluation

making sense of the findings in order to identify a relationship between the symptoms reported and the gathered information

pain

an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage

nociception

neuronal response to intense stimuli, ie, action potentials in nociceptive neurons; the perception of pain may be the consequence of this stimuli but pain is subjective and can be experienced in the absence of this

musculoskeletal

MUSCULOSKELETAL/SYSTEMIC pain - usually decreases with cessation of activity

musculoskeletal

MUSCULOSKELETAL/SYSTEMIC pain - generally lessens at night

musculoskeletal

MUSCULOSKELETAL/SYSTEMIC pain - aggravated with mechanical stress

musculoskeletal

MUSCULOSKELETAL/SYSTEMIC pain - often inconsistent or variable

systemic

MUSCULOSKELETAL/SYSTEMIC pain - less responsive to activity

systemic

MUSCULOSKELETAL/SYSTEMIC pain - disturbs sleep

systemic

MUSCULOSKELETAL/SYSTEMIC pain - less aggravated with mechanical stress

systemic

MUSCULOSKELETAL/SYSTEMIC pain - can be constant or in wavelike pattern

paresthesias

numbness, pins and needles, tingling without external stimulus

cancer red flags

persistent night pain, constant pain, unexplained weight loss of >10 lbs in 2 weeks or less, loss of appetite, lumps/growths, unwarranted fatigue

cardiovascular red flags

SOB, dizziness, chest pain/heaviness, pulsating pain, constant/severe pain in leg or arm, discolored or painful feet, unwarranted swelling

GI red flags

frequent/severe abdominal pain, frequent heart burn/indigestion, frequent nausea/vomiting, change in B/B function, unusual menstrual irregularities

neurological red flags

changes in hearing or vision, unwarranted frequent severe HAs, changes in speech/swallowing, problems with balance, coordination or falling, fainting spells, sudden weakness

miscellaneous red flags

fever or night sweats, severe emotional disturbances, unwarranted joint redness/swelling

concordant signs

familiar signs and symptoms that are to be reproduced during the examination

distal

PROXIMAL/DISTAL palpation is more valid

0

grading tenderness to palpation - no tenderness

1

grading tenderness to palpation - TTP without grimace/flinch

2

grading tenderness to palpation - TTP with grimace/flinch

3

grading tenderness to palpation - TTP and withdrawal

4

grading tenderness to palpation - withdrawal to non-noxious stimulus

selective tissue tensioning

clinical evaluation aimed at placing stress on tissues to try to isolate the "key lesion"; reproducing symptoms is critical

AROM, PROM, resisted tests

List the three components of selective tissue tensioning.

AROM

component of selective tissue tensioning; tells us willingness to move, quality of movement, adequate power, presence of painful arc, substitution/compensations; structures involved can be inert or contractile tissues

contractile lesion presentation

painful arc + painful resistive test

inert lesion presentation

painful arc + negative resistive test

inert

INERT/CONTRACTILE structures: bone, ligament, capsules, fascia, bursae, nerve, dura mater

contractile

INERT/CONTRACTILE structures: tendon, tenoperiosteal junction, myotendonous junction, muscle belly

PROM

component of selective tissue tensioning; primarily stressing inert, non-contractile tissues; not worthwhile in spine; assess available range, end-feel, pain-resistance sequence, capsular patterns

pain-resistance sequence

the relationship of onset of pain with onset of resistance at the end of the PROM; gives insight to acuity of inflammatory process

overpressure

provides end-feel assessment opportunity, and informs you about how willing the patient is to engage end-range of ROM

end feel

sensation imparted to practitioner's hand when an overpressure is applied at the end of PROM

capsular at end of normal range

end feel definition - hardish arrest of motion with some give to it, feeling like thick leather being stretched or as if 2 pieces of tough rubber were being squeezed together

capsular early in range

end feel definition - same sensation for capsular end-feel but occurring prior to expected ROM

tissue approximation

end feel definition - motion ends with a sensation suggesting that motion could continue if not stopped by one body part contacting another

bone to bone

end feel definition - an abrupt halt to movement as when 2 hard surfaces meet

springy block

end feel definition - a noticeable rebound is seen and felt at the end of motion

spasm

end feel definition - a vibrant twang suggesting that muscles have actively or reflexively acted

empty

end feel definition - pain occurs before the end of motion and the patient asks for the motion to stop; the examiner feels no resistance

no pain

PROM pain-resistance sequence definition - no pain is reported by the patient when the examiner moves the part to the extreme of range

pain after resistance

PROM pain-resistance sequence definition - the examiner feels resistance that signals the approach of extreme range, but the patient reports little pain when the joint is moved further

pain with resistance

PROM pain-resistance sequence definition - pain is reported by the patient at the same time resistance is felt by the examiner

pain before resistance

PROM pain-resistance sequence definition - pain is reported by the patient well before the examiner reaches the extreme possible range

reactivity

the irritable response to a given movement

low

LOW/MEDIUM/HIGH reactivity - pain only with stretch at end of motion

medium

LOW/MEDIUM/HIGH reactivity - pain and end feel occur relatively simultaneously

high

LOW/MEDIUM/HIGH reactivity - pain felt before end of available motion

capsular pattern theory

proportional limitations of expected joint motion indicative of "total joint pathology," typically arthritic or inflammatory processes

no inert lesion

classic pattern of inert tissue - pain free, full ROM

total joint pathology (arthritis, synovitis, capsulitis), capsular patterns may arise

classic pattern of inert tissue - painful, limited ROM in all directions

non-capsular patterns due to problems such as ligament sprain or capsular adhesion

classic pattern of inert tissue - painful, altered (limited or increased) ROM in some directions

often means symptomless OA (osteophyte blockages)

classic pattern of inert tissue - pain free, limited ROM

resisted isometric tests

done to assess and/or symptomatic involvement of contractile unit; test in mid-range position!

normal

strong and painless resisted isometric: musculoskeletal

normal

strong and painless resisted isometric: neurological

minor lesion (tendinitis, strain)

strong and painful resisted isometrics: musculoskeletal

normal

strong and painful resisted isometrics: neurological

ruptured muscle or tendon tear, avulsion, deconditioning, myopathy

weak and painless resisted isometric: musculoskeletal

neuropathy or nerve compression

weak and painless resisted isometric: neurological

recent tear/damage

weak and painful resisted isometric: musculoskeletal

serious pathology (infection, etc.)

weak and painful resisted isometric: neurological

overuse syndrome

painful on repetition resisted isometric: musculoskeletal

spinal stenosis, vascular claudication

painful on repetition resisted isometric: neurological

osteokinematics

joint mobility - gross limb movements relative to the body or other external reference; typically measured with a goniometer, inclinometer, etc. (ex: knee flexion)

component motions

arthrokinematics/accessory motions - motions taking place in a joint (or multiple joints) to facilitate a particular active or passive motion

joint play motions

arthrokinematics/accessory motions - motions not under voluntary control that occur only in response to outside forces (ex: ligamentous stress testing, ground reaction forces)

Kaltenborn's concave-convex theory

joint surface geometry dictates the accessory motions, irrespective of active or passive contributions; not universally applicable to all regions (modest supporting evidence at knee and ankle)

same

If concave partner is moving on the stable convex surface, then the roll and slide occur in the SAME/OPPOSITE direction.

opposite

If convex partner is moving on the stable concave surface, then the roll and slide occur in the SAME/OPPOSITE direction.

moves, remains the same

When the concave surface is moving the treatment plane REMAINS THE SAME/MOVES, but when the convex surface is moving the treatment plane REMAINS THE SAME/MOVES.