Intro to MSK - Lecture 2

diagnosis

a label encompassing a cluster of signs and symptoms commonly associated with a classification, disorder or syndrome or category of impairments in body structures and function, activity limitations, or participation restrictions

pain mechanism classifications

nociceptive, peripheral, central sensitization

nociceptive pain

activation of peripheral nociceptive fibers; Chemical (inflammatory), mechanical, or thermal stimuli

peripheral neuropathic pain

Lesion or dysfunction in peripheral nerve, dorsal root ganglion, or spinal nerve root arising from trauma, compression, inflammation, or ischemia

central sensitization pain

•Amplification of neural signaling within CNS that elicits pain hypersensitivity

•Net effect is danger signals are magnified, more intense, & longer lasting; receptive fields of central neurons are expanded & threshold lowered for transmission

nociceptive pain is typically associated with

acute NMS injury or post-op

peripheral neuropathic pain is usually associated with

nerve root entrapment or more distal peripheral nerve sx

central sensitization pain can be associated with

chronic pain syndrome

impairment-based dx; relevant impairments =

contributing factors

Identify which impairments are

related to the patient’s functional (activity) limitations

Relevant impairments = contributing factors

They guide intervention

Treat impairments and Reassess

potential impairments

sensory (pain, loss of sensation, proprioception)

respiration (abnormal breathing patterns)

ergonomics

aerobic capacity/endurance (walking distance)

cranial and peripheral nerve integrity

attention & cognition (fear, decreased motivation, stress)

circulation impairments(abnormal elevation of HR w/activity)

difficulty moving (motor control, joint mobility, muscle quality)

difficulty moving can be due to…

pain, weakness, decreased ROM (joint hypomobility or soft tissue quality/muscle length)

generation and coordination of movement patterns produce

function

pain changes the way the brain

programs movement

altered movement can cause

pain and or weakness

decreased range of motion only matters if it matches

the c/c

for ROM, test

PROM, AROM, PAM

treatments for joint ROM

joint mobilizations and excercise

contracture

true adaptive shortening of skin, fascia, muscle or joint capsule

adhesions

abnormal adherence of collagen fibers to surrounding structures

trigger points

hyperirritable nodule within taut muscle band; local pain and referred pain can be reproduced via palpation

causes for soft tissue hypomobility

contracture, adhesions, trigger points

using best current evidence, clinical practice guidelines make recommendations for:

exam (tests and measures)

dx classifications

prognosis

intervention

outcome assessment

clinical practice guidelines focus on

structures, function and pain categories related to movement

clinical practice guideline pros

• summarize a large quantity of research

• grades quality of evidence

• makes recommendations for exam and treatment

• assists PT and patient in decision about appropriate health care

clinical practice guideline cons

• tells you very little about the pt. in front of you

• does not take into account other pillars of evidence-informed practice (clinician experience, pt. values/expectations)

• high threshold for inclusion

pillars or evidence informed practice

• clinician experience

• pt. values/expectations

• best evidence

diagnostic classifications - LBP with mobility defcits

soft tissue, joint, nerve

diagnostic classifications - LBP with movement coordination deficits

motor control, muscle activation, timing

diagnostic classifications - LBP with muscle performance deficits

strength, endurance, power

treatment based classifications existed

prior to CPGs

treatment-based classification clusters

signs and sx of patients who benefit from a certain type of treatment

research exists for treatment-based classification only for

lumbar and cervical regions

treatment based classifications for LBP

• manipulation

• stabilization exercise

• directional preference

• traction

medical diagnosis AKA

pathoanatomical or structural

medical dx is ____ based; addresses ____

pathology; tissue pathology

a medical diagnosis addresses tissue pathology:

• structural/functional change in tissue

• signs and sx determine pathology

• if tx improve, the signs/sx disappear

non MSK pathology

cancer, diabetes mellitus, heart disease

NMSK pathology

fracture, dislocation, degenerative arthritis, ACL tear, radiculopathy, myelopathy, ligamentous sprain, muscle strain, stenosis, osteoarthritis, etc.

the medical model can help with PX, but not always;

sometimes difficult to find relevant pathology

using the medical model, even if you can DX the structural anatomical pathology, often does not provide;

Tx guidance

the medical model provides a medical perspective on condition which we need to know to plan;

intervention as well as precautions or contraindications

MOI - macrotrauma

trauma causing immediate, noticeable injury (sprain, strain, dislocation, fx)

MOI - microtrauma

repetetive loading, excessive compression or tensile strain; over-training, improper training, muscle imbalances, poor movement patterns or ergonomics

overview of NMSK medical dx

• ligamentous sprain

• muscle strain

• dislocation/subluxation

• tendinopathy

• fracture, stress fracture

• cartilage injury

• nerve injury

dislocation

displacement of boney partners in a joint resulting in loss of anatomical relationship

subluxation

incomplete or partial dislocation of bony partners in a joint

tendinitis; when true inflammation, the problem should/will respond quickly to

rest, ice, NSAIDS

inflammation of tendon tissue is _____ the cause of tendon pain

rarely

tendinopathy has a hx of

overload - chronic

tendinopathy often has pain w/

• PROM that stretches the tendon

• active use of involved mm/tendon unit

tendinopathy may limit

motion

key clinical findings for tendinopathy

• resisted static (isometric) test for tendinopathy; strong, painful at musculotendinous structure

• tender at site with or without visible swelling of tendon

• impaired function, strength, muscle length, pain, motion

TX for tendinopathy:

individualize!

• isometrics for pain relief then

• slow, heavy isotonic with eccentric component in attempt to help matrix repair and progressively increase load

fracture healing timeframe:

day 1-6: inflammation (antisepsis, coagulation)

day 7-9: reconstruction (coagulation, callus forming)

day 10-30: remodeling (apoptosis)

types of fracture through a long bone

greenstick, transverse, comminuted, spiral, compound

other types of fracture

avulsion, compression, stress

bone stress injury: stress reaction

too much pressure

bone stress injury: osteoporotic fracture

not enough pressure

pediatric fx classification: type iii and iv

requires surgery, prognosis is usually fair

pediatric fx classification (SALTR)

• type i: straight across

• type ii: above

• type iii: lower

• type iv: through

• type v: rammed/crushed

how to review x-rays: ABCs

• alignment

• bones

• cartilage

3 types of articular cartilage injury

1. DJD/OA: degenerative or just normal changes over time

2. RA - inflammatory process

3. chondromalacia (aka osteochondritis dessicans, OCD)

osteoarthritis; images are not always

sympromatic

OA affects

synovial joints

OA characterized by

fissures, cracks and general thinning of joint cartilage with or without synovial inflammation

for OA, avoid fearful terminology

• “degenerating“

• “wearing out“

• “bone on bone“

primary OA

most common, no known cause

secondary OA

may occur as a result of articular injury such as fracture, meniscal injury or repetitive microtrauma

OA impairments

pain, stiffness, crepitis, joint effusion, atrophy, loss of flexibility, impaired balance, loss of function

• depends on joints involved

OA dx

decreased joint space + symptoms

RA

• joint deformity and ankylosis

• multiple joints complaints of pain

• stiffness > 60 minutes on awakening

• swelling and synovitis

• loss of appetite, low grade fever, mild weight loss, fatigue

LMN =

peripheral neuropathy

UMN =

myelopathy

peripheral neuropathy

disease or injury of peripheral nervous system

• anywhere along peripheral nerve/LMN, either nerve root or further distal

radiculopathy

nerve root lesion

radiculopathy can cause increased

DTR (hyporeflexia)

myelopathy

any disease/disorder of spinal cord itself

myelopathy occurs to the

anterior horn of spinal cord or motor nuclei of cranial nerves

myelopathy can cause increased

DTR (hyperreflexia)

nerves are designed to

absorb tension and compression loads and move within surrounding structures

peripheral neve injuries can be caused by

pressure, traction, friction, anoxia or laceration, cooling thermal or electrical injury

sign of nerve tissue compromise

sensory loss combines with motor loss

three types of nerve injury

• grade 1: neurapraxia

• grade 2: axonotmesis

• grade 3: neurotmesis

neuropraxia

transient physiologic block caused by ischemia from pressure or stretch; no Wallerian degeneration

sx of neuropraxia

pain, no or minimal muscle wasting, weakness, numbness, proprioception affected

neuropraxia recovery

minutes to days; usually complete recovery

axonotmesis

internal architecture preserved; axon and myelin sheaths damaged and wallerian (axon) degeneration occurs distal to injury site, connective tissue sheaths intact

axonotmesis sx

pain, muscle atrophy, complete motor, sensory and synpathetic function lost

axonotmesis cause

prolonged stretch or compression resulting in ischemia and necrosis

why is classifying an injury as acute important

It guides the eval to a different set of impairments that are tested and tx’d a different way than if the injury were subacute or chronic

acute injuries intervention progression model

1. tissue healing

2. functional abilities

3. patient goals

4. patient behaviors