Interpretation of Lesion

What should I do first?

  • You need to determine what there are Red Flags present, Yellow Flags present, in order to take appropriate action

  • Decide if the problem is in the scope of PT practice

  • Is there a need for medical referral

Examination

  • What you do in the the initial examination depends on the Stage of Healing

  • Appropriate measures to assess body structure and function

  • Appropriate assessment of activity limitations: outcome measures

  • Appropriate physical performance measures: when you do these depends on healing

  • Synthesize info. gathered and see if there are clusters of findings that will give you a working hypothesis and PT diagnosis

Review of Acute vs. Chronic Lesions

  • Acute inflammation

  • SHARP, pain, swelling, heat, redness, and loss of function

  • Chronic inflammation

  • characterized by an attempt to repair with increased numbers of fibrocytes and other tissue building cells and the Prescence of granulation tissue

Acute Lesion

  • Have the normal physiological response to adverse chemical, thermal, or mechanical stimulus

  • New and never experienced before

  • Pain is relatively constant or reoccurs frequently

  • Often severe and disabling

  • Characterized by anxiety

Acute

  • Impaired movement; mov’t aggravates

  • With PROM of the related joint there is muscle spasm end feel or empty end feel; may have guarding or muscle spasm

  • Pain is referred and diffuse over the related segment

  • Increase in skin temp

  • Effusion (joint) or swelling

  • Difficulty falling asleep or remaining asleep

Intervention Acute Lesion

  • Goals

  • Decrease pain

  • Control inflammation/edema

  • Protect structures from further damage

  • Prevent the deleterious effects of rest

Intervention Acute Lesions

PRICEMEM

P - Protection: avoid excess tissue loading

R - Rest: absence from abuse rather than absence from activity

I - Ice: 10-15 minutes every 1-2 hours

C - Compression: elastic bandage, pneumatic device, supports to decrease swelling

E - Elevation: do until swelling is resolved

M - Manual techniques: variety of them

E - Early motion: passive, active assisted, active; depends on the lesion

M - Medication: NSAIDS (PT can’t prescribe meds, refer to doctor)

Review of Chronic

  • With PROM there is no muscle spasm or empty end feel

  • Little or no temp. change

  • Usually no problem with sleep, exception is the shoulder and hip due to lying down

Chronic Lesions

  • Pain is typically more aggravating than worrying

  • No alarming associated symptoms

  • Lasts longer than 6 months

  • Others >3months other >4-7 wks

  • Pain experienced before and has reoccured

  • Pain is increased by specific activities and relieved by rest

  • Usually mild/mod

Intervention Chronic Lesions

  • Not inflammatory

  • Minimal modalities

  • Exercise

  • ROM

  • Strengthening: needs to be progressive

  • Balance/proprioception

  • Function

  • Posture

  • Body mechanics: functional activites

  • Return to activity training

  • Conditioning

  • Manual Therapy - massive, jt. mobilizations/manipulation, MET, Craniosacral etc.

  • Education

  • Pain as conceptual inference; body’s best guess that protective action is required

  • Explaining that pain is not a matter of tissue damage or pathology, matter of the perceived need to protect body tissue

  • Discuss that pain is modulated by other sensory inputs and cognitive, social and emotional factors

  • Need activity modification or postures to minimize pain

  • Expected outcome

  • Why one needs to exercise: Patient Related Instruction

  • Cognitive Functional Therapy (CFT) - is an approach that aims to address the multidimensional nature of pain was simultaneously addressing and biomechanical contributors and acknowledging the important roles of pain-inhibitory processes related to reducing the fear of pain

  • Determine painful postures and painful movements and then modify defending postures or movement while introducing helpful techniques such as relaxed breathing, during the movement. aim is decrease symptoms for pt.

  • Graded Motor Imagery (GMI) - starts where person views images of body parts that are displayed and determine if left or right, progresses to explicit motor imagery where person imagines adopting posture shown in the image and progresses to mirror box training

Quick Review of Findings

Response to resistive testing

  • Strong and painless → normal response

  • Weak and painless → Nerve palsy or complete rupture

  • Strong and painful → Grade 1 contractile

  • Weak and painful → More significant contractile lesion grade 2; possible other serious pathology

SEE CHART ON SLIDE 26 AND USE FLASHCARDS

Fractures

  • Review types of fractures and fracture healing from patho

Lesion of Bone: Fracture

  1. Fracture

  • Usually associated with trauma or repeated trauma

  • Osteoporosis and other bone diseases are exceptions; fragility fracture can occur without trauma

  • ID by examination, plain films (x-rays), CAT scan, bone scan

Symptoms

  • Usually VERY painful, deep pain

  • Look at jt. position, malalignment

  • Muscle guarding

  • Swelling secondary to tissue damage

  • Pt will not want to move part because of pain

Management

  • First goal is stabilization of the fracture site, medical management: cast, traction, splint, surgery, etc.

  • Early PT Intervention: needs to understand the medical management of the fracture and soft tissue

  • Check for DVT

  • Safety with bed mobility (UE/LE), transfers (UE/LE), gait and stairs if LE

  • After healing look for signs of malunion; inspect bone structure and alignment. What you do in initial examination depends on the stage of healing

  • Look at stage of healing - Refer to patho lecture for bone healing; Pg. 47-50 Dutton

  • Intervention are for the underlying impairments!

  • We want to know if part of the medical management was Demineralized Bone Matrix: DBM

  • Modalities to assist fracture healing

  1. Pulsed Electromagnetic Field (PEMF)

  2. Pulsed US

  3. Direct Current

  • Safe and effective positioning and movement

  • LE assistive device and gait training (crutches)

Fracture Overview:

  • Decrease in ROM, AAROM, AROM, PROM; later stretching. Where you start depends on the stage of healing. Need to be in contact with MD; how will progress?

  • Decrease in Strength: depends on healing stage and soft tissue involvement; how will we know?

  • Decrease in function: ADL, IADL, gait, transfers, work and leisure activities. In early PT looking for protection; will address restoration of function as bone heals

  • Balance and proprioception come with later stages

Lesion of Bone: Dislocation

  1. Dislocation: joint integrity comprised, and bone moves out of place, usually associated with injury

  • ID by examination and plain films (x-rays)

  • Maybe obvious on inspection, malalignment

  • Usually very painful

  • Protective positioning

  • Unable to move

  • Remember soft tissue injury occurs to the supporting structures

  1. Labral tear

  2. Mm tears

  3. Capsule involvement

Management

  • first goal is reduction of dislocation; may need to go under anesthesia (medical management)

  • depends on severity of dislocation, single vs. recurrent dislocation; will have surrounding soft tissue injury

  • Immobilization, may need surgery for stabilization

  • Healing stages of soft tissue; need protection of structures

  • Common impairments: pain, swelling, loss of motion, impaired motor performance, if LE gait

PT Interventions depends on Impairments and tissue healing

Protection stage for healing:

  • Pain control:

  1. Educate pt. on resting position

  2. Modalities for pain

  • Reduce swelling

  1. Positioning

  2. Modalities

  • Safe transfers/safe gait

  • ADL modification

Lesion of Bone: Demineralization

  • Refer to patho, Dutton pgs. 218-219

  • Result of Insufficient bone formation, excessive bone re-absorption, or both

  • Decrease bone mass, narrowing of the bone shaft, widening of the medullary canal

  • ID with DEXA scan

DEXA Scan:

  • Osteopenia = -1 to -2.5 T score

  • Osteoporosis = <2.5 T score

Most common areas

  • Thoracic spine, ribs, proximal femur, distal forearm

Best method is PREVENTION

  • Stop smoking

  • Decrease alcohol consumption

  • Appropriate body fat

  • Increase calcium and Vit D

  • Decrease caffeine consumption

  • Minimize corticosteroid

  • Exercise: weight-bearing activities, strength training

  • Patient education

General Interventions for Osteoporosis

  • Posture “zone”

  • Strengthening, flexibility, and aerobic conditioning

  • Balance training

  • Safe ADL and IADL

Specific CPG Definitions (Don’t need to know for test)

  • SWB → Static weight-bearing exercise including single-leg standing

  • DWBLF → Dynamic weight-bearing exercise with low force including walking and tai chi

  • DWBHF → Dynamic weight-bearing exercise with high force including jogging, jumping, running, dancing, and vibration platform

  • NWBLF → Non-weight bearing exercise with low force, example low-load high repetition step training

  • NWBHF → Non-weight bearing exercise with high force, example progressive resisted strength training

  • Combination → Combination of exercises types with more than one of the above exercise interventions

Bone: Osteomyelitis - Acute or chronic inflammatory process of the bone secondary to infection with pyogenic organisms or other sources of infections, such as TB, fungal infection, parasitic infection, viral infection

Individuals who are pre-disposed

  • DM

  • Sickle cell

  • Acquired immune deficiency syndrome

  • IV drug abuse

  • Alcoholism

  • Chronic steroid use

  • Immunosuppression

  • Chronic joint disease

Clinical signs and Symptoms

  • Fever

  • Fatigue

  • Edema

  • Erythema

  • Constant pain

  • Tenderness over the involved bone

  • Decrease use of the extremity

Intervention: Medical management with the appropriate medications; may require surgical management

PT: May be involved with bed mobility, transfers, and gait training with assistive device. Maybe involved after cleared to address impairments (ROM, strength, balance/proprio, function)

Osteomalacia - NOT ON TEST

Paget’s Disease - NOT ON TEST

Chondral/Cartilage: Types

  • Fibrocartilage

  • Elastic

  • Articular

  • Know the time frames for the healing of these different cartilages ^^^ pg 44-46 Dutton

Etiology of Chondral/Cartilage Issues

  • Trauma - acute injuries such as dislocation, fractures, sport impact injuries

  • Usually younger, more physically active people

  • Usually in only 1 area; mild to severe

  • Degenerative changes - chronic wear and tear, repetitive microtrauma, underlying conditions such as osteoarthritis

  • Structural abnormalities - that lead to altered joint mechanics

  • Inflammatory disorders - such as RA other inflammatory arthritis

Diagnosis

  • History

  • Clinical assessment

  • Imaging (MRI, CT)

  • Arthroscopic evaluation

Management

  • Conservative management - activity modification, PT, anti-inflammatory medications, intra-articular injections such as corticosteroids or hyaluronic acid

  • PT management will depend on acuity, specific impairments and functional limitations. Will also depend on what was done as medical management

  • physical agents: decrease pain swelling

  • ROM

  • Ther ex

  • Education

  • Balance/coordination

  • Gait training

  • Surgical intervention - for symptomatic progressive chronal lesions that fail to respond to conservative

  • Scope (is there a POC in place)

  • Osteotomy: realignment

  • Joint replacement

  • Microfracture - minimally invasive procedure where small holes are created in subchondral bone to stimulation formation of fibrocartilage, promoting repair and regeneration NOT ON TEST

DO NOT HAVE TO MEMORIZE THE CELLULAR LEVELS OF DAMAGE

Most common lesion of cartilage is Degeneration

Chronic cartilage damage

  • Is the result of continual wear and tear

  • Usually more widespread and located in different areas

  • The cause of the wear and tear on the cartilage differes from indiv. to indiv.

Grading Outerbridge Classification (ON TEST)

Stages of Knee Osteoarthritis

  • Grade 1 - softening of the cartilage in combination with swelling

  • Grade 2 - is where there is fibrillation where there is a partial-thickness defect; the diameter does NOT exceed 1.5 cm or where it fails to reach the subchondral bone

  • Grade 3 - is where the partial-thickness DOES exceed 1.5cm in diameter and/or reaches the subchondral bone

  • Grade 4 - is the most serious occurs where the subchondral bone becomes fully exposed (knee replacement)

Articular Cartilage: Degeneration

  • Clinical Manifestations

  • Boney Enlargement

  • Crepitus with movement

  • Jt. deformity/malalignment

  • Loss of ROM

  • Tenderness

  • Articular gelling

  • Management

  • Education

  • May need assistive devices

  • Activity modification

  • Jt. protection

  • Proper weight

  • Exercise

Intra-articular Fibrocartilage

  • Involves intra-articular fibrocartilaginous discs and menisci

  • Usually tearing from traumatic injury or repeated stress

  • ID with MRI, CT scan

  • Minor lesion - will have clicking of the joint, with specific movements; may have instability, locking

  • Major lesion - usually have greater interference of jt. mechanics with decrease in joint motion in non-capsular pattern

  • If result of trauma, may also cause strain on jt. capsule so will get a restriction of movement in capsular pattern

  • Medial meniscus is often torn over lateral meniscus

  • Surgical options:

  • Palliative -- Include simple arthroscopic debridement and lavage

  • Reparative - this approach consists of marrow stimulation techniques that result in the formation of fibrocartilage.

  • Restorative - This includes osteochondral or astrocyte transplantation and involved inducing newly attracted or transplanted chondrocytes to become mature chondrocytes using growth factors

LOOK AT DIAGNOSTIC WORKSHEET ON MOODLE KNOW GUIDELINES

Articular Cartilage: Loose Body “Locked knee”

  • Fragment of cartilage is free in jt.

  • Occurs in late stages of degeneration as result of avascular necrosis

  • May also be result of traumatic injury

  • Symptomatic when it changes mechanics of jt.

Management

  • Return the displaced structure

  • Manipulation or traction

  • Positioning

  • Removal

PT management depends on impairments and functional limitations

  • ROM

  • Strengthening

  • Functionals

  • Balance/proprio

  • Gait

  • Physical agents; to address pain/swelling

Joint Capsule: Fibrosis

Typically occurs with

  • Prolonged immobilization of joint

  • Low grade inflammatory process of DJD

  • With resolution of acute inflammation of synovium

Adhesive Capsulitis

Risk Factors

  • Female

  • DB or thyroid

  • Age 40-65

  • Previous episode of adhesive capsulitis

Findings

  • Multiregional synovitis; inflammation

  • Synovial angiogenesis (increased capillary growth)

  • New nerve growth in capsuloligamentous complex which may explain heightened pain response

  • Capsuloligamentous complex fibrosis

Adhesive Capsulitis: 4 stages

Stage 1

  • Sharp pain at end of ROM

  • Achy pain at rest

  • Sleep disturbance

  • There is synovial inflammation but without adhesions

  • Minimal or no loss of ROM

  • Early loss of ER with an intact rotator cuff is hallmark sign

  • May last up to 3 months

Stage 2 “Freezing stage”

  • This is the painful stage. Any movement of the shoulder causes pain

  • Gradual loss of motion in all directions; both AROM and PROM. Especially elevation and ER

  • This stage lasts from 3 to 9 months from onset of symptoms

Stage 3 “Frozen stage”

  • Pain might lessen because of less synovitis but still painful

  • The shoulder becomes stiffer and greater loss of motion

  • Using it becomes more difficult

  • This stage lasts from 9 to 15 months from the onset of symptoms

Stage 4 “Thawing stage”

  • Pain lessens significantly or resolves

  • The shoulder’s ability to move begins to improve

  • This stage lasts from 15 to 24 months from the onset of symptoms

Adhesive Capsulitis: Shoulder

  • Joint motion is limited

  • ROM loss >25% in at least 2 planes and ER loss >50% or ER <30 degrees

  • ER loss with arm at side, loss abd, loss IR

  • Capsular end-feel: leathery

  • Pain complains of stiffness and loss of motion

  • Pain varies depending on stage

  • Loss of function: dressing, reaching overhead, reaching behind back or out to the side

  • May have weakness IR, ER, elevators

Adhesive Capsulitis: Intervention

  • Need to determine the irritability; the intervention depends on this

  • If in irritable stage need to reduce the irritability: suggest talk with MD regarding steroid

Joint Capsule: Fribrosis