MTI Foundations I - Nic (2019) Notes

Basic Concepts (Statistics Basics)

• Properties of diagnostic accuracy:

  1. Reliability

  2. Sensitivity

  3. Specificity

  4. Likelihood ratios (LRs)

Reliability

• Consistency of a measurement.

  1. Intra-test reliability: Consistency of measurements by one person.

  2. Inter-test reliability: Consistency of measurements between two or more people.

  3. The kappa coefficient ($k$): Reliability (agreement) after chance has been removed.

     • Most often used for categorical data.

     • Poor reliability: k < 0.50

     • Moderate reliability: 0.50
       onumber \
       < k < 0.75

     • Good reliability: k > 0.75

  4. Acceptable reliability is determined by the clinician.

Sensitivity and Specificity

• Measure how well a test detects a condition when present or confirms its absence.

• Sensitivity – Rule Out (SnNout)

  1. High Sensitivity and a Negative result are good for ruling out a disorder.

     • If the test is negative and highly sensitive, it is likely the condition is not present.

• Specificity – Rule In (SpPin)

  1. High Specificity and a Positive result are good for ruling in a disorder.

Likelihood Ratios

• Combine sensitivity and specificity to indicate probability shift given a specific test result.

• Positive LR: Indicates a shift favoring the existence of the disorder.

  1. The higher the positive LR, the more certain one can be that the person has disorder.

  2. A positive LR of 10 or more strongly indicates the presence of the disorder.

• Negative LR: Indicates a shift favoring the absence of the disorder.

  1. The lower the negative LR, the more certain one can be that a negative test indicates the person does not have the disorder.

  2. A negative LR of 0.1 or less strongly indicates the absence of the disorder.

• If the LR is close to 1, the test provides little information about the presence or absence of a disorder.

Outcome Measures

• Reliable and validated outcome measures must be used to measure a patient’s response to intervention.

• Types of outcome measures:

  1. Observer-based – clinician-based outcomes (CBOs)

  2. Self-report measures – patient-reported

     • Studies suggest these are more reliable than CBOs.

     • Patients appreciate their perspective being central to treatment.

     • Helps clinicians understand functional difficulties.

• Purposes of outcome measures:

  1. Evaluate Change Over Time (most common use)

  2. Discrimination Into Sub-groups (different clinical subgroups have different treatment needs)

  3. Predict Future Status (e.g., higher initial disability score = longer recovery)

• Questions to be answered:

  1. What does the score tell me about the patient’s status?

  2. What is the error associated with the measured value?

  3. How much will the score need to change for confidence that real change is happening?

  4. What is my long-term goal and how does it relate to the outcome measure score?

MCD and MCID

• MCD: Minimally Clinically Detectable difference (measurable change that is statistically significant, not just chance)

• MCID: Minimally Clinically Important Difference (measurably improved above chance, enough to make a difference in a patient’s life)

MCID (Continued)

• Useful in setting short-term goals and establishing reasonable targets.

• Smallest change in scale that is important to a patient.

• Allows examination of Pre-Post treatment scores to determine if the patient has improved noticeably.

• What is my long-term treatment goal and how does it relate to a score on the outcome measure?

Common Outcome Measures

Causes of Joint Dysfunction & Biomechanics and Arthrokinematics

• Arthrokinematics vs. Osteokinematics

  1. Osteokinematics: Study of bone movement.

  2. Arthrokinematics: Study of movement within joints.

• Classical movements:

  1. Traditional description of movement.

  2. Usually osteokinematic motion.

  3. Measured classical movements are divided into active and passive motions.

  4. Examples: Flexion, extension, side bending, rotation.

  5. Assessed to provide a pattern of pain and limitation.

• Joint play

  1. Menell: Involuntary movement present in all synovial joints.

     • Voluntary movement depends on the integrity of joint play.

     • Example: Medial/lateral glide of the tibia on the femur.

     • The amount of joint play is less than 1/8 inch.

  2. Kaltenborn: Short, straight-lined passive bone movement.

• Joint dysfunction

  1. Menell: Loss of Joint Play

  2. Paris: Altered mechanics (increase or decrease from expected normal, or aberrant motion).

  3. Joint dysfunction is common to all injuries/diseases of the musculoskeletal system.

  4. When present alone: Joint dysfunction is the diagnosis.

  5. If joint play is lost, muscles cannot restore it, so it must be restored for the patient.

     • Joint dysfunction is a mechanical problem needing a mechanical solution.

  6. Causes:” 4 ethological factors of joint dysfunction “

     • Trauma (macro or repeated microtrauma)

     • Sustained postures

     • Immobilization

     • Following the resolution of a more serious pathological condition

• Red flags: Additional signs with more serious conditions (swelling, heat, skin discoloration, muscle atrophy).

Joints / Bony Connections

• Bony connections are classified as either Synarthroses or Diarthroses.

Synarthroses

• Named for the type of tissue that connects them:

  1. Syndesmosis: Fibrous tissue (e.g., interosseous membrane between radius and ulna).

  2. Synchondrosis: Hyaline cartilage (e.g., manubriosternal junction).

  3. Synostosis: Bone (e.g., sutures in cranium).

  4. Symphysis: Fibrous cartilage (e.g., pubic symphysis).

Diarthroses

• Synovial joints divided into 4 basic types:

  1. Hinge joints: One surface convex, the other concave. Angular motions in a single plane (e.g., elbow).

  2. Ellipsoid joint: One surface is bi-convex, the other is bi-concave. Large movement in 2 planes (e.g., radiocarpal joint).

  3. Saddle joint: One surface convex, the other concave in 1 plane of motion. Loose ligamentous support (e.g., carpometacarpal joint of the thumb).

  4. Ball and socket joint: One surface convex, the other concave. Angular motions in 3 planes (e.g., hip, glenohumeral joint).

Amphiarthroses

• Tight gliding, slightly moveable joints, with less than 10 degrees of motion (e.g., intermediate cuneiform/lateral cuneiform).

Synovial Joints

• Divided into anatomically simple and compound joints:

  1. Anatomically simple joints: One joint space, two articulating surfaces.

  2. Anatomically compound joints: More than one pair of articulating surfaces (e.g., distal end of humerus), presence of meniscus or disc.

Movement at the Articular Surfaces

• Spin: Movement around an axis

• Glide: One point on one surface contacts new points on another surface.

  • convex on concave gliding, concave on convex gliding

• Roll: New points on one surface contact new points on another surface.

  • convex on concave rolling, concave on convex rolling

• More congruent joint surfaces mean a greater proportion of gliding to rolling.

  • Decreased gliding will greatly affect movement in a highly congruent joint and lead to joint dysfunction (SIJ is more affected by hypomobility than the shoulder).

Convex-Concave Rules

• Joint hypomobility is often treated via gliding movements, so it is important to know how glide should occur for different motions.

  1. Concave moving on Convex: Rolling and gliding occur in the same direction.

     • Examples:

       • Tibia relative to femur (open chain knee flexion/ext)

       • Tibia and Fibula relative to Talus (closed chain dorsiflexion/plantar flexion)

       • Radius and ulna relative to humerus (open chain elbow flexion, extension)

       • Radius and ulna relative to carpals (closed chain wrist flexion/extension, ie hand-heel rock motion)

  2. Convex moving on Concave: Rolling and gliding occur in the opposite direction.

     • Examples:

       • Femur relative to tibia (closed chain knee flexion/extension)

       • Talus relative to Tibia and fibula (open chain dorsiflexion/plantarflexion)

       • Humerus relative to Radius and Ulna (closed chain elbow flexion/extension ie Pushup)

       • Carpals relative to Radius and ulna (open chain wrist flexion/extension)

Tibiofemoral Joint Example

• Flexion:

  • Posterior aspects of tibia and femur approach each other requiring their roll to be in the same direction.

  • Tibia (concave) will glide posteriorly (same direction as the roll) relative to the femur.

  • Femur (convex) will glide anteriorly (opposite direction from the roll).

• Whether it is open or closed chain movement, the direction of the glide for a type of movement does not change.

  • For knee flexion, the Tibia will glide posteriorly relative to the femur.

  • For extension, the femur glides posteriorly relative to the tibia.

• Knee Extension:

  • Posterior aspects of the femur and tibia move away from each other requiring an anterior roll for both.

  • In open chain motion as the tibia is the concave surface, the tibial plateau will glide anteriorly (same as roll) relative to the femur.

  • In closed chain motion as the convex surface the femur will glide in the opposite direction of its roll (anterior), thus the glide of the femur will be POSTERIOR.

• Although which is the ‘moving bone’ relative to the static changes depending on open vs closed chain motion, the relative directions of roll/glide do not change.

• Thus, to facilitate knee extension, the tibia will need to be mobilized anteriorly relative to the femur or the femur posteriorly relative to the tibia.

Joint Positions

Closed-Packed Position

1.  Joint surfaces are maximally congruent.
2.  Joint surfaces are maximally compressed.
3.  The joint capsule and ligament are maximally spiralized and tense.
4.  No distraction is possible and no further movement is possible.
5.  Intracapsular space and volume is minimal.

Loose-Packed Position

• All other positions other than closed-packed

Resting Position

1.  The joint surfaces have the least congruency.
2.  There is least joint compression.
3.  Capsule and ligaments maximally relaxed.
4.  Maximal Distraction possible and greatest movement available.
5.  Intracapsular space and volume is maximal.

Zero Position

• Internationally accepted position from which joint range of motion is taken

Capsular Pattern

• A lesion of the entire joint capsule gives rise to limitation in a capsular pattern. This varies from joint to joint. It is denoted by limitation not of a fixed degree, but in a fixed proportion.

  • This is not only adhesive capsulitis, this can occur with major trauma to a joint, for example ACL tear (Kroon’s example of his niece)

Capsular Patterns - Major Joints (Movements are listed in order of restriction)

• Cervical, thoracic and lumbar spine: Extension/ sidebending and rotation equally limited

• O-A: Extension/sidebending equally limited

• C1-2: Equal limitation of rotation

• Glenohumeral: External rotation/ abduction/ internal rotation

• AC and SC: Pain at end range of movement

• Elbow: Flexion/ extension

• Wrist: Flexion and extension equally limited

• CMC I: Abduction/ extension

• MCP and IP: Flexion/ extension

• Hip: Flexion/ abduction/ internal rotation (although sometimes internal rotation is most limited)

• Knee: Flexion/ extension

• Talocrural joint: Plantarflexion/ dorsiflexion

• Subtalar joint: Decreased varus movement

Spinal Joint Range of Motion (joints have non-linear load displacement curves)

• The total ROM for a spinal motion segment may be divided into 2 zones:

  • Neutral Zone: A small range of movement near the joint’s neutral position where minimal resistance is given by the ligamentous structures.

    1. High degree of laxity in neutral zone and stiffening effect toward end of range

    2. Size of the neutral zone may increase with injury or weakness of the stabilizing musculature and this is a more sensitive indicator than angular range of motion for detecting instability

    3. Increased size of neutral zone may be good indicator of segmental hypermobility

  • Elastic Zone: The part of the motion from the end of the neutral zone up to the joint’s physiological limit.

• Hypermobility is often labeled as instability, but they are not the same.

Characteristics of Single Hypomobile Segment

1. Loss of physiological motion (classical motion)

2. Loss of accessory motion at involved segment

3. Increased pain at end ranges

4. Tissue texture abnormalities

5. Presence of positional Faults (hinge points)

Characteristics of Single Hypermobile Segment

1. Full general spine mobility (may be limited if muscle guarding is present)

2. Increased segmental mobility

3. Pain produced by prolonged stretch

4. Muscle stiffness follows prolonged stretching

5. Muscle stiffness relieved by exercise or movement

6. Ligamentous tenderness in the accessible ligaments

7. Joint predisposed to joint locking

Other signs of hypermobility:

1. Aberrant motion (thigh climbing, bending knees)

2. Flexion is OK, but there is knee flexion or thigh climbing when coming up

3. Frequent self-manipulators

4. Excellent, but short lived relief with manipulation

5. History of trauma (w/ cause of each onset becoming more trivial)

6. Difficulty sustaining any one position for prolonged periods of time

7. Difficulty with holding the head up

Clinical Instability

• The loss of the ability of the spine under physiological loads to maintain its pattern of displacement

  1. Physiological loads: Those that are incurred during normal activity.

  2. Purpose of stability (ability to maintain pattern of displacement)

  3. No initial or additional neurological deficit, no major deformity, and no incapacitating pain.

  • Major deformity: Gross deformity that the patient finds intolerable

  • Incapacitating pain: Pain unable to be controlled by non-narcotic drugs

Management Approach to Treating Low Back Pain & Movement Impairment Syndromes

• “It is disturbed physiology, not disturbed anatomy that causes back pain.” (Waddell)

• Evaluation of low back pain is difficult. We can only diagnose definite pathology in about 15% of patients with back pain.

• It helps to perform a diagnostic triage:

  • Simple backache – 94%

  • True Nerve root pain - <5% (Only small portion of this requires surgery)

  • Possible serious spine pathology

    • Spinal disease (tumor/infection) - <1%

    • Inflammatory disease <1%

• The overarching problem with most PT’s approach to treating back pain is that it bypasses the question of HOW and WHY is the back breaking down in the first place.

• PT’s end up being pain chasers and focus on treating the symptoms with no basic philosophy as to what is the appropriate way to treat spine problems.

• We need to develop a logical basic philosophy to treat back but some things are difficult to identify/measure in research studies: ex) ANTT, CRPS,postural deviations, regional interdependence which often requires we get our data from case studies/series.

• To find the underlying cause of the tissue breakdown you have to incorporate the use of MOVEMENT SYSTEM IMPAIRMENT SYNDROMES

Treatment Based Classification

• Manipulation

• Stabilization

• Specific Exercise

• Traction

McKenzie Approach

• Derangement

• Dysfunction

• Posture

Pelvic Girdle Pain Science

• Acute pain

• Chronic Pain

• Central Sensitization

*Sub-grouping patients with LBP based on signs and symptoms (Mckenzie/TBC)

• evidence shows improves outcomes

• Good inter-rater reliability, regardless of the experience of the examiner.

• Among 12 novice raters, there was 81% agreement in the pairs of classification

• Raters least likely to agree on a classification of stabilization, where there was only 77.5% agreement.

• Subgroups of patients identified by individual subgroup criteria get 75% of patients

• 50% mutually exclusive subgroups

• 25% patients met the criteria for more than one subgroup

• 25% did not meet the criteria for any subgroups

The Pelvic Girdle

• crucial as the torque converter between spine and LE movement. Can’t be properly classified in the TBC system and the McKenzie system. Therefore it warrants its own separate category.

Pain Science:

• Is crucial in understanding how acute back problems sometimes develop into chronic back problems.

• It will also give you the tools to manage chronic pain problems, as the traditional physical therapy approach will not work for these patients.

Subgroup systems Overview- TBC & McKenzie

• Treatment Based Classification System Overview

• Specific Exercise

• Manipulation

• Stabilization

• Traction

• Acute Postural Deformity

Specific Exercise

• Flexion Bias
  * Symptoms
  * Better with sitting
  * Worse walking and even worse standing, worse with overhead activities
  * Increased pain with prone lying, or supine with the knees straight
  * Signs
  * Increased lumbar lordosis, may prefer slouched sitting
  * Limited flexion
  * Painful endrange extension
  * Repeated flexion decreases pain, repeated extension increases pain
  * Sustained flexion decreases pain, sustained extension increases pain
  * Short iliopsoas, latissimus dorsi, pectorals, erector spinae and large glutes

• Extension Bias
  * Symptoms
  * Pain worse with prolonged sitting, worse with driving, worse on stooping and bending
  * More comfortable lying, better walking
  * Increased pain upon rising from a seated position
  * Signs
  * Decreased lumbar lordosis
  * Sits slouched
  * Flexion increases pain, extension centralizes pain
  * Repeated flexion worsens pain, repeated extension centralizes pain

Manipulation

1. More recent onset of symptoms (<16 days)

2. Hypomobility at any level

3. Not having symptoms distal to the knee

4. FABQ work subscale score <19

5. Hip IR with 1 or both hips > 35 degrees

   • Diagnostic accuracy: reference standard for success with spinal manipulation

     • When at least 4 of the 5 criteria were met: +LR =13.2

     • When only 1 or 2 of the criteria were met: -LR = .10

Traction

• Signs and symptoms of nerve root compression (reflex/sensory/muscle strength deficits; SLR + at 45 degrees with pain in the calf)

• Pain or numbness extending distal to the buttock in the previous 24 hours

• Peripheralization of pain with extension

• Positive crossed SLR

Stabilization

• Criteria

  • Age less than 40

  • Average SLR > 91 deg

  • Positive prone instability test

  • Aberrant motion present (thigh climbing)

    • LR/

    • Reference standard for success with a program of lumbar stabilization exercises:

      • When at least 3of the 4 criteria were met: +LR = 4.0

      • When only 1 of the 4 criteria was met: -LR =.20

      • When only 2 of the 4 criteria were met: -LR = .30

• Symptoms/Hx

  • History of lateral shifts in either directions or alternating lateral shifts

  • History of recurrent acute episodes (may be asymptomatic or have low grade pain between episodes)

  • Sustained postures worse than movements; sitting and standing worse than walking

  • Exercise may be painless while being performed but results in increased soreness afterwards

  • Dramatic but temporary relief from manipulation

  • Frequent self-manipulators

• Signs

  • Inability to maintain lateral shift correction

  • Excessive ROM for clinical picture, especially in extension

  • Aberrant motion (instability catch, painful arc of motion, “thigh climbing”)

  • Difficulty resuming upright position (thigh climbing or knee flexion)

  • Increased mobility with segmental mobility testing, shear testing

• Treatment

  • Immobilization:

    • To serve as a reminder for restriction of movement

    • To apply abdominal pressure to decrease load on lumbar spine

    • To maintain normal lumbar lordosis

Red Flags

• Traumatic, neoplastic, infectious and inflammatory disorders where patients need urgent medical attention.

  • 0.8% of patients who visit a doctor with low back pain have a “red flag.”

  • The incidence of tumors in general musculoskeletal practice has been determined to be approximately 1/1000 patients with back pain in private practice multi disciplinary spine centers.

• Subjective Indicators

  • Violent trauma

  • Constant, progressive, non-mechanical pain

  • Previous history of cancer, systemic steroids, drug abuse or HIV

  • Systemically unwell

  • Widespread neurology

  • Structural deformity

  • Presentation age <20 years or >55 years

  • Signs of infection (temp>100 degrees, BP>160/95, resting pulse> 100/min, resting respiration >25/min)

• Spinal Tumor –

  • Can rule out if < 50 years old,

  • No general health changes such as unexplained weight loss,

  • Does not have a history of cancer, and is

  • Responding to conservative intervention.

  • ***When red flags are present, simple imaging and laboratory test (radiographs and erythrocyte sedimentation rate) can help to rule out most tumors.

• The following 8 signs are indicative of serious pathology:

8 Signs Indicative of Serious Pathology

1. Secondary malignant deposits in the spine – assume until proven otherwise

   • A patient who presents with a backache, having a history of malignancy during the previous 2 years

   • Even though the onset is mild and the signs and X-rays are negative.

2. Osteoporosis or secondary deposits:

   • When the onset of back pain is late in life, without any previous history of back symptoms

3. Pathological Fracture of the spine:

   • When there is serious loss of spinal function, or shock, or vomiting after trivial spinal injury or strain

4. Neurological Disease: loss of power that is too widespread to be accountable by a single nerve root lesion

5. Severe pain, deformity and muscle spasm in areas of the spine other than the lower cervical and lower lumbar regions.

   • For example, a lateral shift in the thoracic spine is never a result of a simple movement dysfunction.

6. Constitutional signs, which accompany back pain, suggest disease (fever, unexplained weight loss >10 lbs, malaise and excessive weakness).

7. Loss of sphincter control

8. Continuous pain unrelated to posture

Tissue Mechanics

Collagen

• Principle structural fibrous component of ligaments, tendons, joint capsules, and fascia.

• Principle component of the matrix of most other tissue like bone, cartilage and muscle.

• Collagen is designed to resist tensile loads.

• The composition of collagen allows it to play a major supportive role in both structures that are exposed to tension and compression.

• Collagen based structures are made up of the following building blocks:

  • Water

  • Collagen fibers

  • Ground substance

  • Fibroblasts

Collagen fibers

• Bundles of various sizes which run in crossing/spiraling and intertwining waveform pattern that straightens out under stress.

• The metabolic turn-over rate of the ground substance is 2-10 days. The metabolic turn over time for collagen fibers is approximately 300 days.

  • This structure makes relatively big changes in shape possible, without causing undue stress on the collagen fibers itself.

  • The collagen fibers are made up of collagen fibrils and these consist of fine micro fibrils, which are aggregates of tropocollagen molecules. At every level of organization within collagen assemblies there are cross-links between adjacent longitudinal elements. The elements of the ground substance are responsible for these cross-links

Ground substance

• Functions as a lubricant between the collagen fibers, but it also functions as the initial groundwork upon which new collagen fibers are laid out in the proper direction.

• The ground substance is made up of 2 macro-molecular complexes:

  • Glycoproteins

  • Proteoglycans – GAGs (vitamin C plays an important role). Connected by hyaluronic acids and stabilized by glycoproteins

• Tensile forces are not being absorbed so much by the collagen fibers, but by the molecules of the ground substance.

Collagen-based extensibility is due to:

• Stretching of the collagen fibers (6-8% before failure)

• Uncrimping of collagen fibers

• Glide between fibers and fibrils

• Water content redistribution

Fibroblasts

• Fibroblasts synthesize most of the extracellular matrix of connective tissue

• They are also very active during wound repair, laying down granulation tissue. Fibroblast activity is influenced by various factors such as dietary content, prevalent mechanical stresses and steroid levels

Stress - strain curve (Stress on Y axis, Strain on X axis)

• Characteristics of the stress-strain curve

  • A. Toe region

  • B. Elastic region

  • C. Elastic limit (yield point)-

  • D. Plastic region – permanent deformation

  • E. Maximum stress

  • F. Necking – tissue failure occurs

  • G. Failure point

A. Toe region

• structure settles, slack is being picked up. This is when “uncrimping” of the collagen fibers occurs. Under normal circumstances, most of the functional activities of the connective tissue take place in this region

B. Elastic region

• the stress in the tissue is directly proportional to the strain as long as the elastic limit has not been exceeded. The deformation that occurs in this region is completely reversible

C. Elastic limit

• the end of the elastic region. Critical junction, as the tissue starts to become damaged as the result of being loaded

D. Plastic region

• the tissue begins to lengthen at a rate disproportionate to the stress. This is usually a permanent deformation

E. Maximum Stress

• occurs at the peak of the curve and represents the max load that the tissue can tolerate. Beyond this point the tissue starts to fail

F. Necking

• Tissue failure occurs as the strain rapidly increases, even as the stress decreases

G. Failure point

• a sudden decrease in the stress occurs while the strain continues to rise. This means that the substance of the material has begun to fail. It takes a force of 5-15 kg/mm2 to tear a collagen fiber. It has been shown that when the matrix was artificially removed, that the tensile strength of the connective tissue decreased significantly

Effects of immobilization on connective tissue

• Collagen fibers

  • The amount of collagen fibers does not increase as a result of immobilization. However, new collagen fibers are not laid down along the lines of stress, which can contribute to the restricted ROM

• Ground substance

  • With immobilization, the amount of water, hyaluronic acid and GAG’s decreases significantly in the ground substance.

  • This leads to decreased lubrication between the collagen fibers. The collagen fiber interspace also decreases, which can lead to cross linking of fiber intersections

Physiology of tissue injury and repair

*Rate of healing

• 50% of healing occurs in the first 2 weeks

• 80% of healing occurs in the first 6 weeks

• 100% of healing has occurred by the 12th week

Phases of healing

• In general, healing of soft tissue takes place in 3 distinct phases:

Inflammatory phase – 1-several days

*   clean up injured tissue and activate cells necessary for repair
*   Following bleeding- the inflammation process gets started. Depending on the severity of the injury, this can last from 1 to several days. The inflammation activates the fibroblasts in the injured area. There will be increased permeability of the capillaries, which leads to edema in the tissue. White blood cells infiltrate the area

Proliferation phase -4 to 5 days after injury

*   With the activation of the fibroblasts, the healing process gets started
*   There is a strong proliferation of capillaries, which together with the fibroblasts invade the wound → form granulation tissue.
*   There is a fast accumulation of new collagen fibers.
*   The newly formed scar tissue is still weak.
*   Wound contraction is taking place

Maturation phase:

• This phase can last from several months to more than a year.

  • There is continued synthesis of collagen fibers, albeit slowly.

  • The strength of the scar tissue is being adapted to the demands being put on the tissue. The collagen fibers are being oriented according to the lines of stress.

  • This is a lengthy process

Stage of the condition

• Immediate

  • The few minutes immediately following the injury. First aid by the patient is most effective

• Acute

  • Condition is worsening. Goal of treatment is to limit worsening

• Sub acute

  • Commencing to improve. Status is fragile

• Settled

  • Stabilized. Corrective treatments are well tolerated

• Chronic

  • Primary healing has finished. Behaviors and adaptation

Reactivity (irritability) of condition

• High reactivity: pain is felt before restriction

  • Oscillations

• Moderate reactivity: pain is felt with restriction

  • Oscillate-stretch-Oscillate

• Low reactivity: no pain is felt at restriction

  • Stretch

Degree of contracture formation

• Factors

  • Extent of trauma

  • Degree of inflammation

  • Degree of muscle guarding

  • Amount of collagen laid down

  • Direction of collagen laid down

  • Extent of collagen remodeling

• Remodeling is influenced by

  • Motion

  • Blood supply and oxygen supply to the injured tissue

  • Vitamin C

  • Adequate protein intake

  • Anti-inflammatory drugs

Effects of therapeutic exercises

1. New collagen and proteoglycans synthesized

2. Realignment and lengthening of old fibers

3. Increased interfiber distance

4. Increased lubrication

5. Alignment of new collagen fibers in relation to the lines of stress

6. Cellular modulation (release of enzymes causing breakdown of old connective tissue)

7. Result of therapeutic exercises: increase of