PT 602 week 1
How does the humerus move with adduction/abduction?
Abduction downward slide, adduction upward slide
Tendon/ligament vs hyaline cartilage vs fibrocartilage vs bone for collagen type, PGs and GAGs
Tendon/ligament have large amounts of type I collagen, low proteoglycan content, hyaline has lots of proteoglycans and GAGs and a lot of water molecules, type II collagen forms a mesh and compresses PGs and attached water molecules to GAGs, fibrocartilage has less water and PG and more collagen than type I --> TYPE 1 COLLAGEN TRAPS AND RETAINS WATER IN COLLAGEN NETWORK instead of using proteoglycans to attract and hold water! Bone is also type I cartilage but also lots of inorganic mineral crystals for high compressive strength
Are ligaments/tendons avascular? Articular cartilage? Fibrocartilage?
Tendons/ligaments limited vascularization, articular is avascular and aneural, fibrocartilage on the periphery has some blood flow
Order tendons/ligaments, cartilage, and bone from what can deform most to least before failure, does ligament or bone have a greater young's modulus?
That order, stiffer = greater young's modulus so bone has a greater modulus and a steeper stress/strain line, greater modulus = stiffer, more elastic, need more effort to change length, change in strain within bone will cause a greater change in stress than the same change in strain in a ligament, same shape curve applies for fast loading - stiffer, slow loading = more deformation
What are the four main types of connective tissue/flow chart?
CT proper (loose and dense, tendons and ligaments are dense regular), cartilage, bone, blood
Paratenon vs epitenon vs endotenon
Epitenon encloses fiber bundles, paratenon is a double sheath enclosing entire tendon, fluid-filled paratenon = tendon sheath around fascicles for nerves, BV, lymphatics, related to frictional forces
How does the scapula contract the sternum
S shaped, very little bone to bone contact so there is an articular disc to make the surface more congruent
Describe the ECHOWS model
ECHOWS - physical therapy patient-interview assessment tool, useful in identifying aspects of the interview process that may be improved E - establishes rapport, elicits information about the C - chief complaint, collects the H - health history O - obtains psychosocial perspective, performs the interview W - wrap-up S - summary of performance compares skilled/novice based on if the clinician completed ECHOWS during the patient interview
What is scapation
Elevation in the plane of the scapula (scapular plane), this is 30-45 degrees from the frontal plane diagonal
Disregarding magnitudes of motion (degrees), what are the names of the motions of the clavicle that take place at the sternoclavicular joint and around what kind of axis do each of these occur?
Elevation/depression - A-P axis Protraction/retraction - vertical axis Clavicular rotation - longitudinal axis
Disregarding magnitudes of motion (degrees), what are the names of the motions of the 5 motions of the scapula? What joints are responsible for these motions?
Elevation/depression - SC Protraction/retraction - SC Upward rotation/downward rotation - AC Anterior/posterior tilt - AC Internal/external rotation - AC
Motions of the SC joint
Elevation/depression, protraction/retraction, clavicular rotation
What are the common themes between Kalamazoo model, 4 Habits model and ECHOWS models?
Start by building rapport, hear patient perspective about the chief complaint, demonstrate empathy and build relationship seeing patient holistically, end on a high note with education, diagnosis, joint decision
What is the only joint that connects the UE to the trunk
Sternoclavicualr joint
What is part of a synovial joint capsule
Stratum fibrosum on the outside and stratum synovium on the inside
Fibrous joints
Suture, syndesmosis (interosseus membrane between ulna and radius)
What is the concave/convex rule?
***When a concave articulating surface is moving on a stable convex surface sliding is considered to occur in the same direction as motion of the bony lever ***When a convex joint surface moves on a concave surface the bone typically rolls in one direction and glides in the opposite direction in order to maintain optimum contact
Typically, how much of the total range of elevation of the arm is contributed by the scapulothoracic (ST) joint and how much by the glenohumeral (GH) joint?
-60 degrees scapulothoracic motion -120 degrees glenohumeral motion -2:1 GH:ST
Describe the articular configuration of the proximal and distal segments of the glenohumeral joint
-Glenoid fossa of scapula and head of humerus -Glenoid fossa is shallow so there are many tendons/ligaments holding the joint together
A load applied to a connective tissue can produce creep. What does this mean to the tissue?
-If a force is applied to a tissue and maintained at the same level while the deformation produced is measured the deformation will gradually increase -Force remains constant while length changes -Ex. Hang a weight on the end of an elastic band you get immediate elastic deformation, it will also gradually elongate further over time -Connective tissues will also gradually elongate after an initial elastic response to a constant tensile load then gradually return to their original length (recovery) after the load is removed -Ex. Therapist may apply constant force and tissue gradually elongates
What is the difference in collagen composition for a healthy tendon vs a tendon with tendinosis and an immobilized tendon?
-A healing tendon may be much larger in diameter than an uninjured tendon but because the injured tendon contains less collagen, smaller fibrils, and fewer cross-links it may actually be weaker than its smaller counterpart -Tendons subject to immobilizations show atrophy at the MTJ with a loss of infolding and a decrease in collagen concentration and cross-linking -Exposure to corticosteroids, nutritional deficiencies, hormonal imbalance, dialysis, chronic loading into the high linear region of the stress-strain curve with inadequate time for recovery and sudden large loads may predispose the tendon to injury - same load now produces more deformation -Different tendons in different places have different structures based on their load - ex. Achilles tendon is longer than the palmaris longus tendon -Differences in stress strain curves among different tendons reflect differences in the proportion of type I and type III collagen, differences in cross-linking, maturity of collagen fibers, organization of fibrils, variations in ground substance concentration, and level of hydration. -Enthesis where tendon inserts into bone is a common site of degenerative change and injury, myotendinous junction is stronger so even if it is a common site for muscle sprains and pulls the injury is typically on the muscle side, because the MTJ depends on interdigitation of the muscle and tendon for its strength an injury that distorts the form of the MTJ may decrease its tensile strength and predispose it to further injury -Under normal conditions the tendon is most vulnerable at either end rather than in the midsubstance and healthy tendons rarely rupture
What is the glenoid labrum and what role does it play at the GH joint?
-Attached to glenoid fossa, enhances depth/concavity by approximately 50% -Does resistance to humeral head translations, protection of bony edges of labrum, reduction of joint friction, dissipation of joint contact forces, attachment site for glenohumeral ligaments and tendon of long head of biceps brachii
What is the entheses of a ligament/tendon?
-Attachment to bone -Tendons and ligaments may insert directly into bone via fibrocartilage or indirectly via fibrous attachments where collagen fibers blend into the periosteum of bone which is attached to the underlying cortical bone via Sharpey's fibers "tree roots"
What is Wolff's Law? What happens to bone when someone is very overweight compared to a sedentary person?
-Bone is dynamic and remodels throughout life by responding to changes in forces - ex. Increased pull of tendons, also affected by age, nutrition, metabolism, disease -Wolff's law = the change in bone shape (form) to match function -Overweight = more stress on bones, sedentary = less stress on bones than if someone had a lot of muscles pulling on them everyday from intensive exercise
Discuss how development of strong interpersonal skills can impact the provider/patient relationship
-Communication skills include eye contact etc and can be applied for basic interviewing -Interpersonal skills allow moving beyond scripts so physicians can fully appreciate their patients stories and develop a deeper relationship -Interpersonal skills enhanced through reflection and self awareness which allows physicians to understand their own reactions to patients, to observe how others experience them, to be present in the moment, to remain flexible and responsive in interactions with patients and family members
What is the predominant but not exclusive type of collagen that comprises a tendon compared to a ligament? What kind of force is this type of collagen best at resisting?
-Contain mostly type 1 collagen (more than 95%), tendons contain slightly more type I collagen and less type III collagen than ligaments, increase in type I compared to ligaments is thought to be an adaptation to larger tensile forces since type I is considered stronger than type III, also tendon has them running parallel and ligament the fibers are in all directions
What are the functions of synovial fluid? Lubricate/decrease friction , nourish joint, prevent excess compression/shock absorb
-Covers surfaces of the inner layer of the joint capsule and the articular cartilage and helps to keep the joint surfaces lubricated and reduces friction -Fluid also provides nourishment for the hyaline cartilage covering the articular surfaces -Fluid moves in and out of the cartilage as compression is applied and released -Hyaluronate component responsible for viscosity of the fluid, essential for joint lubrication, reduces friction between synovial folds of the capsule and the articular surfaces -Lubricin is responsible for cartilage-on-cartilage lubrication and gives SF ability to dissipate energy -Changes in these concentrations will affect the overall lubrication and amount of friction present in the joint - lower friction = less resistance to movement
How does the humeral head move on the glenoid fossa to produce a typical range of GH motion? What happens if the expected motion of the humeral head doesn't occur?
-Downward glide with elevation otherwise the head would impinge on the coracoacromial arch, lateral rotation in abduction, A-P translation is variable
What are the fibrillar and interfibrillar components of the ECM?
-Fibrillar component: Contains collagen and elastin -Interfibrillar component: Contains water and proteins, primarily glycoproteins and proteoglycans (PGs)
What is the function of a bursa and what comprises the bursal sac? Where are they found? What is the name and function of the bursa within the shoulder?
-Flat sacs of synovial membrane in which the inner sides of the sacs are separated by a fluid film -Found where moving structures are in tight approximation - between tendon and bone (subtendinous), bone and skin (subcutaneous), muscle and bone (submuscular), or ligament and bone, -Subacromial bursa -Below the acromion process and above the greater tubercle of the humerus -Reduces friction in the space under the acromion, protects supraspinatus/RTC tendons
What structures make up the coracoacromial arch? What structures does the coracoacromial arch protect (or potentially jeopardize)?
-Formed by the coracoid process, acromion, coracoacromial ligament, and inferior surface of the acromioclavicular joint -The subacromial bursa, rotator cuff tendons, and a portion of the tendon of the long head of biceps brachii lie within the subacromial space and are protected superiorly from direct trauma by the coracoacromial arch -Arch is also a physical barrier to superiorly translatory forces acting on humeral head to prevent it from dislocating superiorly but also contact of the humeral head with the undersurface of the arch can cause painful impingement or mechanical abrasion of the structures in the subacromial space, supraspinatus tendon particularly vulnerable since it is under all the possibly impinging structures except coracoid process
How does creep differ from stress-relaxation?
-If a tissue is stretched to a fixed length while the force required to maintain this length is measured the force needed will decrease over time, length remains constant while force decreases -Ex. Therapist may perceive reduced resistance to stretch, less force required to maintain tissue length
What are some of the pros and cons of the different pain assessments discussed in your readings. Specifically: the visual analog scale, the numeric rating scale, the McGill Pain Questionnaire, the body chart, and open-ended interviews?
-Important to closely monitor for acute/post-op pain, in patients with chronic pain overemphasizing pain intensity can be detrimental and focus should be on functional assessment -Many pain characteristics can be measured including intensity, emotional unpleasantness, quality such as burning, aching, lancinating, anatomical distribution, temporal characteristics such as variability, frequency, duration over time, how much the pain interferes with function/everyday life -Most commonly used tools are visual analog scale and semantic differential scales Visual analog and numerical scales - quickly estimate pain severity -Ex. Rate pain on a scale from 1-10, face scale better for children/cognitively impaired, national infant pain scale NIPS -Reflect only the intensity of pain and lack information about the patient's response to pain or the effects of the pain on function and activity -Can combine visual analog scale with questions about QOL to obtain more information about the impacts of pain on a patient's life Semantic differential scales - detailed pain description -Consist of word lists and categories that represent various aspects of the pain experience -Select a word from lists to best describe pain -McGill pain questionnaire - descriptors of sensory, affective, and evaluative aspects of patient pain, group words into categories with different aspects - temporal, spatial, pressure, thermal for sensory and fear/anxiety/tension for affective aspects of pain, cognitive experience of pain based on past experience and learned behaviors to describe evaluative aspects of pain -Semantic differential scales allow the scope, quality, and intensity of pain to be assessed and quantified, counting number of words chosen denotes pain severity, adding rank sums of words chosen can produce pain rating index (PRI), can index 3 major categories of questionnaire -Disadvantages are it is time consuming and requires high cognitive status/literacy, best when detailed information about a patient's plan is needed, as in a chronic treatment program or in clinical research Other measures -Daily activity/pain logs indicating which activities ease or aggravate pain, body diagrams on which the patient can indicate the location and nature of pain, open-ended, structured interviews -Physical examination that includes observations of posture and assessment of strength, mobility, sensation, endurance, response to functional activity testing, soft tissue tone and quality -Consider symptom duration, patient cognition abilities, time
If you wanted to manually distract a joint (separate its joint surfaces), would you choose the close-packed or loose-packed position of the joint
-In the loose packed position the joint has a maximum amount of joint play, an externally applied force such as that applied by a therapist or physician can produce movement of one articular surface on another and enable the examiner to assess the amount of joint play that is present -Movement in and out of the close-packed position is likely to have a beneficial effect on joint nutrition because of the squeezing out of fluid during each compression and imbibing of fluid when the compression is removed
Is the capsule of the GH joint tight or loose?
-Loose - allows for lots of motion
What resources may be available to you when you are looking to obtain patient history information?
-Medical record, patient interview - more medical record access inpatient, may just have form patient filled out in outpatient -Intake form -Caregiver/family member information
MTJ vs enthesis
-Musculotendinous junction (MTJ) ® merge with muscle cells •MTJ stronger than enthesis, but •Sensitive to decreased load (immobilization)
Once a connective tissue has differentiated (specialized), can the cellular and extracellular composition change? If so, what is required to produce that change?
-Need appropriate environment/stimuli to de-differentiate and change the type of ECM they produce - ex. Tendon cells can produce cartilage-like tissue when subjected to compressive forces -Connective tissue structure can be modified by changes in loading conditions, we may be able to manipulate the mechanical environment to cause CT to synthesize materials that will enhance their function!
Nociception vs pain
-Nociception = the neural process of encoding noxious stimuli -Intensity of nociceptive signals is roughly proportional to their originating stimuli but transmission can be facilitated or inhibited at several points -Pain = an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage -Pain = output of the brain triggered as part of the process by which afferent AP are converted into conscious awareness - different than nociception! -Pain can occur without nociceptive input and nociceptive input does not always produce pain -Pain experience can have 3 dimensions - sensory-discriminative, motivational-affective, cognitive evaluative
Endogenous opiate system
-Opiopeptins control pain by binding to specific opioid receptors in the nervous system -Opiopeptins and receptors are present in many peripheral nerve endings and in neurons in several regions of the NS -Found in the periaqueductal grey matter (PAGM) and raphe nucleus of the brainstem - structures that induce analgesia when electrically stimulated -High concentrations of opiopeptins also found in superficial layers of dorsal horn of spinal cord (layers I and II), in various areas of the limbic system, in the enteric nervous system, in nerve endings of C fibers -Opioids and opiopeptins have inhibitory actions - cause presynaptic inhibition by suppressing inward flux of Ca++ and cause postsynaptic inhibition by promoting outward flux of K ions, indirectly inhibit nocicpetive transmission and activity of pain controlling structures -Areas with high levels of opiopeptins such as PAGM in the raphe nucleus strongly inhibit transmission of nociception by spinal dorsal horn neurons causing analgesia -Concentrations of opioid receptors and opiopeptins in the limbic system of the brain associated with emotional phenomena also provides an explanation for emotional responses to pain and the euphoria/relief of emotional stress associated with use of morphine and release of opiopeptins -With stress/anticipation of pain levels of opiopeptins in the brain and CSF become elevated, pain thresholds increased -Endogenous opioid theory = explanation for paradoxical pain-relieving effects of painful stimulation and acupuncture - pain that causes the sensation of prickling/burning can reduce the intensity of less bearable pre-existing pain in the area of application
Why is pain a biopsychosocial experience, not just a biological one?
-Pain is an output of the brain designed to protect you, doesn't come from the tissues -Experiment with same R and B light, how much does it hurt, same stimulus but red color they said it hurt more putting cold rod on their hand -People see intensity knob going up and think pain is going up -Referred pain - in an area that is normal from another area that is not - ex can run knife across rubber hand -VR feeling pain in someone else's hand, looking at other person thinking it is them, put a painful stimulus on other person's arm but it looks like theirs, say ouch it really hurts! Where? On that man's arm, brain produces pain and directs it to mid air -Pain persists - keep running neurons that produce pain and they become better at producing pain -Networks lose capacity to be precise, pain spreads
Where is the periosteum found and what is its function?
-Periosteum = fibrous layer that covers the entire surface of each bone except the articular surface, collagen fibers from ligaments and tendons blend into the periosteum, sharpey's fibers pass from the periosteum to deeper layers of bone -Periosteum houses cells that are precursors to osteoblasts and osteoclasts and capillaries for nourishment, reservoir for cells needed for growth and repair, if periosteum is damaged healing capacity of bone will be decreased
What (not where) is the close-packed position of a joint? Are the capsule and ligaments of a close-packed joint tight or loose?
-Position in which the joint surfaces are maximally congruent and the ligaments and capsule are maximally taught -Usually at the extreme end of a ROM -Here a joint possesses its greatest stability and is resistant to tensile forces that tend fo cause distraction (separation) of the joint surfaces, little or no joint play is possible -Ex. Full extension of humeroulnar, knee, and interphalangeal joints -In loose-packed position of a joint articular surfaces are relatively free to move in relation to one another, any other position than close packed
Do the glenohumeral ligaments reinforce the capsule anteriorly or posteriorly? What other ligaments or muscle/muscle tendons reinforce the GH capsule?
-Reinforced anteriorly -RTC muscles and coracohumeral ligament also support the joint -The capsule is taught superiorly, slack anteriorly and inferiorly, capsule tightens when humerus is abducted and laterally rotated -Susceptible to anterior dislocation?
Describe the resting position of a typical scapula on the thorax
-Scapula rests on the posterior thorax approximately 5cm from the midline between the 2nd-7th rib -Scapula is internally rotated 35 degrees to 45 degrees from the coronal plane, is tilted anteriorly 10-15 degrees from the vertical, and is upwardly rotated 5-10 degrees from the vertical
What are the primary 2 bursae of the GH joint?
-Subacromial bursa -Subdeltoid bursa
When treating a pediatric patient, describe ways in which a good rapport can be built with child and family.
-Talk to the child and to the parents, find common interests -According to the article rapport begins from the opening moments of the interview, if the interview starts on a negative note it is challenging to recover -Effective physician/child/parent relationship requires getting to know the patient and parents, interest in the child as a person, attention to the child's and family's values, understanding the way each family member experiences the child's illness -Physician achieves these tasks via listening skills, respect, empathy, understanding the role of play and children's different developmental and cognitive stages, and effective non-verbal communication with congruence between words, tone, and body language
What are the structural differences between a loaded tissue that is in the toe region, the elastic region, plastic or beyond the ultimate failure point?
-Toe region = small force applied produces deformation, crimp or slack in collagen is taken up, force can be transmitted through collagen fibers to bony structures ligaments connect to -Elastic - deformation is not permanent, structure will return to original dimensions after load is removed, crimp here Yield point - end of elastic region, material will not immediately return to original state when load is removed but may recover in time -Plastic region - after the load is removed the material will not recover its original length, deformation is permanent - microfailure = tears and failures in collagen fibers that would be repaired by synthesis of new tissue/cross linking of collagen -Ultimate failure point = failure load applied, cannot take any more, rupture/fracture - macrofailure
What does stress/strain depend on?
-Type of stress and strain that develop in human tissues depend on the material, the type of load applied, the point at which the load is applied, the direction and magnitude of the load, and the rate and duration of loading
All connective tissues are 'viscoelastic' materials. Because viscoelastic materials are both elastic and viscous (think: gel or mucous), what behavioral characteristics do viscoelastic materials demonstrate that are different than elastic materials that you are familiar with (e.g., a rubber band)?
-Viscosity refers to a material's resistance to flow, it is a fluid property and depends on the PG and water composition of the tissue -A tissue with high viscosity will exhibit high resistance to deformation -A less viscous fluid will deform more readily -When forces are applied to viscous materials they exhibit time-dependent and rate-dependent properties -Viscosity diminishes as temperature rises or loads are slowly applied and increases as pressure increases or loads are readily applied -Viscoelastic materials are capable of undergoing deformation under either tensile or compressive forces and returning to their original state after removal of the force, deformation and return is time-dependent
Does applying a force rapidly to a tissue increase or decrease its stiffness?
-When a load is applied rapidly tissue becomes stiffer and larger peak force can be applied to the tissue than if the load were applied slowly, subsequent stress relaxation is also larger than if the load was applied slowly, creep will take longer to occur with rapid loading -Viscosity (resistance to deformation) increases when a load is applied quickly
Connective tissue is composed of cellular and extracellular components. Define the cellular and extracellular components that make up connective tissues?
1) Cellular - cells of all connective tissues derive from mesenchymal precursor cells that differentiate into different connective tissue cells, either fixed in tissues or transient within the circulatory system -Fibroblast = basic cell of most connective tissues, produces the extracellular matrix -Depending on the mechanical and physiological environment the fibroblast produces different types of connective tissue and receives a new name - chondroblasts (cartilage), tenoblasts (tendon), osteoblasts (bone), cells are called fibrocytes/chondrocytes/osteocytes when they mature and become less metabolically active, cell can go through several cycles as a blast/cyte depending on need to produce more CT matrix -Connective tissue cells can de-differentiate and change the type of extracellular matrix they produce given the appropriate environment/stimuli 2) Extracellular - part outside of the cells, composes almost the entire volume of tissue and determines tissue function, matrix contains mostly proteins and water and is organized into fibrillar components and a surrounding matrix -Fibrillar component: Contains collagen and elastin -Interfibrillar component: Contains water and proteins, primarily glycoproteins and proteoglycans (PGs)
What motions make up shoulder elevation
Abduction and flexion
Are the contributions of the ST and GH joints to elevation of the arm expected to occur sequentially or simultaneously? What is a common proportional relationship?
2:1 relationship, when you start to move your arm most movement is from glenohumeral joint alone then there is contribution from scapular motion - after around 30 degrees, abnormal quality of motion to see scapula move before humerus - like a shrug then raise arm, at 90 degrees there is approximately 70 degrees GH and 20 degrees ST
What is the neutral (scapation) plane of the scapula?
30-45
All synovial joints have the following features:
A joint capsule that is composed of 2 layers A joint cavity that is enclosed by the joint capsule Synovial tissue that lines the inner surface of the capsule Synovial fluid that forms a film over the joint surfaces Hyaline cartilage that covers the surfaces of the enclosed contiguous bones -Synovial joints may also include accessory structures such as fibrocartilaginous discs, plates, or menisci, labra, fat pads, and ligaments -Discs, menisci, and synovial fluid help prevent excessive compression of opposing joint surfaces by spreading applied forces over large areas
In shoulder elevation what happens at the AC joint, SC joint, and GH joint
AC joint upward rotation, GH joint external rotation and abduction, SC elevation and posterior rotation
Acute vs chronic pain
Acute = less than 30 days relating to a specific injury/disease process, chronic = outlasted typical healing time of involved tissues, often 3-6 months -Acute pain = direct result of actual or potential tissue injury due to a wound, disease, or invasive procedure, intensity/distribution/character matches patient history, relationship between sx and tissue state, nociception, peripheral and central sensitization, and psychosocial factors contribute but resolve as tissues heal, pharmacological and patient education treatments that pain is normal and will resolve, cryotherapy, thermotherapy, compression, and ES can help manage -Preventing acute from becoming chronic - intensity/duration? Presence of severe depression/possible risk factors? Genetic predisposition? beliefs/fear? -Signs that peripheral and central sensitivity are not resolving as expected such as aberrant movement patterns, primary or secondary hyperalgesia, allodynia, hyperpathia, or trophic changes should be noted and addressed to avoid this -Chronic pain - common, ⅓ US residents had at some point in their life, spinal pain is most common and one study showed there was a 19% prevalence in the US in a given year and a 29% lifetime prevalence, another study found approximately 57% of all Americans reported recurrent or chronic pain the previous year - 62% had been in pain longer than 1 year, 40% reported constant pain -Diagnoses commonly associated with chronic pain include chronic spinal pain, fibromyalgia, neuropathy, complex regional pain syndrome (CRPS), phantom limb pain, poststroke pain, osteoarthritis and rheumatoid arthritis, headache, cancer pain, temporomandibular joint disorder, IBS, interstitial cystitis -Analgesics often prescribed, physical agents have benefit of giving patients some control over their own symptoms, min risk of adverse side effects, can help individuals stimulate their sensory and motor cortices by interacting with their injured body parts, may slow or reverse smudging in sensory homunculus -Physical agents also allow patients to practice pain management such as muscle relaxation, controlled breathing, attention diversion -Most difficult when tissue dysfunction cannot be identified as being the cause of the pain or when tissue damage is not commensurate with the characteristics of the pain -Chronic pain management should begin with identifying and weighing the pathophysiological pain mx - nociception, peripheral sensitization, central sensitization, or psychosocial that have not resolved -Central sensitization and psychological changes will almost always be present but may not be the primary perpetrators of pain - take history to find what the primary perpetrators are
Disregarding magnitudes of motion (degrees), what are the names of the motions of the scapula that take place at the acromioclavicular joint and around what kind of axis do each of these occur?
Anterior/posterior tipping - coronal axis Internal/external rotation - vertical axis Upward/downward rotation - A-P axis
Motions of the AC joint
Anterior/posterior tipping, IR/ER, upward/downward rotation
Physical stress theory
As physical stress level increases there is death, decreased tolerance (atrophy), maintenance, increased tolerance (hypertrophy), injury, death, threshold for adaptation is with maintenance, hypertrophy, injury
What type of forces is type 1 vs type 2 collagen associated with?
Body has 90% T1 which resists tensile forces, T2 associated with compressive forces
What structures does connective tissue make up?
Bones, bursae, capsules, cartilage, discs, labrums, menisci, plates, ligaments, tendons
Glycosaminoglycans (GAGs)
Carbohydrate portion of PGs consists of long chains of repeating disaccharide units called GAGs, similar to glucose in structure, distinguished by number and location of attached amine and sulfate groups, most attach to proteins to form PGs except hyaluronic acid which exists on its own, PG can contain up to 100 GAGs which stick out from the protein core to form a shape like a bottle brush -GAG chains attract WATER into the interfibrillar matrix, creating a tensile stress on the surrounding collagen network, collagen fibers resist and contain the swelling which increases the rigidity of the extracellular matrix and its ability to resist compressive forces/support the cells -Play an important role in fastening the various components of the extracellular matrix together, in adhesion between collagen and integrin molecules in cell membranes, and as inhibitors of angiogenesis 1 PG can contain up to 100 GAGS, these attract and bind water which allows CT to withstand compression, some tissues such as articular cartilage must withstand high compressive forces so they have higher PG and GAG content than other types of CT
What mechanisms are involved in peripheral and central sensitization to pain? The authors call central sensitization "dysfunctional pain" in some places, but the term "central sensitization" is preferred.
Central sensitization - most important feature is that is results in the patient's symptoms to no longer reliably reflect the state of the tissues - like a car alarm going off, alarm/pain is real but no one is really trying to steal the car! -Central sensitization can cause pain/other unpleasant sensations that are typically not confined to an anatomic or peripheral nerve distribution and have an inconsistent response to physical activity or stress, typically initiated by a nociceptive stimulus but can continue indefinitely once established with no/minimal peripheral stimulus -Peripheral sensitization is nerve pain -Psychosocial pain is like central sensitization but with a mental trigger, no hyperpathia/allodynia/cold sensitivity
What does the pec major clavicular head do vs sternocostal head?
Clavicular does flexion, sternal does extension
Collagen vs elastin
Collagen - main structure of most connective tissues, found in all multicellular organisms, most abundant protein in the human body (25-30% of protein in mammals), tensile strength similar to steel, responsible for functional integrity of CT structures and their resistance to tensile forces -Basic building block - tropocollagen molecule, cross link into fibers that can be arranged in different ways, often waxy with a crimp that disappears when stretched Elastin - other fibrillar component of CT along with collagen (makes up a much smaller portion) but molecule is single alpha-like strands without a triple helix unlike collagen, strands are cross linked to form rubber like elastic structures, fibers branch freely and are found in all joint structures as well as skin, tracheobronchial tree, and walls of arteries -How much give a tissue needs depends on how much collagen/elastin it has - ex. Aorta has 30% elastin and 20% collagen, ligamentum nuchae has 75% elastin and 15% collagen, achilles tendon has 4.4% elastin and 86% collagen
What bony landmarks can help you identify and palpate the long head oof the biceps tendon?
Coracoacromial ligament, transverse humeral ligament (tendon sheath under this) - long head attaches to supraglenoid tubercle (blends with labrum between scapula and humerus), short head to coracoid process
If the deltoid acted independently to produce shoulder abducton without synergistic contraction of infraspinatus and teres minor what detrimental effect may this have on position of humeral head in the glenoid? What is the value of the infraspinatus and teres minor contracting along with other RTC muscles to maintain GH alignment during shoulder abduction?
Deltoid has a line of pull up, RTC compress humeral head in flenoid and pull more down so it does not crash into the clavicle
Describe how diffusion nourishes articular cartilage
Diffusion, when compressed some fluid moves out of the cartilage into the joint space through pores in the superficial layer of the cartilage, when compressive force is removed fluid flows back into cartilage, need joint motion/WB activity
Describe scapular dyskinesia/adhesive capsulitis
Dyskinesia has winging, posterior motion/anterior tipping (maybe anterior pec is tight?), try Y exercise, maybe SA is weak, adhesive capsulitis arm cannot raise fully, poor quality motion, idiopathic, scar tissue adhesions, impaired ROM, freezing/thawing stages
Fibroblast vs chondroblast
Fibroblast is the basic cell of all CT that produces the ECM and can differentiate, found in tendon, ligament, skin, bone, creates type I collagen, chondroblast is a differentiated fibroblast found in cartilage, produces mostly type II collagen
Cartilaginous joints
Fibrocartilage in synphysis, hyaline cartilage in synchondrosis
What motions make up elevation of the arm and what are the prime mover muscles?
Flexion and abduction, flexion = anterior deltoid and pec major clavicular head, secondary coracobrachialis and biceps, abduction = supraspinatus and middle deltoid
How do you palpate the superior and inferior medial scapula borders
Follow spine to medial border and go above/below, superior medial border tilts anteriorly so you have to dig in
What is stress and how do you calculate it?
Force per cross-sectional unit of material, S=F/A force over area, expressed in pascals (N/m2)
What is the speeds test and what is another follow up test
Forward flex arm supinated against resistance, pain = biceps tendonitis - elicit pain due to tendonitis of the long head of biceps via isometric resistance applied to the shoulder, resist flexion and supination, can also do yergason's test to apply isometric resistance at elbow/forearm to see if shoulder pain is reproduced, resist flexion
What is the predominant function of fibrocartilage and how does this relate to the type of collagen?
Found in joints with little motion such as intervertebral discs, glenoid and acetabular labra, articular surface of the temporomandibular and SI joints, meniscus, -Less water and proteoglycans and a greater percentage of collagen than articular cartilage (mostly type I collagen compared to type II in hyaline) -T1 collagen has varying organization and orientation, traps and retains water in collagen network instead of using proteoglycans to attract and hold water -Has some blood supply, typical only in peripheral regions, like hyaline is avascular in more central regions -Relies on diffusion through loading for nutrient exchange in central portions -Relies on dynamic mechanical loading for adequate nutrient exchange for tissue life
What are the 3 types of cartilage
Hyaline, fibrocartilage, elastic
What are the 6 levels and stages of reflection that one may experience at any given time?
Level 1: zero reflection/me stance/disconnected - vent feelings -Level 2: empathetic reflection/observer stance/empathetic connection - put Ed in the company's shoes -Level 3: relational reflection/you and me/us stance/personal connection- look at relationships in company -Level 4: systematic reflection/you and me others stance/contextual connection - look at whole organization as a system -Level 5: self reflection/me (internalized stance), incorporating connection - moved from blame stance to understanding the system he worked in, what have you learned about yourself from this? -Level 6: transcendental reflection/other universal stance/universal connection - other areas Ed can work on about himself outside of work
How does the composition of articular (hyaline) cartilage compare to that of ligament and tendon? What is the predominant function of articular (hyaline) cartilage and how does this relate to type of collagen? Upon what forces is this dependent?
Loading forces, same structure as other connective tissues with a small cellular component and large extracellular matrix but the ECM contains much more interfibrillar material than that of tendons or ligaments - more PGs/GAGS to hold water and more type 2 collagen, -Unlike ligaments/tendons ECM has a large proportion of proteoglycans and GAGs along with a lot of water -Most is type II collagen that forms surrounding mesh and compresses the proteoglycans and attached water molecules -Low coefficient of friction - 20x lower than ice on ice, smooth motion -1-3 mm thick -Avascular and aneural - relies on diffusion for its nutrient supply -Relies on fluid flow to maintain health - proteoglycans attract water that creates a swelling pressure in the T2 collagen meshwork they are held in -Compression increases the swelling pressure resulting in tensile stresses in the collagen fibers - like squeezing water balloon, increased pressure in outer material -When compressed, some fluid moves out of the cartilage into the joint space through pores in superficial layer of cartilage -When compressive force removed fluid flows back into the cartilage -Repetitive fluid flow allows nutrients to be brought in and waste removal, dynamic mechanical loading can come from joint motion and weight bearing activity - ex. walking
Long head vs short head of biceps
Long head travels through shoulder, common source of pain, functionally unimportant, may rupture, short head inserts in coracoid process, outside shoulder joint, functionally important, rarely a problem, distal insertion on radial tuberosity may develop tendinopathy/rupture
What causes a bending strain?
Longitudinal load on both ends of bone creates tensile stress above on convex side and compressive stress below on convex side
What start up movements did we do in class
Move, stretch, contract, cool down, wall slides with head shoulders butt contact, doorway stretch up/down different trap muscles, cat/camel, pushup/plant with shrugs, shoulder clocks/circles
Gate control theory of pain
Nociceptive signals can be inhibited at the spinal cord by nonnociceptive input
Describe the path of nociception to the brain
Nociceptor detects pain and either A delta or C fiber sends signal to dorsal horn of spinal cord, cross over, spinothalamic tract goes to thalamus, thalamus projects to primary somatosensory cortex
Osteokinematics vs arthrokinematics
Osteokinematics - rotary movement of the bones in space during physiological joint motion - observable movements of the bony levels in the sagittal, frontal, and transverse planes that occur at joints, typically described by the plane in which they occur, the axis by which they occur, and the direction of movement -Ex. Osteokinematic movements at the knee joint include F/E of the tibia on the femur in the sagittal plane on a coronal axis Arthrokinematics - accessory motion, refers to movements of joint surfaces relative to one another, often one is stable and serves as a base for motion while the other surface rolls, slides or spins
GH joint: Primary and secondary movers for shoulder flexion
PM are anterior deltoid and pec major clavicular head, SM are biceps brachii and coracobrachialis
GH joint: Primary and secondary movers for shoulder extension
PM are posterior deltoid and latissimus dorsi, SM are triceps brachii long head, pec major sternal head, teres major
GH joint: Primary and secondary movers for shoulder lateral rotation
PM infraspinatus and teres minor, SM posterior deltoid
ST joint: primary and secondary movers for depression
PM lower trapezius, SM latissimus dorsi and pec minor
ST joint: primary and secondary movers for retraction
PM middle trapezius and rhomboids
GH joint: Primary and secondary movers for shoulder adduction
PM pectoralis major, latissimus dorsi, teres major, SM coracobrachialis
GH joint: Primary and secondary movers for shoulder medial rotation
PM pectoralis major, subscapularis, teres major, SM latissimus dorsi, anterior deltoid
ST joint: primary and secondary movers for downward rotation
PM rhomboids and latissimus dorsi, SM levator scapula and pec minor
ST joint: primary and secondary movers for upward rotation
PM serratus anterior and upper trapezius, SM lower trapezius
ST joint: primary and secondary movers for protraction
PM serratus anterior, pec major, SM pec minor
GH joint: Primary and secondary movers for shoulder abduction
PM supraspinatus and middle deltoid
ST joint: primary and secondary movers for elevation
PM upper trapezius, SM levator scapulae and rhomboids
Hyperalgesia
Pain from noxious stimuli with an intensity or duration out of proportion of the stimulus (part of central sensitization)
What is the difference between patient and relationship centered care?
Patient centered care focuses on the patient's illness experience, acknowledges each patient and family as unique, and considers culture, personality, and related factors relevant to the process of health care, patient rather than disease is central Relationship centered care enhances patient centered care by including ways a patient and a physician relate to one another, physician understands his or her interactions with patients influence the course and outcome of care
What is strain and how do you calculate it?
Percentage change in the length or cross-section of a structure or material, Strain = (L2-L1)/L1, expressed as percentage with no units
Without concern at this time as to the axes or magnitude (degrees) of contributions, what roles do the acromioclavicular joint and sternoclavicular joint play in scapular motion during elevation of the arm?
Posterior rotation and elevation?
Nociceptive vs. neuropathic pain.
Primary chronic nociceptive pain -Pain from stimulation of nociceptors by mechanical, chemical, or thermal stimuli mediated by intact CNS -Usually clear stimulus response between movement/position and sx, felt at or near the site of injury but may be referred to other areas of the body Peripheral neuropathic pain -Arises as a direct consequence of a lesion or disease affecting the peripheral nerves -Typically manifests as nerve trunk pain and dysesthetic pain or both - nerve trunk pain is deep and aching, dysesthetic is from damaged or regenerating neuronal fibers, electrical/burning/lancinating quality -Worsened by activities that compress or stretch the involved nerves -Signs include pain with active and passive ROM of the involved limb, tenderness to palpation of the involved nerve, tenderness/inflammation of tissue enervated -Treat with education on peripheral nerves, gentle movement to help restore circulation, treating local dysfunction affecting nerve, ES/cold/heat to gate pain sensation, strength/conditioning program -Nerve conduction may be compromised if accompanied by negative sx such as hypoesthesia and weakness
Primary and secondary motions of the ST joint - includes the SC and AC joints
Primary is upward/downward rotation, elevation/depression, protraction/retraction, secondary is anterior/posterior tilting and IR/ER
Proteoglycans (PGs)
Proteins found in connective tissue, ground substance = mix of PGs and water, GAGs attach to PGs -Form a reservoir for nutrients and growth factors that attach to these molecules -Play a role in directing/limiting the size of collagen fibrils -Tissues with high compressive forces like cartilage have more PG, with different GAGs than tissues that resist tensile forces, tissues subjected to compressive vs tensile forces have different PGs
What is the lift off test
Put hands behind back clasped and lift off back, tests for subscapularis IR
In inspecting AROM what should you pay attention to
Quantity (goniometer degrees), quality (smooth? SH rhythm normal?), symptoms (at what point is there pain?)
Allodynia
Sensitivity to normally innocuous stimuli such as brushing or light touch (part of central sensitization)
Function of Sharpey's fibers
Serve as "roots" for tendon or ligament in attaching to the periosteum of bone attached to underlying cortical bone via Sharpey's fibers
Where do you align the goniometer for the shoulder and for the knee?
Shoulder greater tubercle, lateral epicondyle of humerus, olecranon, knee greater trochanter of femur, lateral epicondyle of femur, lateral malleolus of fibula
C fibers
Small unmyelinated nerve fibers that transmit APS relatively slowly - 1.0-4.0 m/s, dull, throbbing, aching, or burning pain that may even be reported as tingling or tapping, pain has a slow onset after initial noxious stimulus, is long lasting, diffusely localized when stimulus is intense, often emotionally difficult for patients to tolerate, accompanied by autonomic sweating/increased HR and BP, nausea, pain can be reduced by opioids
Considering the lines of pull of the muscles, explain why the deltoid needs the synergy of the rotator cuff muscles when the deltoid is flexing or abducting the arm.
Supraspinatus has more of a superior pull while the other 3 have more of a downward pull, all compress the humeral head in the glenoid, supraspinatus is most compressive and can independently abduct the humerus
What is the difference between T1, T2, and T3 collagen?
T1 found in tendons bone, ligaments, skin, anulus fibrosis, menisci, fibrocartilage, joint capsules, cornea and accounts for 90% of body collagen, T2 is hyaline articular cartilage, nucleus pulposus, vitreous humor, T3 sound in skin, blood vessels, tendons, ligaments
Discuss two evidenced based models of communication and relationship competencies that can be utilized in practice when working with a patient and their family according to Rider (BPEE)
The four habits model and the Kalamazoo consensus statement framework, the four habits model is invest in the beginning, elicit the patient's perspective, demonstrate empathy, invest in the end and kalamazoo is build a relationship through interview, open the discussion, gather information, understand the patient's perspective, share information, reach agreement, provide closure
What type of joints are the glenohumeral and tibiofemoral? Describe key features of this type of joint.
The glenohumeral joint is a multiaxial, ball and socket joint, while the tibiofemoral joint is a uniaxial hinge joint. However, they are both synovial joints.
Young's modulus
The slope of the elastic region of the stress strain curve, change in stress over change in strain
Trabeculae
Thin plates in cancellous bone laid according to stress placed on bone, bone density changes across a bone depending on the loads placed on it
What is type I vs type II collagen better for?
Type 1 better for tensile strength and type II better for compressive strength
What muscles help do upward rotation of the scapula and what help with downward rotation?
Upper and lower trap and serratus anterior help with upward rotation, levator scapulae and rhomboids help with downward rotation
What is the primary motion of the scapula during elevation of the arm?
Upward rotation
A delta fibers
small diameter myelinated fibers that transmit AP faster than C fibers at approximately 30 m/s, more sensitive to high intensity mechanical stimulation, can also respond to heat/cold, pain is sharp, stabbing, prickling, pain sensations have quick onset after noxious stimulus, last only a short time, localized to area from which stimulus arose, not generally involved with emotions, not blocked by opioids -Generally 50% sensory fibers in a cutaneous nerve have nociceptive functions, 80% are C fibers and remaining 20% are A delta fibers -If a brick lands on someone's foot the initial sharp sensation is transmitted by A delta fibers in response to high intensity mechanical stimulation of the nociceptors from impact of the brick, later deep ache transmitted by C fibers and provoked by chemical mediators of inflammation released after initial injury and by mechanical stimulation
Synovial Joint Capsule:
•Fibrous Capsule (» Capsule) -Gets nutrition from superficial and penetrating blood vessels -Effectively same as capsular (and extracapsular) ligaments in most ways •Synovial Membrane: -Intima: lining cells responsible for production of synovial fluid and nutrient/waste exchange; -Subsynovial lining: carries blood vessels to and support intima (Merges with periosteum).
Synovial fluid
•Nourishes hyaline cartilage •Small amounts of Plasma-like fluid, plus: -Hyaluronate: Viscosity à âfriction •Resistance to shear inverse to rate of shear •átemperature à âviscosity -Lubricin: cartilage-on-cartilage lubrication •Boundary lubrication •Fluid-film lubrication
