MIDTERM General Clinical Ortho, Ankle and Foot, Joint Mob, Soft Tissue Mobilization, Documentation, Clinical Ortho Knee, Hip, Peds, Spine

ICF Model, what 2 levels is intervention focused on?

-Health Condition (disorder or disease)—> 1. Body structure and function (ROM, strength, mood, endurance, pain, sensation) 2. AL (walk, bathe, dress, driving, sitting, work/school tasks) 3. PR (go to work, school, parent, athlete) -contextual/personal (background, features not part of health condition: sex, age, gender, lifestyle, habits) and environmental factors both funnel into these -*interventions/TS mainly focus at body struc and func and AL level*

Findings for Pts respond better after manipulation for ankle sprain

-3 of 4 findings (manipulation = fast) 1. Symps worse when standing 2. Symps worse in evening 3. Navicular drop greater or squal to .5mm 4. Distal tibfib Joint hypomob (compared to other side)

1. What is the best treatment for LBP with cognitive or affective tendencies?

-may be depressed, high fear avoidance, pain catastrophizing -2 Qs Dep : little interest or pleasure in doings things, felt down depressed hopeless past month -Fear Avoidance therapy focus de emphasize anatomical correlations, encouraged pts to take active roll, educated that LBP is condition *not disease*, performed graded ex program (general LBP program) -this method showed to lower disability scores and pain scales in high FABQ pts -pts with low FABQ when given therapy had more disability than indiv with standard care (so actually make non fear avoidance pts do worse then normally would have)

1. What is cavitation? What to do if you dont get it? 2. When is manip effective in treating LBP? 3. Consequences HVLAT? Contraindications? 4. Safe and effective HVLA techniques?

1. Formation of vapor and gas bubbles within fluid —> collapse vapor cavities to give noise, not necessarily better results if get -1/2 time come from targeted segments, other half no -if not get then move on to mob, STM, exercise (strength, stretch, bodymechanics/posture) 2. *With acute LBP higher result*, chronic not so much 3. L/S = fracture, HNP, cauda equina Syndrome -lack of consent, lack of approp diagnosis, age (children or elderly), bone path (RA, cancer, tumor, infection), lig instab, pregnancy, neuro symps, inflamm (RA/downs), vascular (VBI), bleeding diatheses 4. Position locking, min leverage thrust, *do not perform at END RANGE*, final minor adjustment

Assessment of Joint Mob: Osteo and arthro, where is AOR, treatment plane? Joint pos? How to measure

1. Osteokinematics: movement of bone around axis 2. Arthrokinematics: movement of bone around another bone -ant/post glides, traction, compression (not used in tx, only for assessment if no pain resting/NWB, see if have pain with comp) 3. Joint Surfaces: talus convex in reference to concave navic (moon) -in joints with multiple artic go with largest (talus and calc go with post calc convex) 4. Treatment Plane: in concave joint surface 5. Joint position: joint at end of flexion, extension, mid range (resting, open or closed packed) 6. Grades of motion

Normal End Feels and Abnormal and IDign Pathological Joint

1. Soft: charac of soft tissue approx (knee flexion) or soft tissue stretching (ankle DF with knee ext) 2. Firm: charac of muscular or capsular/ligamentous end feel -firm endfeel is variable among indiv dep on age, size, degen changes 3. Hard: occurs when bone or cartilage meet (elbow extension and flex) -*abnormal*: when different than expected end feel of joint or occurs at diff point in range than is normal -dysfunctional joint look for *quality, quantity and end feel* -hypomobile joint = stop occur sooner -hyper = later

1. What is the difference between the spondys? 2. What is lumbar instability and how does this differ? 3. What ICF category would these be put in? How would they present? 4. Which treatment category would they benefit from? Why?

1. Spondylolysis: defect or weakening of pars interarticularis without ant slippage -mainly at L5/S1 from stress fracture in young athletes or congenital failure ossification of pars -Spondylolisthesis: ant slippage bc fractured pars (Grades 1-5, 3 or above = surgery) -high in football and gymnasts, pain with extension, can cause nerve compression, may have palpable step off 2. Lumbar instab typically 20-40 y o, needs to change pos often, may have directional pref towards flex but *end ranges hurt* -inconsistent hypomob and often not correlated with radiographs -so unlike spondy cant see with radiograph but cause same instab issues just No fracture pars, general instab 3. LBP with movement coordination impairments: Movement coord can be LBP and associated (referred) LE pain (acute, subacute, chronic) -restricted lumbar ROM adn segmental mob (segment hypermob may be present) -movement coord impair lumbopelvic regions/mob defecits thorax/lumbopelvic/hip regions -diminished *endurance tests* trunk or pelvis 4. Stabilization: factors favoring are pos PIT, aberrant motion, younger age <40,m SLP >90 (new way says just 1st 2) -spondythesis group respond well to exercises motor control TA and Lumbar Mult -broaden term stab ex of TA and LM to "motor control ex" where reteach how to activate SKMS (LBP pts show decreased activation these SKMS when lift arms etc) -shown to be more effective than graded exercises for instab pts -stab exercises not shown to benefit general LBP pts more than general exercise program, just those with instab *so stab exercises not for all LBP pts!* -Always want to *fix impairments that pull them into extension* (tight hip flexors, tight QL, back extensors) -Extension peripheralizes so do STM to anything that pull her into extension (QL, erector, so not in extended) -PA hip to get mor hip extension so back not inextension -Flexed pos so glutes prob weak, work on that to help extend hip so not overextend lumbar

LE Neuro Exam

*DO BEFORE MANIPS!* Reflexes: Patellar Tendon: L4, Achilles: S1, Babinsky Sensory Testing: 7 General Screening Spots • L2 = Lat Fem Cut • L3 = Femoral • L4 = saphenous • L5 = deep peroneal • L5/S1 = superficial peroneal • S1 = Sural • S2 = Post fem cut Myotomes: hip flexion L2 (femoral) iliopsoas rec fem L3: knee extension (femoral) Quads L4: DF (deep peroneal) Tib ant L5: toe ext (deep peroneal) EHL, EDL S1: PF (tibial) gastroc soleus L2 tie your shoe, L3 extend your knee, L4 heel to floor, L5 toe to sky, S1 touch the sun -*SLR*: PROM (hip flex knee ext, DF), symps felt between 35-70 -SLR —> symps bring down to where stop then DF to see if bring on or cervical flexion -*Slump*: PROM (DF, cervical, slump, knee ext), put hands behind back

1. What is the classification system for LBP and Leg Pain 2. What are ways to treat?

- can be for radicular or referred LE pain 1. Neuropathic Sensitization Grup: "centralized pain" -ramping up of CNS where have paresthesias/ANS changes (sweating, cold, burning pain, hypersensitivity to pinprick/touch/pain) -no normal pain sensation 2. Denervation Group: Happens with *prolonged injury to nerve* -see reflex changes, SKM Power defecits, defecits in sensation -may potentially require surgical intervention if come back 3. Peripheral Nerve Sensitization: no centralization of symptoms, no neuro defecit (reflex changes, muscle power, sensory changes) just mechanical sensitivity of nerves (SLR/Slump) -nervous tissue irritated a bit (inflamm of nerve itself), mechanical sens of nerve 4. Musculoskeletal: synonymous with referred pain, leg pain without hypersensitivity, no Neuro defecits -no sensitivity of nerve itself when tension nerve but still leg pain so some type of Referred musculoskeletal issue (disc, facet) 2. Nerve Mob: only help group with peripheral nerve sensitization (group 3) -so just because someone has leg pain *nerve mob exercises may not help* -Traction: not help ppl with general LBP, only those with LBP with leg pain (can have reflex changes, sensory changes) -group most benefit from traction: presence of leg symps, signs of nerve root comp, peripheralization with extension movements (stenosis or large herniated disc), crossed SLR (contra SLR elicit pain on ipsi side = sign large herniated disc)

STM uses, rules, contraindications (relative too)

-*uses*: address tissue restrictions (superficial to deep), reduce spasm, improve lympahtic flow/decrease edema, reduce pain, improve ROM/flex, increases temp exchange due to change peripheral blood flow, improve balance when combined with mob -*rules*: superficial layers FIRST then move to deep (deeper slower, superficial faster) -force applied in direction of max restriction -choice of technique depend on exgtent of restirction, amount discomfort, degree irritability -*contra*: infection, acute inflamm process, acute curculatory condition, obstructive edema, acute RA, sypersensitive skin, suture/hemmorrhage sites, fracture (acute), hypermob, DVT, constant severe pain, advanced diabetes -*relative contra*: joint effusion or inflamm, RA not in a state of exacerbation , presence of neuro signs, osteoporosis

Intervention by Irritability Level and What must all Interventions include

-Assessment Sign: amount of pain with walking etc -Prescribed Intervention -Parameters -Ability to describe potential compensations -Reassessment Sign (usually same as assessment sign, what we assess) -sometimes immediate (perform something see immediate change I.e. STM improve flex) -other times not: eccentric strengthening take long term to improve MMT

Choose your intervention/tx and ICF

-Knee pain with muscle power defecits -treatment: strengthening of hip abductors (glute med) -sidelying clams = minimize PF compression but maximize glute med -not standing bc high irritability -bc moderate severity and high irritability may want to target endurance parameters (bc needs to go up 12 stairs)

What is the treatment based classification system?

-4 categories can put patients in to determine approp treatment 1. *Manipulation*: not enough spine movement so need to get movement -*Clinical Practice Guidelines* for when to place pt here-4/5 97% chance manipulation will decrease disability by 50% with 2 tx a. No symptoms distal to knee b. Recent onset of symptoms (<16 days) c. Low FABQ score (low fear avoidance, <19) d. Hypomobility of lumbar spine e. Hip IR > 35 deg 2. *Stabilization*: unstable category; back moves too much, would benefit from stabilization -younger age (<40), + PIT, SLR >90, Aberrant motion -Greater general flexibility (post party,m, average SLR ROM >90) -aberrant catch/instab during flex/ext ROM -For pts *postpartum*: pos post pelvic pain provocation and ASLR and modified trendelenberg & Pain provocation with palp of long dorsal SI lig or pubic symph 3.*Specific Exercise*: pt would benefit from specific exercises based on periph/centralization phenom/findings a. Extension: for discogenic pathology, treat w/ ext ex -Symptoms distal to butt, *centralize* w/ lumbar extension, *Peripheralize* w/ lumbar flexion, Directional preference for extension b.Flexion: spinal stenosis likely, pain with stand and walk, go away when sit, treat with flexion ex -Older age (>50), Directional preference for flexion (widens spinal canal), Imaging evidence of *spinal stenosis* c. Lateral Shift: many times have to do w/ herniated disc and where it is relative to nerve root (shift towards or away) -Visible frontal plane deviation of shoulder relative to pelvis (shoulder left of pelvis = lat shift left), Directional preference for lateral translation of pelvis -*MUST TREAT LATERAL SHIFT FIRST* 4.Traction: signs and symptoms of nerve root compression, no movements centralize symptoms, periph w extension (stenosis or large herniated disc) pos crossed SLR (large herniated disc)

Procedure for Each Manipulation and Criteria/contraindications to Give Manip

-CPR: hypermob at at least 1 segment, low FABQ (>19), recent onset >16 days, no symps distal to knee, hip IR (4/5 = 97% chance decrease disab 50% with 2 tx) -Contra: lack of consent, lack of approp diagnosis, age (children or elderly), bone path (RA, cancer, tumor, infection), lig instab, pregnancy, neuro symps, inflamm (RA/downs), vascular (VBI), bleeding diva theses 1. Sidelying HVLA (high V low amplitude thrust): pt sidelying (towel if nec) —> straighten lower leg —> flex upper to segment (right before move) —> upper body rotation via grab arm —-> rotate down to proximal segment (right before move) —> pelvic rotation up to distal segment (right before move) —> adjustments to localize tension —> *LOG ROLL* to you so you over them —> stab thorax and gentle thrust down on pelvis (*body weight over humerus*) 2.General Lumbosacral HVLA: pt supine bring pelvis to you —> position lower limbs away —> cross contra leg over ipsi —> upper body away from you —> pt cross arms —> ID ASIS -> rotate pt to you via shoulder girdle *without lose sidebend* —> thrust in curved plane on contra ASIS

Explain the rehab protocol for tendinopathies.

-EdUReP 1. Educate on correct body pos (glute med weak = adduction = pronation etc) -Movement re education (windshield wipers from the hip not the knee so when stand can lift arch from glutes not knees) 2. Unload: doing things that wont load tendon: soft tissue, ice, exercises without a lot of pressure on post tib (windshield wipers, dont get them standing i.e heel raises or squatting) -maybe bracing/taping orthotic, assistive devices, modification to activities or task(stool to jump from truck so not load knee/ankle as jump from high up) -work on other body parts that are contributing to dysfunction (work on strengthen hip abductors so no valgus and no pronation) -sitting working on arch control 3. Reload: Strengthening for full WB activites and functional activites (calf raises, squats) -post tib tendon eccentric loadinf shown to be good and concentric during *WB* with band (ala can do calf raises or NWB with band), gastroc/soleus = calf raises -think about parameters (endurance, strength, hyper) 4. Prevent: think about the cause of the dysfunction (movement pattern, structural) so prevention should be aimed at changing that cause -changing body mechanics, movement re education -Maybe not overpronate, maybe valgus of knee so work on keeping knees out -Gain end range motion, gain strength elsewhere, train balance and higher function, EDU

Choose your Intervention/Tx and ICF

-Knee pain with Mob Def (then train movement coord) -treatment: soft tissue mob to right distal ITB sidelying in 40 deg of knee flexion bc this is where have pain -followed by medial patella tilt grade III oscillatory (higher grade bc sidelying so lower stress on joint) -oscillatory aimed to decrease pain (2-3 beats per second for 40 seconds)

Choose your intervention and ICF

-Knee pain with mobility deficits -STM of gastroc or soleus or joint mob (depending on what limiting) -right ankle DF movement with mob partial WB with knee flexed 40 deg (bc that's where have pain) -secondary to moderate severity adn high irrit

PFP Syndrome (MOI, what it is, aggravators)

-common overuse injury -mal alignment patella and femur lower contact Adam with higher mechanical stress -crepitus may be present -squatting, kneeling, stretch to the knee extensors and or prolonged sitting aggravates

Discoid Menisucs in Peds

-congenital where meniscus shaped like a disc (not a C shape, doesnt have bow tie in sagittal MRI) -big cartilage pad in meniscal space sp cant get full extension, popping, catching

1. What is OA and what are the stages? 2. What are the key things to keep in mind when dealing with a inmpatient post op THA?

-degeneration to the joint, damage to articular cart -stage 1 = fraying of articular cart -2 = fissures on cartilage disrupt cartilage matrix -3 = subchondral bone begin to harden and osteophytes form -4 = no articular cart (bone on bone) 2. TALK TO THE NURSE BEFORE ENTER = for how has been doing, meds etc -Prior level of function: help assist with goals (if in a wheelchair for 6 months before surgery, walking may not be good vs if high activity before) -home help/discharge situation: home with assistance vs inpatient rehab (insurance dictate) vs SNF (if inad assistance at home) -equipment they may need -*orthostatic hypotension*: low BP from sit up —> will be dizzy, white, sweating, cold clammy -*precautions*: post hip no flex, add, IR, ant ext, ER, add -adjust bed to how it is at home for bed mob (railing? Height?) and transfers on toilet important bc so low want to make sure can do and with precautions in mind (flexion) -look for ability and willingness to accept weight on leg -Neuro screen: post approach near sciatic so check hammie function (knee flex, bc sciatic innervate) and more distal (tibial and common fib PF, knee flexion may be too painful anyways to test) -usually dont check active ROM post op be pain and inhibition so do *active assisted*

Forces that act on the hip during gait and important muscles in gait

-high compressive forces at the hip during stance phase (high acetabular contact —> high compressive loads on hip especially mid stance) -If pt comes in with symptoms at certain phases of gait cycle can clue you in to pathologies -Beginning of gait cycle = add long, glute med, glute min -Lots of glute med especially in stance so important to be strong to control compressive forces at hip and stab

Ankle Manipulation (what it is, indications, pre treatment assessment, contraindications)

-high velocity thrust close to end range of motion that is repeated 2x and reassess in standing/walking 1. Indications to perform: pain felt at anterior ankle, restriction of talo crural DF in standing 2. Pretreatment assess: DF end feel knee extended and flexed -WB DF measurement (contribution of multiple joitns) -pain (what and where) -functional reach measurement (DF measure in standing degrees, anterior reach length) 3. COntra: lack of diagnosis (cant see what problem is so dont do just in case cause more damage) -pt pos cannot be achieved due to pain/resistance -lack of pt consent -age related: young children (not reach skeletal maturity) older people (fragile skeletal system)

Stress Vs Strain Curve and Grades of Tissue Tears and Talocrural Joint Sprain Specific (time to return to normal activities, swelling, ambulation)

-stress vs strain, have toe region, elastic region up to yield pt, then plastic region between yield and failure point -tendon, lig, bone (bone more steep, less deform to failure) 1. Grade 1: minor tear, fibers stretch but not tear, occur at yield point 2. Grade II: Partial tearing, occur inbetween yield and failure point 3. Grade III: Tissue tear completely, not able to handle anymore stress, occur at failure point -Grade I: mild swelling, full WB, 1-2 weeks -Grade II: moderate swell, full WB may need assistive device, 4-8 week -Grade III: severe swelling, limited to no ability ambulate without device, 12-16 weeks

ACL Sprain (MOI, acute and chronic presentation, surgical options) MCL and PCL Injury Pearls (MOI, what to avoid)

1. *ACL*: valgus knee force, hyperextension, rotation -70% non contact related from deceleration, cutting, pivoting -acute = swelling, laxity, pain -chronic = unstable joint, loss of function -*surgery*: BPTB (ant knee pain), hammies (strength losses up to 10%), allograft (high fial youth) 2. *MCL*: often accompanied by ACL injury (valgus stress) -avoid activites causing knee valgus stress (breastroke, *dependent pivot transfers*, W sitting 3. *PCL*: traumatic hyperflexion (tibia post) -avoid posterior tibial trans (kneeing on ground, knee extension ROM lie prone instead of supine so tibia glide post from gravity, avoid hammie activation (lunges, bridges) bc antagonist pull tib post)

General Red Flags

1. *fatigue* if interfere with daily activities, social life, work AND >2-4 weeks 2. *Fever* >99.5, unknown origin, >2wks, no MD consult 3. *weight loss* lose 5-10% body weight no change diet or ex, lose or gain 10-15 lb 2 weeks 4. *nausea* unknown origin and MD not aware OR worsening 5. *Orthpnea* (SOB when lying flat) severe at rest, related to position (esp supine) 6. *palpitations* (irregular heart beat or fluttering) if have with chest pain, lightheaded, dypsnea (SOB) diaphoresis (sweat) 7. *Peripheral Edema*: bilateral (CHF), whole body edema, sudden onset without traumatic event 8. *leg pain* with weak/absent pulses femoral, popliteal, post tib, dorsalis pedis 9. *cough* hemoptysis (blood) 10. *raised or elevated HR* w/ nausea, chest pain, SOB 11. *high BP* >180 systolic, >110 diastolic = emergence medical treatment especially with headache, dizzy, nausea 12. *high respiratory rate* w/ light headed, weak, chest discomfort 13. Paresthesia

1. What are the factors favoring/against specific exercise treatment? 2. Manipulation? 3. Stabilization? 4. Traction?

1. *for*: Strong preference for sitting or walking -centralization with motion testing -peripheralization in direction opp of centralization -*against*: LBP only - no distal symps (nothing to centralize) -no movements change symptoms (no periph/central) 2. *for*: CPR = no symptoms distal to the knee, recent onset (<16 days), low FABQ (l;ow fear avoidance <19), hypomobility lumbar spine, hip IR >35 (at least 1 hip) -4/5 yes = 97% chance disability will improve 50% w 2 tx -*against*: symps distal to knee (likely not facet issue bc not refer past knee, manip help facets), increasing episodic freq (may be move coord imp ICF/spondy or Lumbar instab where mob not help), periph w motion testing, no pain with mob testing 3. *for*: + prone instab test (pa on trouble segment to repro pain, lift legs pain go away pos bc recruiting all SKMS to stab (global skms) and in real life not activate local stab like mult so hurt), aberrant motion, younger age <40, SLR >90 (new modified CPR only include 1st 2) -*against*: neg PIT, absent aberrant, FABQ < 9 (low fear avoidance), no hypermob with lumbar spring testing 4. Can help LBP with leg pain (referred or radiating) *for*: presence of leg symps (referred or radiating), signs of nerve root compression, peripheralization with ext movements (discogenic), crossed SLR (SLR uninvolved repro symps on involved = high large likely herniated disc)

1. What are the 3 types of Goals? 2. What is the ABCDE format of goal setting? 3. What are the POC Components?

1. A) Participation Goals: purpose of PT intervention for this pt, specific roles in which pt wishes or needs to participate (play 12 holes of golf at country club with no device with pain less than 2/10 in 2 weeks B) Activity Goals: predicted functional performance at the end of therapy that will result from PT (walk 12 stairs w/o assistive device with pain less than 2/10 in 2 weeks) C) Impairments Goals: expected improvements in impairments of BSF that will result from therapy, *SHOULD BE RELATED TO ACTIVITY GOALS* (15 heel rises on left leg with no assistance with no pain in 2 weeks) 2. *Actor*: ID who will accomplish the goal (pt will...) *Behavior*: select the expected behavior (task, functional activity) -ID pts goals and expectations, relevant environmental and personal factors that can affect activity perf *Conditions*: deg context, circumstances, and support needed (in hospital corridor with rolling walker and supervision) *Degree*: deg a quantitative specification of perf (for 100 feet in less than 2 mins, 12 steps pain less than 2/10) -consistency (success rate, accuracy, frequency) flexibility (environ, conditions of activity) efficiency (time, distance, speed) *Expected time*: deg time period to achieve goal 3. Intervention plan: proposed frequency and duration of visits, planned date for re eval and or anticipated discharge, 3 types of interventions (coordination and comm, patient related instruction, treatments), documented informed consent

1. What are some hip impairments that can lead to LBP? 2. What are some ways to assess LBP stemming from the hips?

1. A) weak abductors —> contralateral pelvic drop —> ipsilateral trunk lean (*hip fatigue leads to greater postural changes than from ankle fatigue during SLS*) -could also be from hip adductor tightness which is causing them to have difficulty activating hip abductors = drop B) Limited hip extension from hip flexor tightness (lead to dircumduction or ER of pelvis which stresses back) -Also tight hip flexors = ant tilt pelvis (iliacus originate iliac fossa, psoas at ant T12-L4) = extend lumbar or psoas can directly pull spine C) Tight hip extensors = prevent ant pelvic tilt when sitting so post tilt and spine flexed so LBP -Want to unload tissue early on in to so can give pt something right away to use to take load off -Roll for behind back, wedge to sit on to decrease hip flexion -can teach ant pelvic tilt by sitting on a higher surface so hips less flexed -cue pelvis move NOT extend back, demonstrate on higher surface then go to lower (where will be more difficult) -so cue them at work need hips higher than knees (high surface) to promote ant tilt 2. Assessments for LBP: Look at posture for ant pelvic tilt -Sit to stand to see if lean to one side bc weakness on the other - To see if really is hip issue (ant pelvic tilt) that is causing back pain then do Thomas test to see if tight -Defecits in single joint hip flexors = STM iliopsoas and stretching -pt tight hip flexors = may have hip extensor inhibition (bc cant extend when hip flexors tight) so would do MMT hip ext for baseline, STM hip flexors, then MMT again extensors to see if improve

1. How does the treatment based classification system differ from the Clinical Practice Guidelines (ICF) categories? 2. Compare and Contrast the outcomes of Manipulation vs Mobilzation

1. CBG parallels TBC with 3 exceptions: -Incorporates ICF terminology of body function impairments -Addresses psychosocial domains by adding LBP w/ related cog and affective disorders & generalized pain -Assesses Levels of acuity in terms of duration of symps and relat to movement 2. Manip: Found that can get someone 50% Better in 2 tx with manip if fit CPR and given manip -BUT of other 3 groups those that had manip even tho negative on CPR so not fit category = still improved (slightly better than other groups) -manip (sidelying and thrust tested) compared to PA mob on pts who fit manip CPRs showed that manips improved symps 50%, mob less but still work -Mob: study with pts that fit manip TBC received manip or receive PA mob show that MOB still help improve pain, disability, motion just slightly less than manip -*so mobs still work if pt not comfortable w manip*

1. How would a patient with LBP w Mob Defecits present? Manual exam findings? 2. Acute vs Chronic findings and tx? 3. What TBC category would they fit into? Tx?

1. Can't move a lot, Usually *facet* pathology, unilateral LBP local non radiating but referral into butt or thigh -onset from strain, unguarded move, awk move -presence of lumbar, thoracic, pelvic girdle or hip segmental motion def -symps repro e end range spinal motion (bc facets compress most here) and provocation of involved lower thoracic, lumbar or SI joints -*findings*: limited lumbar spine, thorax, pelvic girdle or hip ROM -limited segmental mob, soft tissue palp = restriction or SKM guarding, limited excursion LE SKM length tests -repro of symps with provocation of involved lower T, lumbar or SI segments 2. *acute*: distinguishing features = restricted ROM and segmental mob, symps repro w provocation of involved segments -tx: mob/manip focused on improving mob and reducing pain -*subactute*: distinguishing features = pain occurs mid to end rages, symps repro w provocation of involved segments -tx: mob/manip focused on improving mid to end ranges 3. Manipulation TBC bc not getting enough movement -can also do ob treatments like sidelying rot or bolster sidebending to open up facets on side facing up

Joint Position and Mobilization and how use and Positions of Ankle Joint

1. Closed Packed: one closed packed pos, movement actively or passively very limited 2. Open Packed: many open packed (everything else is open if not closed or resting) 3. Resting: one resting pos, most open packed = allow most amount of accessory movements (glides, compression, traction) -used to *assess* joint's mob and *tx* in early stages/begin with resting pos (joint have most amount of move so expect most amount all directions) -improve motion in many directions with use of open Packed positions (make less open packed for more intense tx I.e. post glide to improve DF range, make more DF away from 10-15 deg PF (resting) to make to more intense) -*do not treat in closed packed* -ANKLE: closed = max DF -open = all pos not closed packed -resting 10-15 PF midway between maximal inversion and eversion

What are the Components of a Diagnosis Statement?

1. Differential diagnosis: ID of the nature and location of path (ID of the Syndrome, health condition or target disorder) 2. Classification: determine etiology (analysis of *causal* factors producing path = acute strain likely the result of repet overhead activities while painting...) -movement system or other recognized classification system 3. Relation to AL and PR: analysis of functional consequences of the condition and how interfering with partic in key roles (pain and weakness interfere with normal ADLS esp dressing)

Stages of Tissue Healing and Symptoms/Patient Level at Each (for intervention planning)

1. Hemostasis: after injury up to 6-8 hrs, can last 2 days (bleeding/stop bleeding (clots form)) -highly irrit, difficulty finding pos of comfort, impaired ROM 2. Inflamm: after injury up to 7-10 days peaks 2-3 hrs (blood vessel dilation) -irrit improving, capsular restrictions in specific areas of sapsule, SKM inhibition, SKM length impairments 3. Proliferation: 1 day after injury up to 6 wks, peaks 2-3 wks (ECM begin to form) -restriction of capsule improved but remain, strength and flex impair 4. Remodeling: 2-3 days after injury up to *1 year*, peaks 3 months -functional limitations resolving, strength impairments improving but remain, underlying path considerations

What is the Acute Care Intervention Planning Continuum for the Different Stages of TIssue Healing? (Abilities for each stage)

1. Hemostasis: after injury up to 6-8 hrs, can last 2 days (bleeding/stop bleeding (clots form)) -highly irrit, difficulty finding pos of comfort, impaired ROM 2. Inflamm: after injury up to 7-10 days peaks 2-3 hrs (blood vessel dilation) -irrit improving, capsular restrictions in specific areas of sapsule, SKM inhibition, SKM length impairments 3. Proliferation: 1 day after injury up to 6 wks, peaks 2-3 wks (ECM begin to form) -restriction of capsule improved but remain, strength and flex impair 4. Remodeling: 2-3 days after injury up to *1 year*, peaks 3 months -functional limitations resolving, strength impairments improving but remain, underlying path considerations

Movement Analysis Steps (what do do first, second theird etc) and how to develop POC (what is imp about movement anal?)

1. ID what is going on: PRIMARY BSF 2. Hypo what is happening 3. Assess the impairments appropriately 4. Develop Goals -*POC*: assess, treat, reassess -look for impairment improvement (does the impairment change after tx) and functional improvement (does the movement change after tx)

Kaltenborn and Maitland's Approach to Joint Play Testing

1. Kaltenborn: used to describe amount of movement and perceived resistance during manual joint testing (*joint stretch*) -emphasis on straight line movement within joint -feel for abnormal resistance to motion w/ emphasis on *end feel* -during testing glides often repeated several times using diff speeds of movement (repeat so can get accurate assessment of mob in case person guarding or your mistake) -*3 point scale of grades*: 1. Grade I: *loosening* movement, very small traction/separation, nullifies normal compressive forces on joint (up to point where take up slack) 2. Grade II: *tightening* movement first takes up slack in tissue surrounding joint then tightens tissues (slack —> midway/*R1*) 3. Grade III: *stretching* movement applied after slack has been taken up and all tissues become taut (midway/R1 —> *R2*) -*HOLD THE POSITION for 7-10 seconds* and repeat 3x 2. Maitland: joint play using both rotational and translational movement in a joint (to alleviate *pain*, allow synovial fluid mob, exchange fluid bet tissues) -oscillatory Movements (*2-3 applications per sec for 40 sec*) -feel for abnormal resistance to motion and monitors pt symp -Grade 1: *beginning range*, a small amplitude (small amount of movement) at beginning of movement -2: *mid/free range*, large amplitude performed within free range but not moving into any resistance -3: *mid range to end range*, large amplitude performed up to limits of perceived range -4: *end range*, small amplitude performed at limit of perceived range -*grade 1 and 2 for pain reduction, 3 and 4 for increase ROM* -*REASSESS TO SEE IF HELP REDUCE PAIN*

1. What ICF category would SIJ dysfunction be in? How would they present? 2. What pop is this condition common in? 3. Where is their pain? 4. How do you determine SIJ path? What to look for? 5. What are possible interventions?

1. LBP with mob def: unilateral LBP with local not radiating pain, can be referred to butt or thigh -onset from strain, unguarded move, awk move/pos -lumbar, thoracic, pelvic girdle or hip segmental motion def -symps reprod with end range spinal motion and provocation of involved lower thoracic lumbar or SI joints (end range = provoke these areas) 2. Post partum (lig lax needed to give brith), not common males >50 3. May be localized to PSIS or just inferior, may radiate to butt or groin region -more pronounced with single leg standing or landing one leg 4. Laslett Cluster 3/4 = 94% sens (distraction, thigh thrust, compression, sacral thrust), palpation of bony landmarks for symmetry to det side of dysfunction (PSIS, ASIS, Sacrum, ligaments), ASLR (SLR while you compress to mimic SKM stab see if no pain and go farther) -Can use Gillet march test: one hand on PSIS other on S2, flex leg of PSIS, PSIS should go inferior to S2 to indicate pelvis post tilt before sacrum move = dissociated move -Forward bend test: both thumbs PSIS bend forward lumbar spine should flex then sacrum nutate them PSIS ant rot (inominate rotate after sacrum, if not then hypomobile SIJ) -Sacral Rotation Test: palpate bilateral sacral sulcus, pt sidebend to illicit pain and you feel for sacrum to contralateral rotate to side of sidebend (bc follow lumbar spine coupling) so sulcus on side sidebend should get deeper/move away (sidebend right, sacrum rot left, if not then SIJ hypomob) -looking at mobility SIJ and *change in symps* 5. Active mobilization: isometric SKM activation to bring SIJ into Alignment (use hip flex/ext for unilateral tilt, piriformis/mult for sacral rot) -piriformis attach ant sacrum —> greater troch so ER femur so hold femur stable at contract = pull sacrum forward -mult contralateral rotate spine so stab spine = bring sacrum back -Passive Mob: you ant/post rotate one side of inominate or rotate sacrum to neutral

Sources of Hip Pain and Movement Dysfunction

1. Local Neuro/Musculoskeletal: intra articular (capsule, labrum, osseous structures) extra articular (muscles, tendons, bursae, local peripheral nerves) 2. Remote/Referred Neuro/Musculoskeletal: regions that can refer symptoms to the hip -lumbar spine: facet joints of lower lumbar spine can refer and nerve roots -L1 & L2 refer anteriorly -L3 & L4 refer laterally -L4 & L5 refer posteriorly 3. Systemic/visceral sources: genitourinary (hurt when pee?), inguinal hernias (especially in males, pain with cough or sneeze, laugh), local infection (recent surgery, drug use, fever, recent illness?)

What is the relationship for manipulations and stabilizatin treatments for LBP pts (criteria for when to use each)? What are their outcomes when applied to different LBP groups?

1. Manip: CPR = no symps distal to knee, recent onset <16 days), low FABQ <19), hypomob lumbar spine, hip IR >35 2. Stab: younger age <40, pos PIT, SLR >90, Aberrant Movements present -pts with LBP who met CPR for lumbar manip showed increase TA and LM SKM thickness immediately after manip which could help with recruitment of tissues -manip also help with people negative on rule even more than exercise help with those pos and neg on rule (help everyone) -stab shown to not be any more effective at helping pts without instab than general exercise (only superior benefits for those with lumbar instab/spondy) -

1. How do you determine the appropriate management approach for a LBP patient (triage by the first contact health care provider)? 2. What about the appropriate rehabilitation approach once a pt is triaged to rehab management?

1. Must determine If pt is appropriate for PT, needs medical management or self care management A) medical management indicated by red flags present in interview, medical comorbiditis that would interfere with rehab, leg pain with progressive neurologic deficits B) rehabilitation management: medium to low psychosocial risk status (fear avoidance), low psychosocial risk status with predominantly leg pain, Minot or controlled medical comorbidities C) Self care management: low psychological risk status, predominantly axial LBP, minor or controlled comorbidities 3. 3 categories to put them in and they can progress through A) Symptom Modulation: intervention focus on controlling their symptoms bc high -recent (new or recurrent) symptoms, avoid certain postures, AROM limited/painful -neuro exam can reveal increased sensitivity -*tx*: directional preference exercises, manip/mob, traction, active rest B) Movement Control: interventions to improve quality of movement -AROM may be full with *abberrant motions*, impaired flexibility, activation, control *tx*: improve *quality of movement* via local (nerve, joint, soft tissue) and global stab (activation, acquisition/disassociate/coordinate motion of lumbar from LE/UE, assimilation/subconscious control of multiplanar movement into ALDS) -do via sensorimotor exercises (recruiting correct SKMS), stab exercises, flexibility exercises/STM (bc tissue dysfunction in other areas can lead to movement impairment at back) C) Functional Optimization: intervention focused on maximize physical performance, getting people back to what they want to do -aggravated by movement system fatigue (get tired at end of exercise), impaired endurance, strength, power -*tx*: strength and conditioning exercises, work or sport specific tasks, aerobic exercises, general fitness exercises

1. What are some characteristics of LBP with radiating pain? What causes it? 2. What are some physical exam components? 3. Interventions?

1. Nerve root inflamm from disc disorder, Stenosis or nerve irrit from local tissue inflamm -onset is insidious with gradual buildup or trauma assoc with flex & rot or axial load/compression -have numbness/tingle into LE with *dermatomal dist*, weakness into LE within myotomal pattern, pain in LB or butt and or LE -symptom repro with ext > ipsi side > ipsi rot for nerve compression same side as LE sumo -disc then flexion, Slump and SLR for limited nerve mob -relief with nerve decomp and unloading pos (contra sidebend > flexion) -*stage of tissue healing important* to consider for symptom patterns 2. Posture observation (DP, lateral shift), lumbar spine ROM (active, response to repeated motion, overpressure as needed), neuro exam (MMT, sensation, DTRs, Nerve tension SLR/Slump) 3. Pt education for positions that reduce strain/compression nerve root -manual mechanical traction or manual therapy for adjacent tissues to involved nerve roots with mob def -neural mob exercises in pain free ranges

Analyzing Patient's Movements: Reasons for Altered Movement and General Pain Patterns

1. Pain: what are the pain generating structures of the region -trauma, overuse -we can change this via soft tissue, joint mob, edu, modalities 2. Neuromuscular: strength or control issue (not strong enough to move right way vs not have control of movement to do right way) 3. ROM: bony deformity, joint path, shortened SKM 4. Habit: work, sport, leisure 5. Structural Deformity (mild to extreme, not a lot we can do about this)

What is balance defined as? What are the 3 systems involved? What is proprioception? Where are the receptors located? What are signs of deficits?

1. Persons ability to maintain pos, voluntarily move and react to perturbation while control body COM in respect to BOS -involves vestibular, visual and somatosensory 2. Proprioception: important role in coordinating SKM activity, where body is in space (sensory input involving static joint pos, joint move, V of move, force os SKM contraction) -*can be conscious (limb placement) or unconscious (modulation of SKM function)* -receptors in skin, joint capsules, ligs SKMS, musculoskeletal tendinosis junctions 3. Rhomberg/Sharpened >30 sec -SLB unequal between sides

Directions of Arthrokinematic Testing (ankle specific) and order

1. Posterior glide: post glide tibia on talus = increase PF, post glide talus = increase DF 2. Anterior: tibia = DF, talus = PF 3. Traction: sep of joint surface, should not cause pain if does then indicates path 4. Compression: useful as an assessment tool if joint not painful at rest or MWB (if painful w/ comp then = path) -NOT USED IN TX tho -traction first bc usually relieve pain, compression last bc provocative

Peds Injuries: what types Common, classifications

1. Salter Harris Fracture Classification Growth Plate Injuries: *Important to know where the fracture occurs (above or below growth plate) to see how it will impact them functionally later* -Goes from least to most involved -Type 1 = traction injury, nothing crossing growth plate -Type 2 above growth plate -Type 3 below plate (picture misleading, not crossing the growth plate still underneath) -Type 4 through plate (now affecting plate) -Type 5 crush injury (fall from high injury and ram growth plate together and erase it) -Cannot recover function of growth plate once fracture (may have some growth on side not affected tho) 2. Avulsion Injuries: occur at apophyseal site (secondary ossification center and site of tendinosis attachment to bone) = weakest point of musculotendinous unit ACL and tibial eminence, patellar tendon and tibial tub/osgood schlatter -at risk after growth spurt (muscle adn tendon growth lag quickly behind bone growth creating tension at apophysis) -type 2 avulsion = microtrauma lead to bony prominences bc lay down new bone from repetitive stress over time —> can lead to full avulsion

1. What are the generalized guidelines to treat non specific LBP? 2. What are the characteristics of pts with an unclear classification of LBP?

1. Stay active w/ active rest -low stress aerobic exercise after 2 weeks and remain as active as possible within pain limits -remind them that most persons w/ LBP return to full working cap 2. Tend to be less affected by their pain (lower levels of disability, fewer fear avoidance beliefs, longer duration of back pain -so do not fit in any treatment based classification categories (manip, stab, specific moves, traction)

Components of The Examination

1. Subjective: health screening/subjective exam -preliminary assessment statement (a little about pt) -preliminary ID as appropriate for PT 2. Objective: task/movement Analysis -hypo of key impairments -tests and measures -final assessment statement (what do we have, what are we going to do about it, why) -GOALS: ABCDE format (actor, behavior, condition, degree, expected time) 3. Intervention: treatment (*EDUCATION IMPORTANT*) -directed toward BSF adn function impairments -directed toward AL -directed toward PR

STM techniques

1. Sustained pressure: maintain constant pressure while providing clockwise or counterclockwise force 2. Effleurage (massage): generalized technique with direction of force distal to prox (can use base of ulna, dorsal hand, thumb) 3. Strumming (massage): performed perpendicular to muscle belly 4. Petrissage (massage): several sub categories of techniques involving compression of soft tissue structures (kneading, rolling, picking up techniques)

1. What is HVLAT? CPR? How does it work?

1. high velocity low amp thrust: FABQ <19, onset <19 days, at least 1 hypomobile segment in LS w/ PA, hip IR >35, no pain below knee *SO DO NEURAL EXAM* (4/5) = better outcomes) A) *Biomechanical Effects*: fibrous adhesions dev —> thrust manip sep z joint —> gapping of z joint breaks adhesions —> z joint can move normally -but correction of spine pos unlikely to solely be responsible for clinical benefits bc changes not lasting, pain not solely come from spinal pos or stiffness B) *Neurophysiological Responses*: change in nocioceptor afferent system = change in pressure pain threshold (same pressure less pain response) -changes in autonomic NS, changes in Hoffman reflex (decrease SKM firing/spasms) -changes in SKM perf (manip take pain away so after SKMS able to fire better) -changes in neuropeptides in blood vessels (after manip pain modulating enzymes higher in blood stream so can go to other areas of pain to suppress) -Cortical excitability: area in brain control pain change after manip C) *Placebo Effect*: hard to placebo a manip so more when you give pt high expectations manip work better

1. What would a patient with LBP w/ related (referred) LE pain present with? 2. What treatments may help and what TBC category may they be in? 3. What about for lumbar stenosis (how present and what category)?

1. mainly *discogenic path* -Tends to worsen w sustainedflexed postures (sitting, forward bend) -can be centralized and diminished w positioning, manual procedures and/or repeated movements -can see lateral trunk shift, reduced lordosis, limited lumbar extension mob -Responds to repeated movements into extension (may require lateral trunk shift correction prior to repeated ext) -may require mob into extension 2. Specific Exercise TBC: based on centralization/peripheralize toon phenomenon -would be for extension if discogenic issue (repeated extension exercises, lateral trunk shift correction) 3. Age > 65, relief of pain with sitting (flexion), pain with stand and walk, wide based gait -would probs be ICF LBP w radiating pain bc neural involvement -would be in specific exercise flexion category: use flexion ex, manual therapy, body weight support on treadmill to treat

1. What are the clinical findings and treatments for the movement control Triage group? 2. What are the components of Local Mobility for Movement Control? Exam findings and treatment for each? 3. Global Stability?

1. triage for rehab intervention have symptom mod, motor control and functional optimization -Interventions to improve quality of movement -*clinical findings*: Low to moderate stable pain levels -AROM may be full with *abberrant motions*, impaired flexibility, activation, control *tx*: improve *quality of movement* via local (nerve, joint, soft tissue) and global stab (activation, acquisition, assimilation) -do via sensorimotor exercises (recruiting correct SKMS), stab exercises, flexibility exercises/STM (bc tissue dysfunction in other areas can lead to movement impairment at back) 2. Local Mob: Nerves *exam findings*: positive sensitized neural tension tests (slump, SLR, femoral nerve tension etc) *tx*: if symps agg reclassify pt into symptom modulation approach -Joint *exam findings*: limitation, asymmetry or hypomob of joint motion in lumbar or adjacent regions (joint palp for mob, ROM findings etc) -*tx*: manual therapy for joints (manip or mob) -Soft Tissue *exam findings*: impaired soft tissue compliance to manual therapy or passive change in joint pos -*tx* manual therapy for soft tissues (passive stretching and STM) 3. Global Mob: Activation *exam findings*: poor ability activate indiv SKMS or isolated movement patterns (cant activate TA, Mult, scap retractors, breathing pattern) -*tx*: training to activate hypoactive SKMS or isolated movement patterns (abdominal hollowing, scap restriction, breathing pattern) -Acquisition *exam findings*: impaired ability dissociate or coordinate thoracolumbar and lumbopelvis movements (lumbar from UE/LE, SLR, active hip extension, hip abduction etc) -*tx*: training to acquire skill to disassociate/coord movements of lumbar and adjacent regions (single plane co contraction exercises, balance coord) -Assimilation *exam*: impaired control of multiplanar movements under dynamic loading conditions (poor squat, poor lunge, poor rotation) -*tx*: training to assimilate loaded multiplanar movements into ADLS (step up/down progression, sit to stand)

What are steps to treating a THA after they first wake up?

Begin with brief strength screen in supine ◦ Bein away from hip joint bc may be scared and painful so do ankle pumps, UE strength, ab, flexion ◦ VITALS • Supine to sitting: no hip flex, add, IR ◦ Raise head of bed so easier to assist in transfer ◦ Lower bed so feet won't dangle when sitting ◦ Step by step: prob up on elbows —> long sitting with Extension at hips then swing legs • Sitting to Standing: raise bed so hips not flexed and easier to stand ◦ Lean to right adn keep left leg extended to avoid excessive flexion and use right UE to help raise herself ◦ Can have L UE on walker but do not pull walker as stand ◦ Assist with gait belt • GAIT: 3 point step to (walker, involved, uninvolved) ◦ Involved first so can control WB with walker Study showed that working on hip abductor strength helps post THA —> can work on this early esp bc can do NWB an

Pros and Cons to Immobilization

PRO -reduced risk re injury -provide stab to joint so can heal -decrease swelling (provide some compression) -decrease pain (immobilize, keep from stressing painful structures) CONS -cartilage degeneration (bc not load joint) -decreased mechanical and structural prop ligs -decreased bone density -weakness/atrophy SKMS

SINS

Used to determine how aggressive the PT exam may proceed 1. Severity: intensity of symp, limitiation in activities, examples (scale 0-10, mild mod severe other pain scales etc) 2. Irritability: time of ONSET, time required for symp to DISSIPATE, relationship between these times and magnitude of symp (i.e. Throwing first pitch = pain last 20 mins = highirritability while 100 pitches pain 10 mins = low) 3. Nature: description of symptoms (tingling, weakness, sweating, not just focused on pain) and therapist interpretation of the possible pathology (hypo list --> tingling = nerve issue?) 4. Stage: progeression and stability of symptoms (improving, stay same, worsen) or time frame for injury/tissue healing (how far along is healing process; inflammatory response 48-72 hours can last 7-10 days, tissue formation 10 days - 6 wk, remodeling 6 wk - 12 mo or *acute < 14 days/subacute 14-3 months/chronic > 3 months )*