All PHM
Upper limb tension test 2b (ULTT2b) - Radial nerve
(radial nerve: patient supine, ABD arm 30 degrees, depress shoulder girdle, extend elbow, move forearm into full pronation, then flex wrist & fingers, have patient side-bend neck away from side you are assessing)
muscle performance volume power -Most Adults = ___ - ___ sets of ___- ___ repetitions - Older/Novice = begin ≥ ___ set ___-___ repetitions
-Most Adults = 2 - 4 sets of 4-8 repetitions - Older/Novice = begin ≥ 1 set 4-8 repetitions
muscle performance volume strength: -Most Adults = ______ - _______ sets of _____ - ______ repetitions -Middle aged/Older = begin ≥ ____ set of _____ - _____ repetitions
-Most Adults = 2 - 4 sets of 8 - 12 repetitions -Middle aged/Older = begin ≥ 1 set of 10 - 15 repetitions
PT's DO NOT prescribe medication of any kind but you can suggest they choose to take ________ meds
OTC
the ____________ prompts the patient to ranked activities in order of importance to the patient and allows us to measures patient's perception of ability to perform specific activities
PSFS (patient specific functional scale)
the goals that you establish with your patient should include the items that they have listed on the ________
PSFS (patient specific functional scale)
What is the MOI of lateral epicondylitis?
Repetitive or sustained extension of the wrist, heavy gripping with repetitious pronation and supination.
when dealing with muscle performance, the mode of performance follows what principle
SAID principle (specific adaptations to imposed demands)
Hypothyroidism
A disorder caused by a thyroid gland that is slower and less productive than normal
Pain Control (FAST) ___________ involves a variety of different systems and coordinated function
ROM
Pain Control (FAST) ___________ is the arc through which active and passive movement occurs at a joint or a series of joints and the angle(s) created during this limb or trunk movement
ROM
Neural Testing - 1. innervation via peripheral nerves: 2. innervation via spinal nerve segments: 3. position sense (proprioception) 4. Neural ________________ tests
1. peripheral: cutaneous sensation 2. spinal: dermatomes, myotomes, DTR (deep tendon reflex) 4. compression
The following are a list of PT symptoms associated with dysfunction to what joint -Difficulty with mouth opening, mastication, speech -Headaches-temples and side of head -Pain and fatigue when eating chewy or hard foods -Cervical tension/ pain
TMJ
this is a term used to describe the four neurovascular compression syndromes associated with the neurovascular bundle of the brachial plexus (medial trunk, C8-T1) and the subclavian artery and vein
TOS (thoracic outlet syndrome)
(T/F) Shortening of the soft tissues can cause nerve issues
TRUE
(acute/chronic) nerve pain may be from inflammation via pressuring structures, but (acute/chronic) nerve pain may be evidence of scarring and tension on the entire continuous structure or some specific area
acute, chronic
in this method of injury recovery, the therapist helps the patient perform the activity in a different way
adapt/compensate
therapists can employ a number of treatment strategies from the body function perspective including:
addressing 4/5 cardinal signs of inflammation (pain, redness, swelling, heat) promote optimal healing by introducing tension (at appropriate times)
Positive test for anterior interosseous nerve compression: patient substitutes by using ____________ __________ (innervated by ulnar nerve)
adductor pollicis
what are some signs and symptoms of neural tissue involvement in compression/entrapment? (5)
antalgic posture (person looks in pain) movement dysfunction (limited AROM/PROM) + neural tension test (related to movement dysfunction) nerve palpation produces pain PE confirms neural pain (& rules out other potential causes)
this nerve is a motor nerve for the FPL and FDP if there is compression of this nerve there are no sensory symptoms ; instead there would be a loss of ability to flex IP joint of the thumb and DIP joints of the fingers branch of median nerve
anterior interosseous n
Cubital Tunnel boundaries - Anterior: Lateral: Posteriormedially:
anterior: medial epicondyle and MCL (of the elbow) lateral: ulnohumeral lig postmed: FCU (fibrous bands of 2 heads)
what does the articular or nonarticular orthoses mean?
articular: crosses joint non: doesnt
What are the 5 guiding principles of rehab?
patient-centered continually reevaluate (question) diagnosis (PTD) view interventions through ICF perspective ongoing patient edu choose appropriate frequency of treatment (and know when to discharge)
Chronic (what is chronic?) - If acute flare-up in chronic case, wear night _________ - Otherwise, avoid _______________ immobilization and encourage functional use (______ splints PRN)
splint prolonged soft
when assessing newborns (for brachial plexus traction injuries), you should observe: any ____________ movement Muscle __________ & __________ Limb ____________ Check for evidence of _________ issues
spontaneous tone bulk length circulatory
what is the best test for carpal tunnel syndrome
square shaped wrist
_______________ is responds to changes in neural input instead of resistance includes balance (COG/BOS)
stability
__________________ is the ability of our body to develop forces when disturbed in order to maintain a given condition both statically (postural) or during movement (neuromotor)
stability
design classifications of orthosis: No moving parts. Immobilize the joints they cross. Can be non-articular. Most common orthotic made.
static
design classifications of orthosis: Static base with mobilization force via non-elastic parts (nylon cords, strapping materials, hinges, turnbuckles).
static progressive
this type of training is designed to activate muscles as they function exercise happens automatically during movement without conscious activation
stealth exercises
Treatment from the Body Function Perspective: Pain and Anti-inflammatory Medications NSAIDS (non ____________ anti-inflammatory drugs) -Aspirin -Ibuprofin -Motrin -Advil -Alleve -Not __________
steroidal Tylenol
muscle _______________ is the muscle force exerted to overcome resistance under a specific set of circumstances
strength
in regards to muscle performance we want to understand ___________ (prime movers) vs ____________ (complementary muscles/postural muscles)
strength stability
2 most common impairments that are cancer-related side effects
strength, soft tissue
when treating a short and strong muscle consider prescribing a ________________ exercise for the muscle's antagonist
strengthening
Even though there are currently no clinical practice guidelines for treating TOS, what are some things you can do as a therapist
stretch with manual therapy (if it's a tight m. causing), address inflammation and pain, correct posture
reasons to mobilize with orthosis: Controlled ______________ alters cell proliferation-prescribed motion allowed. 1.Remodel ________ tissue. 2.Elongate _____ tissue. 3.Increase __________ 4.Assist in ______________ use by substituting for weak motion 5.Provide exercise_________________
tension scar soft PROM functional resistance
what is the second most common neural entrapment problem, after carpal tunnel
cubital tunnel syndrome (ulnar nerve compression/entrapment) ("Funny Bone" pain)
all of the following are the same as ___________________ - Repetitive stress disorder (RSI) - Repetitive motion injuries (RMI) - Overuse syndromes
cumulative trauma
Radial Tunnel Syndrome •Compression of the radial nerve by the: - Tendinous origin of the _____________ -Tendinous origin of the ________ (arcade of Frohse) -Distal edge of __________ at exit
extensor carpi radialis brevis supinator supinator
Radial Tunnel Syndrome •Pain in the ______________-__________ muscle mass that radiates into the forearm •Pain with wrist ___________ and _______________ OR wrist __________ with ________________ (traction on nerve) •Splint......
extensor-supinator extension/supination flexion/pronation Elbow flexed, forearm neutral, wrist extended
frequency of treatment depends on what factors
extent of injury, healing time, level of "skilled" service needed, changes in intervention/treatment program
T/F: CNS nerves can regenerate even following a complete transection (laceration)
false
T/F: rest and inactivity are synonymous
false
T/F: steroid injections should be the initial form of treatment for tendon injuries
false (should be reserved for chronic injuries, after intensive use of other approaches for at least 2 months has failed)
what is the most important aspect of treatment when treating a newborn (0-3 months)
family edu also positioning, ROM, using daily activities to keep injured side involved, paying attention to sensory deficits, etc
_____________ can become "bound" to the muscle, resulting in loss of gliding between the muscle and its fascia and the development of bands of tightness in the muscle and/or "trigger points"
fascia
__________________ enables adjacent structures to move upon each other and helps absorb and disperse shock throughout the body
fascia
__________________ surrounds every muscle of the body and provides support to other soft tissues
fascia
_____________________ is composed of collagen, elastin, and a polysaccharide gel-like ground substance
fascia
- Excessive fear of pain that leads to avoidance of specific or global movement/activity - All pain is bad and is making things worse - Excessive guarding of movement - Decreased use and protective posturing
fear avoidance
How can head & neck surgery/radiation cause dysfunction in the TMJ?
fibrosis (radiation, scarring, mm weaknes & atrophy after surgery) intraarticular damange
anterior interosseous syndrome loss of ability to ______ IP joint of the thumb and ______ joints of the fingers
flex DIP
Pain Control (FAST) _____________ is the maximum extensibility of a muscle-tendon unit can also represent extensibility of joint capsule/ligament
flexibility
what are the parts of the UE eval that arn't as important for neural injuries?
flexibility, ligament testing, joint accessory motion testing
Netative test anterior interosseous nerve compression: patient has intact anterior interosseous and is able to contract ______________ and ______________
flexor digitorum profundus and flexor pollicis longus.
In the sagittal plane,. what postural deviations are often noted in breast cancer survivors?
forward head, kyphosis, IR shoulders (rolled forward)
Symptoms for carpal tunnel (pain, weakness)
intermittent or persistent night and day paresthesia pain in median nerve distribution weakness of ABD poll brevis, intrinsics, and FDS weak grip/pinch
respect the injury, but don't be _________ by it
intimidated
Forces that facilitate myofascial release The ________________ forces include respiration, muscled contraction, and eye movements, along with theorized forces such as inherent tissue motion and body rhythms.
intrinsic
what are the construction rules for the hand?
Maintain the 3 arches of the hand to: improve fit, comfort and function.
Postural deviations: Therapists should apply biomechanical principles to their treatment. They should understand and encourage ________________ posture and movements
"typical" or "optimal"
Diagnosing thoracic outlet syndrome (TOS) - Anterior Scalene test
(Adson's Maneuver) -pt. sitting -PT monitors radial pulse - Pt. turns head toward test arm while PT laterally rotates and extends the pt's. shoulder - pt. takes deep breath and holds 15-30s - PT records if pulse disapears - if pulse goes away AND symptoms then TIGHT ANT SCALENES m
Diagnosing thoracic outlet syndrome (TOS) - Cervical Rib test
(Halstead Maneuver) locate radial pulse, then apply downward distraction on arm while pt. hyperextends neck and rotates to opposite side if pulse goes away AND symptoms then pt. might have cervical rib
Diagnosing thoracic outlet syndrome (TOS) - Pec Minor test
(HyperABD maneuver) - Tester palpates patient's pulse, then fully abducts patient's arm. - apply overpressrure for 30-45 seconds - Obliteration of pulse in abducted position AND symptoms indicates tight pec minor
Diagnosing thoracic outlet syndrome (TOS) - Costoclavicular syndrome test
(costoclavicular syndrome) -pt. sitting -PT monitors radial pulse -PTabducts arm to 45 degrees, laterally rotates and extends the pt's. shoulder (head in neutral) - pt. retracts and depresses scap -PT downwardly distracts UE - pt. takes deep breath and holds 15-30s - PT records if pulse disapears - if pulse goes away AND symptoms then compression by clavicle or 1st rib
Wartenburg's Sign - special diagnostic sign for Ulnar nerve involvement
(inability to ADD pinky finger from ABD position due to loss of innervation to palmar interosseous mm)
Upper limb tension test 2 (ULTT2) - Median nerve
(median nerve: patient supine, ABD arm 30 degrees, flex elbow, depress shoulder girdle, extend elbow, move forearm into full supination, extend wrist & fingers, have patient side-bend neck away from side you are assessing)
Upper limb tension test 1 (ULTT1) - Median nerve
(median nerve: patient supine, ABD arm 90 degrees, depress shoulder girdle, flex elbow and move arm into lateral rotation, extend elbow moving forearm into full supination, extend wrist and fingers, have patient side-bend neck away from side you are assessing)
what components are involved in improving ROM
(no set parameters) (depends on what patient can handle) PROM--->AAROM---> AROM partial ROM or full ROM gravity (assissted, eliminated, restricted)
Test of the Anterior Interosseous Nerve / Pinch-grip test
(patient asked to pinch tips of index finger and thumb together tip-to-tip; if there is involvement of ant. inteross. nerve the patient will exhibit abnormal pulp-to-pulp pinch - positive test)
differential diagnosis test for pronator teres syndrome
(patient sitting, elbow flexed to 90, therapist strongly resists pronation as elbow is passively extended; positive test = reproduction of symptoms including numbness/tingling along median nerve distribution)
scapular flip sign (for identifying injury to accessory nerve when patient cannot lie prone for standard test)
(patient standing with arm at side, elbow flexed to 90, resisting external rotation while visually examining and palpating scapula; positive: if medial border lifts or flips from the thoracic wall)
Upper limb tension test 3 (ULTT3) - Ulnar nerve
(ulnar nerve: patient supine, ABD arm 30 degrees, depress shoulder girdle, full flex elbow, move arm into lateral rotation, extend wrist & fingers and bring them to the side of the patient's head, have patient side-bend neck away from side you're assessing)
What is the manual therapy rule
(with manual therapy) you must always prescribe at least one exercise or therapeutic activity to maintain length/ROM gained (in the mm you just treated) (can be a stretch, strengthening exercise, or both)
Chronic Median Nerve Compression presentation
- Priest's hand" (thenar & intrinsic loss) - Decreased sensation to volar (palm) radial hand
Cumulative Trauma Intervention examples
- Splint (if applicable) - Task/Activity modification - Sleep and rest positions - Modify your existing tools - Soft tissue work - Physical agent modalities - Strengthening when appropriate - Stretch and work towards balance of structors
What are contraindications to manual therapy?
- acute injury - acute inflammation - tissues that are extremely painful - other common sense issues
manual therapy has what 6 major benefits?
- reduce pain - relax muscles in spasm - lengthen shortened muscles - increase ROM - optimize posture/alignment - improve funx
3 straps on splint: ____" from prox edge (wide) Slightly angled at _______ to prevent strapping over styloid (wide) From ________ of hand to _______ side of orthotic. (thin)
1 wrist palm ulnar
____________ is obtained through trial and error with 3-5 min rest between attempts. you load to failure over 3-5 attempts
1 RM
__________ is the max weight that can be lifted for one complete repetition of a movement/exercise
1 RM (rep max)
a nerve can regenerate up to _____ per day
1 mm
the minimum interval between steroid injections should be ___ weeks
6
the Borg RPE scale is on a scale of ______ to ______ and measures ____________
1-20 rate of perceived exertion
the science of fabricating and fitting orthoses
orthotics
what is the framework for pain control (FAST)
Flexibility (mobility/ROM), Activation Strength and Stability Training movement
Orthoses Classification (4 things)
1. Articular/nonarticular: most are articular. 2. Location: where on the body 3. Direction: What motion it facilitates or limits 4. Purpose: mobilize or immobilize
what is the process of exercise prescription
1. analyze imposed demands 2. assess 3. identify impairments 4. select exercise and parameters (risk v benefit, physical stress theory) 5. assess outcomes
How we choose the orthosis to make...(7)
1.Intent of orthosis 2.Design Classification 3.Individual characteristics (age, skin) 4.Function and sensation 5.Cosmetics 6.Cost 7.Materials
Twenty minute pressure check for splints: If redness persists after _____ min with orthotic removed, must be fixed
10
when estimating someones 1 RM, it is most accurate when repetitions are below ________
10
muscle performance volume endurance ≥ ____ sets of ____ - _____ repetitions
2 15 20
Muscle Performance frequency: rest/recovery:
2-3 days/week 2-3 min between sets, at least 48 hours between sessions for a single muscle group
Cancer is the ____ leading cause of death in the US.
2nd (1st is heart disease)
Effects (continuing damage) of intervention (radiation) can last up to ______ years post radiation
3
regarding steroid injections, use a max of _____ injections at one site
3
splint: Arm troughs should be ________ length of extremity if you cross a joint.
2/3
Splinting for Carpal Tunnel - Splint wrist in neutral to _____ of ___________ - _______ wear; free during day Unless symptoms are severe Moderate effectiveness shown in trials that have some methodological issues.
30/extension Night
many significantly injured (mod-severe Grade II and Grade III injuries) soft tissues are weakest at ___-___ weeks post injury
3, 4
Muscle Performance Strength Intensity Novice to intermediate= ____-____% 1RM Experienced = > or equal to ____% 1RM Older and Sedentary = begin ___-___% 1RM
60-70, 80, 40-50
axillary web syndrome (cording) occurs in at least _______% of women after breast cancer surgery and/or radiation therapy
30
Muscle Performance Power Intensity -Most Adults = ______% - _____% ___ RM -Older = _____% - _____% _____ RM
30% - 60% 1 RM 20% - 50% 1 RM
Splinting for Cubital Tunnel - Elbow in _____ to _____ of ______ (or comfortable) - Forearm: neutral to slight_______
30-40 flex pronation
lateral epicondylitis is common in people over _____ and the ________ is the most common offender. It should heal on its own in _____ to ____ years.
40 ECRB 1-2
____% of patients with hand and neck cancer (HNC) after surgery and radiation/chemo had limited mouth opening (trismus/TMJ dysfunction)
50
Acute (what is acute?) - Immobilize ____ to ____ days day and night - Offer gentle exercise, basic self-care tasks, light IADL's. - Limit ________ and ___________ positions
7-10 force and aggravating
Splinting for Radial Tunnel Immobilization with the elbow in flexion (______), neutral forearm rotation and slight wrist____________ (____ degrees)
90 dorsiflexion (extension) (20 deg)
De Quervain's Tendonitis/Tenosynovitis(Tenovaginitis) involves what muscles?
ABD PL EPB
Chronic ulnar nerve compression common muscles invloved?
Ab digiti minimi Flex dig. Minimi Opponens dm Lumb (R,S) D/P interossei FPB (deep, uln head) AD Pollicis
Distal Extensor Tendonitis fill in most common muscles in this tendonitis: 1st dorsal compartment: 2nd DC:ECRL/ECRB 3rd DC:EPL 4th DC:EDC/EI 5th DC:______ 6TH DC: ______
Abd Pol Lon and Ext Pol Brev EDM ECU
a ___________ trigger point: is symptomatic with respect to pain, usually causing radiating pain when compressed
Active
____________ ___________ injuries may show no obvious signs of trauma, but can be very irritable to the client.
Acute nerve
The brachial plexus is comprised of a group of nerves arising from what spinal nerve roots?
C5-T1
_________________ _________________ on the improvement of functional limitations due to impingement for steroid or analgesic injections
Conflicting evidence
Thermoplastic Performance Characteristics - _________________: fit intimately into contoured areas (more comfortable) - _______________: can take repeated stresses (good for donning and doffing circumferential splints). - _______________: how long material lasts. -____________ : strong and resistant to repeated stress; important for large splints which support weight of limb - _______________: cooler (but can overstretch holes) -____________: texture of finished product; coated are easier to keep clean
Conformability Flexibility Durability Rigidity Perforation Finish
Neural Mechanics •____________ structure •Designed for ______________ •Surrounded by _______________/_________________
Continuous movement musculoskeletal/ connective tissue
_____________ can be categorized as Extensor tendons are arranged in compartments, tendonitis can be localized to these specific compartments
Distal Extensor Tendonitis
where is the pain in De Quervain's Tendonitis/Tenosynovitis
Distal, radial, dorsal wrist pain
this is a combo of conditions that are a result of brachial plexus traction during birth characteristic position: *"Waiter's tip"* shoulder extension, shoulder ADD, shoulder medial rot, elbow extension, forearm pronation, wrist and finger flexion
Erb-Klumpke
in therapy we can modify _________ or _________ doing the action
activity (to individuals level) person (increased to activity's level)
a shortened pec major combined with post-intervention pain can also cause a limitation in what 3 arm motions
ER, ABD, (full) flexion
Forces that facilitate myofascial release ________________ forces are applied by the therapist and include the application of appropriate amounts of tension via compression, traction, and/or twisting (Greenman, 1996).
Extrinsic
when making splints the water should be boiling (T/F)
FALSE
(T/F) anterior interosseous syndrome can present through sensory and motor symptoms
FALSE NO SENSORY SYMPTOMS
T/F You can always perform manual therapy in isolation
FALSE You should never perform manual therapy in isolation
defined as difficulties an individual may have in executing a task or action
activity limitation
clinical setting: use of the _______: - functional status assessment - goal setting - treatment planning and monitoring - outcome measurement
ICF
research: ___________ is used for impact, intervention and application research
ICF
social policy: _______ is used in disability policy, anti-discrimination law, disability evaluation
ICF
treatment from body function perspective - chronic inflammation, how do you treat it?
ID source of ongoing irritation and eliminate it (or alter person's activities so it no longer has adverse impact on person)
interventions that protect and rest musculoskeletal tissues - ________________________:cast, splint, internal fixation
Immobilization
a ___________ trigger point: clinically quiet with respect to pain until compressed
Latent
pre-fabricated splints: Advantages - _______________, ready to use, appearance Disadvantages - May not address all _____________ areas, lack of adequate support, may not be able to be modified
Less expensive problem
Compression or Entrapment of the Primary UE Nerves •Identify ______ (posture, habitual movements, activity-related, etc.) •Use _________ ____________ / differential diagnosis tests designed to assess the gliding of neural structures along their anatomic courses from the spinal cord to the periphery. •Pain with a neural tension test could indicate an area where gliding is restricted and/or the nerve is compressed by a _______________ structure •Rule out ____________ ______ involvement / compression on spinal nerve root
MOI neural tension neighboring cervical disk
*Key*: Remove the ______, guide tissue healing, and prepare the tissue for return to activity
MOI (mech. of injury)
what are the steps of diagnosing neural entrapment (Identify...)
MOI (posture, repetitive activity, both), nerves involved, nerve irritability, structures at fault (what is causing the compression/entrapment)
what are some MOI's for cummulative trauma?
Mechanical stress Tissue irritation Inflammation Collagen organization Scarring Change in local gliding mechanisms
____________ is irritation of the mm originating off the medial epicondyle (commonly FCR, PT, but could also be FCU, FDS)
Medial Epicondylitis (Golfer's Elbow)
This technique works well when you are dealing with bands of myofascial restrictions in one or more muscles. (parallel to muscle fibers)
Myofascial Release along Fascial Lines
Nerves can become inflamed (neuritis) just like any other ST. The therapist's job is to identify the MOI and remove it. What are some treatment options for neural inflammation? (5)
NSAIDs steroid injection PRICE Ultrasound (pulsed) movement (via gliding, increases axoplasmic flow)
Stretching - Capsule/Ligament Mode: move ________ and ________ away from each other; end __________ Intensity: ______ load Duration: Duration + frequency:
O and I/ ROM low long duration total end range time (TERT; MAXIMIZE)
Chronic Median Nerve Compression can affect what 4 muscles?
Opponens pollicis AbPB FPB 1st/2nd lumbricales
all of the following are examples of ______________________: 1. Patient-Rated Wrist Evaluation 2. Patient-Rated Tennis Elbow Evaluation 3.Disability of the Arm, Shoulder& Hand
Outcome Measurements
what are some outcomes of cumulative trauma?
Pain, loss of motion & strength
_______________________ are commonly due to a combination of muscular problems (some short, some weak) as well as potential joint capsule problems. Treat through manual therapy and therapeutic exercises/activities.
Postural deviations
what are some presentations of chronic ulnar nerve compression?
Presentation: 1."Claw hand" 2.Decreased sensation 3.Weak grip
treatment from the body function perspective: PRICE =
Protect (reduce chance of further injury to tissue) Rest (promote proper healing) Ice (reduce blood flow, decrease perception of pain) Compression (prevent and reduce swelling) Elevate (prevent and reduce swelling and hyperemia)
this is a subjective scale that therapists use to gauge the intensity and how hard a patient is working during a specific activity
RPE (rating of perceived exertion scale)
____________ commonly caused by irritation/swelling at the Arcade of Frohse and mimics or may occur with lateral epicondylitis
Rad N Compression
what is the standardized assessment for cumulative trauma were the score indicates risk for musculoskeletal issues
Rapid Entire Body Assessment (REBA)
What are two outcome measures appropriate to use in cancer survivors with shoulder dysfunction?
SPADI (Shoulder Pain & Disability Index), DASH
Thermoplastic Handling Characteristics - ________________: degree that it sticks to itself; coated materials are less likely to stick to self - ____________: Resistance to stretch; can be handled aggressively without losing form - _____________: The ability for the material to return to its former size and shape when reheated. (0-100%) Allows reheating and reshaping several times. - _______________: The ability for the material to mold closely over the body part w/out manual assistance; gravity assisted. Better for small splints; must handle gently. - ________ time and _____________ time
Self-bonding Elasticity Memory Drape Heating working
4. Function and Sensation of orthosis - ___________design. - ____________ hand exposed when possible - Only include the fingers and thumb if necessary. - ________________ demands.
Simple palmar Occupational
What does SMART goals stand for?
Specific, Measurable, Attainable, Relevant, Time bound
Treatment from the Body Function Perspective: Pain and Anti-inflammatory Medications ____________ such as: -Medrol dose packs -Local injections (Caution!)
Steroids
nerve involved in De Quervain's Tendonitis/Tenosynovitis
Superficial radial nerve involvement common
This technique involves placing tension on the bands of tightness (ie: myofascial restrictions) in a shortened muscle , then gently passively lengthening the muscle for several repetitions. With the patient in a resting position, palpate with one hand for areas of greater tension in the muscle. Once you've located these, gently apply downward pressure into the restriction with the base of your hand (thenar eminences). This "loads the fascia."
The "Norwegian Pump"
what nerve compression can be described as having symptoms of sharp, achy pain over the ulnar-volar forearm, paresthesia/pain in ring and little fingers and FCU, weak pinch due to weakness of ADD pollicis and deep head of FPL
Ulnar Nerve Compression or Entrapment in the Cubital Tunnel
why do we not call them splints?
We don't get paid for splints we get paid for orthoses.
______________________ works well after direct MFR techniques have been used, given that it is typically less intense for the patient and fosters greater relaxation prior to the conclusion of manual therapy.
Ward-Greenman
This technique of manual therapy emphasizes use of the hands to introduce compressive and twisting forces on the tissues to effect a release/relaxation response. Therapists can apply this technique to any muscle or area of fascial restriction.
Ward-Greenman myofascial release
MOI for medial epicondylitis
Wrist flexion, pronation, gripping- with wrist flexion
consider the magnitude and type of tension being applied to healing tissue ultimately, the best tension is the:
activity that the person wants to return to doing
the following are examples of _______: - learning and applying knowledge - general tasks & demands - communication - mobility - habits
activities
Goals and treatments that duplicate as much as possible the ___________ and ________________ that the patient will be performing when they leave therapy optimizes the patient's potential to do these activities following discharge
activities and settings
describes functional status and is the execution of a task or action by an individual
activity
froment's sign test for compression of the ulnar nerve Negative test: If the ulnar nerve is intact, the patient will use the ________________ ____________ to adduct the thumb, while keeping the interphalangeal joint____________ Positive test: If the ulnar nerve is injured/irritated, the patient will compensate by using the ___________________ (innervated by anterior interosseous branch of the median nerve) , indicated by __________ of the interphalangeal joint of the thumb
adductor pollicis extended flexor pollicis longus flexion
orthosis _____________: - Monitor progress toward goal areas - Get patient feedback on orthosis - Look for signs of a worn orthosis - Adjust orthosis and replace worn straps as needed
aderence
what are the musculoskeletal conditions associated with thyroid dysfunction
adhesive capsulitis (frozen shoulder) rotator cuff disorders dupuytren's contracture (in the hand) trigger finger CTS (carpal tunnel) limited joint mobility
(+) _____________ acceleration to initiate movement & decreased inertia near ______ of movement; (-) acceleration with eccentric/downward movement
agonist/end
What are two important keys in preventing contracture (in newborns-children)
alignment, ROM
in this method of injury recovery, the patient makes gains, however the extend of their injuries does not allow return to pre-injury levels of activity
alleviate (the problem)
Atrophy from radiation, as well as surgical damage can cause a reduction in the size of the pec major, as well as shortening which causes what
altered overhead biomechanics (having difficulties with reaching overhead)
Following surgery, radiation, & chemotherapy for breast cancer, what are some changes that take place in the muscle(s)?
atrophy (due to changes in parenchyma and vascular tissues) CT constraints (leads to muscle contractures)
besides muscle changes (weakness or shortening), what other factors can contribute to altered biomechanics and limit overhead movement
axillary cording, lymphedema, scarring
this condition is characterized by a palpable cord of tissue beginning in the axilla and continuing distally down the arm the cord is thought to be comprised of lymphovenous tissue
axillary web syndrome (cording)
Nerves have circulation exterior to the nerve, what helps deliver nutrients inside the nerve?
axoplasm
vast majority of axonal nutrients (lipids, proteins, etc) are synthesized in the neruonal cell body and transported along axons through the _______
axoplasm
head and neck surgery is named based on what
level of lymph nodes being removed
Physical Stress theory Stress: --> Response: _____________ --> decreased tolerance to stress ______________ --> no tissue change _______________ --> increased tolerance to stress ______________ --> tissue injury ______________ --> tissue death
below maintenance at maintenance exceed maintenance excessively high extreme
What is the most common brachial plexus traction injury
birth injury (due to large birth weight, breech presentation, multiparity, assisted delivery, and/or forceful downward traction on the head during delivery)
the following are all examples of ______ _________: - mental functions - sensory functions & pain - voice and speech functions - functions of the CV, hematological, immunological, and respiratory systems - function of the digestive, metabolic, and endocrine systems - genitourinary and repro functions - Neuromuscular and movement-related functions - functions of the skin and related structures
body function
relates to an individual's anatomy, physiology, and psychology and how each part performs individually or as part of a system
body function and structures
Guiding principle of rehab 3: View your Interventions through the perspectives of the ICF Model what are the 5 factors that health condition are based on?
body function and structures activities participation environmental factors personal factors
the following are examples of ________ _______: - structure of the NS - the eye, ear, and related structures - structures involved in voice & speech - structure of CV, immunological and respiratory systems - structures related to the digestive, metabolic and endocrine systems - structure related to genitourinary and reproductive systems - structures related to movement - skin and related structures
body structure
View your ortho interventions as a progression through the ICF: _________ > _________ > ______________
body structure and function, activity, participation
This manual therapy technique is great for lengthening muscles that are in mild to moderate spasm, or that have become shortened due to muscle imbalances.
bowstringing
This technique of manual therapy can be incorporated into general massage, and if used with greater force becomes a friction massage.
bowstringing
this describes what manual therapy technique: Place the patient in a maximally comfortable position, with the muscle relaxed as much as possible. Using the thenar eminence of your hand, or perhaps your thumbs, gently and slowly apply pressure that is perpendicular to the direction of the muscle fibers.
bowstringing
what are the mechanical interfaces / potential areas of compression/entrapment for the *ulnar* nerve
cubital tunnel (via triceps) ulnar groove FCU (Arcade of Frohse) Guyon's canal (b/w hamate and pisiform)
multiple RM (rep max) can assess what 2 things?
can assess endurance vs strength
_______________ has proto-oncogenes that go through mutation become activated oncogenes, then activated oncogenes transition the cell from normal status to diseased/mutated status
cancer
this disease/condition occurs when normal cells transition to cells that don't have the same regulations on replication cell division
cancer
the _______ _____ __ ___________ will help to determine when the therapist can being to introduce tension to injured tissues. __________________ of most or all of these is a good indicator of when to begin to mildly stress tissues. The ___________________ of any of these following the introduction of tension usually indicated that the tension applied exceeded the tolerance of the tissue
cardinal signs of inflammation Reduction recurrence
this condition of the median nerve is caused by inflammation from over-use, weight gain (common during pregnancy), scar adhesion, square wrist, etc
carpal tunnel
- Exaggerated orientation towards painful stimuli or a painful experience - Disassociation between pain ratings and physical findings - Jump to worst case scenario - Less adherent & poorer prognosis
catastrophizing
Where are mechanical interfaces and areas of potential entrapment for the brachial plexus
cervical rib, anterior scalene, clavicle and first rib, pec minor
what is the most common/traditional drug therapy for cancer
chemo
sustained pressure applied to a local region of the nerve, either internally or through the skin
compression
what are the 5 most common MOI's for nerve injuries? which ones are nerve in continuity injuries?
compression, entrapment, constriction, traction, laceration
thyrotoxicosis
condition caused by excessive thyroid hormones (toxic)
Guiding principle of rehab 1: be patient-centered •Occupational roles: self-care, work, & leisure •Postures and habits •Medical status •Psychosocial aspects •Values, beliefs •Responsibilities •Abilities & limitations •Desired outcome(s) and goals •Family and significant others
consider everything that makes the person who they are
gravity is constant based on a ____________________
constant location
a reduction in nerve diameter caused by adjacent tissues
constriction
Each nerve is a __________ structure with origins from the spinal cord, although these nerves have different names as they branch, they are parts of the same ___________ structure
continuous
When assessing 3 months - 18 year olds (for a brachial plexus traction injury), you must consider: Muscle ____________ leading to decreased ROM and joint deformity _________ deficits ___________: lack of usage of the affected extremity and use of compensatory patterns involvement of the unaffected extremity due to __________
contractures sensory apraxia overuse
Key Elements of Exercise Prescription - Choose exercises that ____________ sustained posture(s) - Achieve ______________________ before, during, and at the end of each exercise - Assess patient performance of exercises and note deviations that may include improper recruitment patterns, ____________________, and/or interference by soft tissue impairments - Adequately ___________________ in the form of verbal and/or physical cueing to assure proper muscle activation and/or to correct deviations from __________ __________
counteract proper alignment substitutions provide feedback optimal motion
what are the 6 things we can do to treat neural compression/entrapment?
decrease inflammation Teach the person anti-tension position Alter the activity ("habit") Treat the compressing structure Postural correction Improve neural gliding
what are methods of treating neural compression/entrapment
decrease inflammation (NSAIDs), alter activity (habit causing MOI), postural correction, nerve glides (neural mobilization)
this term refers to a nerve that's irritated in one area being more likely to become irritated in another area a lesion at one site predisposed development of another lesion
double crush injury
downward rotation of the scapula causes disorientation of the glenoid fossa and makes it face downwardly, what effect does this have on the GH joint
decreased static stability
When the shoulder is at rest, what biomechanical problems are noted at the shoulder/scapula when the spinal accessory nerve is injured? (scapula is...)
depressed, downwardly rot, ABD (protracted on thorax) (can also be winging or tipping)
Correlation between pain and ___________________
depression
_________________ is the the origin(s) of the person's problem and how it affects the person's ability to function
diagnosis
_________________ names the pathophysiology, primary impairment, functional limitation, and/or disability toward which the OT or PT will direct treatment
diagnosis
design classifications of orthosis: Static base with mobilization force via elastic assistance (rubber bands, springs or elastic cord).
dynamic
when using ____________ the force is based on % elongation regardless of resting length torque depends on force angle
elastic resistance
what are common posture changes in the frontal plane following breast cancer surgery (2 months - years later)
elevated shoulder (operative side) elevated scap (operative side) ABD scap (operative side)
Protection and Rest To allow tissues to heal, therapists must protect them from continued trauma by _________ or ___________ loading of the injured structures
eliminating, reducing
neural issues usually result in what type of end feel when assessing PROM?
empty
muscle______________ is the ability of muscle to sustain forces repeatedly or to generate a force over a period of time
endurance
mechanical distortion by a fibrous band or within a fibrous canal
entrapment
_____________ factors (ICF) Products and technology Natural environment and human-made changes to environment Support and relationships Attitudes Services, systems and policies
environmental
factors that are not within the person's control (i.e. family, work, gov't agencies, laws, cultural beliefs)
environmental factors
using a given resistance and number of repetitions able to be performed to estimate an individual's 1RM based on mathematical predictions
estimated 1 RM
what do therapists base their prognosis on
evidence (scientific knowledge), ethics, experience
The most successful treatment strategies are those that ________ ________ the functional aspects of activities that the patient wishes to resume and the environments in which they occur
exactly simulate (duplicate)
consequences of immobilizing healing tissue too long
excessive development of scar tissue, loss of mobility (hypomobility)
Graded _______________ -Perform exercise/activity to the point of pain -This point becomes the goal/threshold for future treatment -Positive reinforcement with meeting/exceeding goal
exercise
____________ is more effective than no intervention on functional limitations... or [subacromial] injections for impingement
exercise
Graded _____________ -Perform modified version of exercise/activities that are feared/painful -Gradual progression toward the exercise/activity
exposure
Presentation for Radial N compression: Pain in __________ and ________ mm mass Pain radiates into distal forearm, radial styloid and __________ space Pain with wrist ________/___________ (stretch) or wrist __________/______________ against resistance
ext/supinator index web flex/pronation ext/supination
Types of neck dissections - ________ ___________ neck dissection: removal of one or more additional lymph node groups or non-lymphatic structures or both, not encompassed by the radical neck dissection
extended radical
In reconstruction surgeries of the head & neck, what are the two common flap types used?
free flap, pedicle flap (vessels left intact - less likely to fail than free flap)
__________ allows changing of lever arm length depending on where the weight is added and require stabilization
free weights
using _________ helps mimic functional activities
free weights
Guiding principle of rehab 5: Choose Appropriate Frequency of Treatment and Know When to Discharge -frequency depends on many factors - initial visits will likely be more ________ - intermediate visits should reflect __________ - final visits can have gaps of a _______ or more
frequent tapering week
_____________ manual therapy would help will all of the following: •The tendons of the extensor pollicis brevis and the abductor pollicis longus (De Quervain's tenosynovitis) •Extensor carpi radialis brevis (involved with lateral epicondylitis / "tennis elbow") •The transverse humeral ligament and the long head of the biceps brachii •Supraspinatus insertion (just proximal to the greater tuberosity).
friction massage
_________________ helps to decrease pain and it serves to break down abnormal scar tissue cross-links. A systematic review of the literature suggests that it is most effective when used in combination with other therapies, including cold, ultrasound, and exercise
friction massage
________________ goals address contexts/environments important to the patient
function
what are the end results of exercise prescription
functional movement, occupational performance
______________________________ are co-created by the patient and therapist
fundamental goals
Nerves are continuous structures that typically __________ along their courses
glide
the ___________ drive your treatment plan.
goals
______________ is a force that always acts downward
gravity
"Loading" the Fascia: Direction of Force changing directions to: •Upward and downward •Left and right •Clockwise and counterclockwise. •Assess the direction that causes the ______________ tension and hold the fascia there; assess in the other directions, until the fascia is "loaded" in all _______________
greatest three planes
the state of the individual at any given moment
health condition
what are the components of the ICF disablement model
health condition (disorder/disease), body function and structure, activity (limitations), participation (restrictions), environmental factors, personal factors
consequences of mobilizing healing tissue too early or with too much force
hypermobility (tear or stretch healing wound), non functional
The therapist's primary role in musculoskeletal rehab is to maximize the _________ ____________ for the tissues' own healing capability and to assist to the patient in resuming __________ ____________ (occupations) that are important to the patient
ideal conditions pre injury activities
what can the various intents of the orthosis?
immobilization mobilization restriction
Splinting for DeQuervain's Tendonitis - Thumb and wrist ________________ splint. - If superficial radial nerve is flaring, _______ splint may be more comfortable.
immobilization soft
this type of drug therapy utilizes an individual's immune system to fight the cancer
immunotherapy
Many therapists inappropriately focus their treatment goals on _________________
impairments
custom splints: - _______________ and custom fit, able to modify (advantage) - _______________, time required to construct, appearance (disadvantage)
individualized More costly
this force acts in any direction, is related to acceleration, and occurs with most all natural movements
inertia
If the limitations to activity or restrictions to participation are _________________, the therapist must work to optimize the patient's residual function
irreversible
Precautions and Contraindications to Neural Gliding / Mobilization •__________ disorders or __________ pain •Neurological changes are ___________ -acute compartment syndrome -injury likely to cause neurological deficit •Inflammatory, systemic, and ineffective disorders that affect the _____________ system -abscess -Guillian barre •____________ spinal cord •Marked injury or _______________ -spinal instability •Linking with MOI will avoid misdiagnosis
irritable/severe worsening nervous Tethered abnormality
what are the steps of progression
isolate and edu add resistance add functional positioning combine functional position and resistance add stability challenge add speed and attentional focus
this condition is typically due to immobility and increased collagen formation leading to fibrosis typically manifests as a capsular pattern of restriction, accompanied by loss of joint play and component motions. Interventions include manual therapy (joint mobs and soft tissue releases)
joint capsule hypomobility
reason to restrict during orthosis: Limit some aspect of ________ ________ 1.Limit __________ after nerve or tendon repair OR bone-ligament injury. 2.Provide or improve joint__________ 3.Assist ______________ use.
joint motion motion stability functional
_____ ____: which are typically (but not always) weak. Strengthen via a number of therapeutic exercises/activities
lengthened mm
- Medical professionals or patient's own research uses words, terms, or concepts that generate fear, anxiety, despair, or hopelessness - Diagnosis focused (wear it like a badge of honor) - Imaging focused - Internet junkies - Dwell on jargon & medical terms - Can lead to fear avoidance and catastrophizing
labeling
transection of the neural structure, causing an interruption in its continuity
laceration
studies have shown another effect of surgery and/or radiation is changes to the _____________ which can cause: inability to IR the arm, extend the arm, and/or pull down on objects
lat dorsi
in erb's palsy there is sensory loss of the _________ aspect of the arm, first and possibly _________ digits
lateral second
________________ is irritation of the common origin of the wrist extensors (ECRL, ECRB, EDC, ECU): order as they descend on the lateral epicondyle.
lateral epicondylitis
- Concept concerning one's belief in their own control over a situation specifically relating to illness, sickness, and health - Control over our consequences vs destiny/fate
locus of control
_________________ goals should focus on the activities related to the patient's desired outcome (items on the Patient Specific Functional Scale or COPM)
long term (LTG's)
what are some various ways tension can be applied to tissue (5)
manually, active exercises, resistive exercises, mechanical methods, weight bearing
Klumpke palsy is __________ roots (____-___)
lower C7-T1
What spinal nerve roots innervate the intrinsic mm of the hand?
lower roots C7-T1
interventions that protect and rest musculoskeletal tissues - alteration of activities:
maintain optimal levels of function while preventing unnecessary loading of tissues (e.g. shortened work time, taking frequent rests, use of proper body mechanics)
What is the goal of PT intervention for patients suffering from spinal accessory nerve injury?
maintain/regain PROM (in muscles, ligaments, and joint capsules of GH, scapulothoracic, AC, and SC joints)
patients make the greatest gains when therapy focuses on functional activities that are_______________________
meaningful
tissues remodel in response to:
mechanical demands placed on them (more stress = more dense tissue; too much stress = torn tissue)
these are areas in which the nerves can be compressed or entrapped and thus irritated
mechanical interfaces
Diagnosing Neural Entrapment •Identify ___________ -Posture -Repetitive activity -Both of these •Determine the _________ involved •Determine if the nerve is __________ or ____________ •Determine "structure(s) at ___________": What is causing the compression or entrapment? -Link with MOI and modify activity -If soft tissue in nature, perform manual therapy and gentle stretching -If related to muscular weakness, prescribe exercise
mechanism of injury nerve(s) irritable or non-irritable fault
_______________ theory supports patient-centered functional goals
motor learning
Types of neck dissections - _________ __________ neck dissection: removal of all lymph nodes by radical neck dissection with preservation of one or more of the non-lymphatic structures (i.e. spinal accessory n., internal jugular v., and/or sternocleidomastoid m.) (now more common neck dissection)
modified radical
Difference between modified radical mastectomy vs radical mastectomy - Modified: Radical:
modified: removes entire breast, lining of chest wall mm, and one or more lymph nodes; radical: modified radical mastectomy plus removes chest mm
_____________ is a max # of repts a submax weight can be lifted
multiple RM (rep max)
_____________ is the max weight that can be lifted for multiple complete reps of a movement/exercise
multiple RM (rep max)
this condition/impairment is due to disuse or immobility. Strengthen via various therapeutic exercises or activities
muscle atrophy
manual therapy is an effective adjunct to _____________ rehab and it is most effective when combined with other treatments, particularly __________________
musculoskeletal exercise
___________________ applies the principles of biomechanical loading of soft tissue and the neural reflex modifications by stimulation of mechanoreceptors in the fascia.
myofascial release
during _________________ loading can also occur in the direction away from the barrier in an indirect fashion.
myofascial release
in _______________________ the resistant barrier may be engaged directly with tissue stretching
myofascial release
__________ __________ uses "on" and "off" system -They should move through the glide until they feel "on" and then stop. -Back off last motion until they feel "off." -Resume rest of motion. -The idea is that you will gradually move with greater motion and less "on" time. -Can use a similar approach with your manual therapy
nerve gliding aka "neural flossing"
what are some common mechanical interfaces where a nerve could become compressed/entrapped and thus irritated
neural branches, unyielding interfaces (fascia, ligament, muscle), neural tunneling (particularly through muscles), superficial areas
treatments for subacute/chronic carpal tunnel syndrome •Splint at_______ • ________________ _____________ about repetitive activity and sleep positions •Avoid prolonged ________________ and encourage ___________ _______ •Neural ___________ & tendon gliding •Potential surgery (carpal tunnel release)
night Patient education immobilization and encourage functional use gliding
How can the affected side of a spinal accessory nerve injury be unloaded to keep it from injury?
not carrying heave objects on involved side (for years) hook thumb in pants/jacket pocket (unloads upper trap) use arm sling (reduces pain)
what are some words used by patients to describe pain that is neural in origin
numbness, burning, stabbing, radiating, tingling, stinging
to understand a person's limitations in performing activities that are important to them as well as the environments in which they happen, the therapist must do what
observe patient perform the activities (or attempting to perform it) (when possible, in the actual environment)
Guiding principle of rehab 2: continually re-evaluate You achieve this through _______ _______, measurement, and ________ _________ that occurs during subsequent patient visits
ongoing observation, critical thinking
Stretching - Muscle/Tendon Mode: move_______ and _______ away from each other Intensity: "_________" pull/stretch Frequency: Duration: Volume:
origin and insertion gentle >2-3 days/week (more = better) 10-30 sec holds 2-5 reps
______________ is used to describe a single device. A rigid or semi-rigid device that supports a weak or deformed body member, or restricts or eliminates motion in a diseased or injured part of the body. An orthosis can be custom fabricated, custom fit or prefabricated.
orthosis
In determining treatment strategies, the therapist asks: what therapy interventions can I use to achieve the patient's desired __________ and ____________? What modalities/techniques can help the _________ _________ _________ of the body? how can exercise and/or activity prescription prepare the person for return to ______________________ and contexts? Is this the _______ __________ strategy that I can employ? Does the treatment I have selected have ________ _______?
outcome and goals natural healing processes their daily life/roles most functional scientific merit (also - is this treatment patient-centered and evidence-based?)
Treat pain compassionately - Therapist should listen, validate_______, act as a support in order to facilitate return to _______. - Workplace design________________ show good evidence in promoting return to work. - Education about "__________"
pain work modification safe pain
symptoms of ulnar tunnel nerve syndrome?
parathesias, cold intolerance in ring and pinky fingers; intrinsic atrophy of ring and pinky fingers
involvement in life activities societal perspective (context) of functioning
participation
the following are examples of _____: - self-care - domestic life - work life - recreational life - interpersonal interactions/relationships - major life areas - community, social, and civic life
participation
problems an individual may experience in involvement in a life situation
participation restriction
Key Concepts of Musculoskeletal (Orthopedic) Assessment - Understand your ______________ (occupations, environments/contexts) - Understand typical ________________ and _________________ - Understand the ___________________ (formulate a diagnosis)
patient posture and movement/biomechanics MOI
Guiding principle of rehab 4: Perform Ongoing Patient and/or Caregiver Education Key: Because ________ ______ is an integral part of rehab, therapists must take the time to perform it properly. Teaching occurs during therapy. patients get out of their home programs what their therapists put into them
patient edu
___________________ for splints: §Purpose of the orthosis and goals §Activity modification. §How to take orthotic on and off §Skin Hygiene §Cleaning and care of the orthotic §Teach how to modify the orthotic if needed §Precautions and what to do if the following occur: §Any redness, pain, decreased sensation, increased edema §Wearing schedule and where to put your orthosis when not wearing it (NOT NEAR HEAT) §Write all of this down. Make a copy and put in the medical record.
patient education
what muscle may be the most affected by breast cancer treatments
pec major
studies have reported muscle morbidity of what 3 muscles following surgery combined with radiation for treating breast cancer
pec major, serratus anterior, lat dorsi
studies have shown another effect of surgery and/or radiation is shortening of the _____________ which can cause: scapular tilting/tipping anteriorly scapular winging imbalance with lower trap during scapular depression (altered scap depression) difficulty with movements requiring force in pushing the body up on a stabilized arm (due to altered scapular depression)
pec minor
Treating Thoracic Outlet Syndrome: If _________ ___________ or ____________ _____________ are involved, perform soft tissue releases via manual therapy
pectorlais minor anterior scalene
what are neuromuscular consequences of cancer drug therapy (4)
peripheral neuropathy (sensory and motor) (one of the most common side effects of cancer treatment) myopathy (damage to muscle directly; catabolic steroids break down mm) arthraglias/myalgias (pain syndromes) body comp changes (osteoporosis)
Symptoms of superficial radial nerve syndrome
persistent pain and/or hypersensitivity over radial dorsum of hand
what is the PEO model
person, environment, occupation (activity)
_________ factors (ICF) Race Gender Age Educational level Coping Style Motivation
personal
various elements that make the individual unique
personal factors
when using _________ the lever arm differs compared to free weights and muscle length-tension curve
plates/machines
MOI for TOS is usually ________ __________ and _______ _________ with some muscles being excessively tight and others being very weak
poor posture muscle tone
Scarring after breast cancer surgery can be tightly adhered to the chest wall, what could this effect/influence
posture
Nerves are positively and negatively effected by _____________ and ____________ ___________ just like other soft tissues.
posture habitual movements
muscle _________________ is work produced per unit of time and is a product of strength and speed
power
Note with padding in splints—adds more ________________! Bubble material out or remake depending on problem.
pressure
for nerves one must also consider the ramifications of ______________ on one part of this continuous structure, causing _____________ in the rest of the structure.
pressure tension
_____________ is the determination of the level of max improvement that a patient might attain and the amount of time to reach that level
prognosis
_____________________ "predicted outcome" of the course of care/treatment the clinician provides educated/well-informed hypothesis
prognosis
Guiding principle of rehab 2: continually re-evaluate Continually critique your chosen intervention(s) and ask yourself: Am I giving this person the best care that I possibly can? Always consider the "_____________________" of treatment, and continue to challenge the patient, ultimately preparing the patient for ______________ to ____________
progression return to activities
what is the most common muscle involved in medial epicondylitis?
pronator teres
Compression of Anterior Interosseous Nerve Compression can be caused by the ______________ or the proximal arch of the ____________, or if the anterior interosseous branches more proximal than typical, it may be compressed by the ligament of ___________ and/or ___________ __________
pronator teres flexor digitorum superficialis Stuthers lacertus fibrosis
this is a condition of the median nerve that mimics carpal tunnel syndrome, but is less common and the patient doesn't have night pain and parasthesia symptoms: pain in volar (palmar) forearm, parasthesia along median nerve distribution
pronator teres syndrome
what are the most common entrapment syndromes for the median nerve and anterior interosseous nerve (3)
pronator teres syndrome (median) anterior interosseous syndrome (branch of median) carpal tunnel (median - constriction)
what does PRICE stand for
protect, rest, ice, compress, elevate
interventions that protect and rest musculoskeletal tissues - ____________________ : brace, splint, strapping, taping
protected mobilization
Things to consider for rehab after nerve lacerations: Extent of recovery function is influences by level of nerve laceration (the more _________ the injury, the lower the recovery of function), degree of trauma (crush, avulsion, or clean cut), and age perform a thorough neural exam (particularly sensory and motor)
proximal
In any nerve injury in continuity, _____________ structures should be evaluated to rule out involvement contributing to pain, especially in ____________ __________ pain
proximal chronic neural
what neural condition is usually misdiagnosed as lateral epicondylitis (muscular problem) due to its location of pain near where to the radial nerve exits near the supinator
radial tunnel syndrome
Types of neck dissections - ___________ neck dissection: removal of all lymph node groups from levels I-V with sacrifice of internal jugular v., sternocleidomastoid m., and spinal accessory n. (historically most common neck dissection)
radical
interventions that protect and rest musculoskeletal tissues - ____________________ : assistive devices, adaptive equipment
reduced loading
function of thyroid
regulate metabolism
influence of the thyroid on rotator cuff
regulates growth and apoptosis (normal/controlled death of cells during organism's growth & development) of cuff tendons
reasons to immobilize: 1.Symptom________ 2. ________ positioning 3.Prevent joint contracture; increase ____________. 4.Protect___________ structures (wound, fx) 5.Improve joint___________ 6.Decrease_______ 7.Increase functional use
relief Edema PROM healing alignment pain
Cumulative trauma: a group of health disorders arising from _______________ biomechanical _____________ to muscles, tendons, ligaments, joints and neurovascular structures
repeated stresses
what are typical MOI's of cubital tunnel syndrome (4)
repetitive elbow motion, resting on elbows, triceps hypertrophy, FCU overuse
what is the common MOI for radial tunnel syndrome
repetitive use of wrist extensors or mechanical pressure
in this method of injury recovery, the patient returns to pre-injury function (or better)
resolve (the problem)
Depending on the extent of injury and prognosis, therapists can help patients recover from their injuries in what 3 possible ways?
resolve the problem alleviate the problem adapt/compensate
it is possible that, during the early stages of healing, the injured part(s) should be __________ from further injury with a gradual (and thoughtful) return to previous activities and participation
rested/protected
main impact of axillary web syndrome (cording)?
restricts overhead motion and shoulder ABD
Types of neck dissections - ______________ neck dissection: any type of cervical lymphadenectomy where there is preservation of one or more of the lymph node groups removed by the radical neck dissection (now more common neck dissection)
selective
design classifications of orthosis: No moving parts on orthotic. Static orthotic that is remolded periodically to improve joint motion or muscle length.
serial static
studies have shown another effect of surgery and/or radiation is weakness of the _____________ which can cause: winging of medial border of scap altered resting scap position altered overhead elevation of arm altered scapulo-humeral rhythm potential impingement with overhead activity
serratus anterior
When the Scapula is Positioned in Downward Rotation... 1. The __________________ and______________ muscles become stretched and weak = problems initiating scapular ____________ _____________ 2. The ___________________ and ___________ (___________________) become short therefore _____________ and ____________ rotation of scap!
serratus anterior lower trapezius upward rotation. levator scapulae rhomboids (downward scap) elevation downward
_________________ goals might address beginning and intermediate steps
short term (STG's)
_______ _______: which are typically overly strong. Stretch via a number of manual therapy techniques and therapeutic stretching exercises
shortened mm
in erb's palsy is a result of brachial plexus traction during birth and includes motor loss of what? (4)
shoulder ABD, shoulder flexion, elbow flexion, and wrist extension.
what are the neuromuscular consequences of radiation therapy (3)
skin wounding (desquamation) bone demineralization fibrosis (skin, muscle, neurovasc tissue, GI/GU tract, heart/lungs)
klumpes palsy this condition is a result of brachial plexus traction during birth and includes motor loss of the _________ mm of the ________ and sensory loss of the __________ aspect of the __________
small mm of the hand and sensory loss of the medial aspect of the upper limb
Because a nerve is _________ tissue it has the potential to become inflamed and irritated; it also has the ability to ________ after injury (maybe not to pre-injury level tho)
soft heal
Nerves are subject to the same forces and healing processes as other _______ tissues, so one can expect inflammation, scarring, adhesion, and diminished gliding, just as you would expect with any other ______ tissue.
soft soft
Key Concepts of Musculoskeletal (Orthopedic) Rehabilitation - Understand and apply knowledge of....... - Manage _______________ and ____________ (modalities, meds, application of protection/rest as needed) - Gain __________________ at the joint(s) - Gain muscle _________ and ___________ / restore normal posture - Gain normal _______________ (movement re-education) - Address return to ____________________ through exercise, activity, and adaptation (if needed)
soft and hard tissue healing inflammation and pain Range of Motion length and strength movement function/occupations
what are the materials available for splints?
soft splint and plaster casting
- Emotional or psychological distress produces or intensifies physical symptoms either for an acute period or for recurrent/chronic time-frame - Single or multiple physical manifestations - Poor stress management - Reported pain intensity is associated with increase stress/emotion/memory - May predispose patient to other maladaptive coping
somatization
3 categories of cancer treatments from the ortho perspective
surgery, radiation, drug therapy
what are some mechanical interfaces that may entrap or compress the median nerve and/or the anterior interosseous nerve
subscap pec minor pronator teres lig of struthers bicipital aponeurosis proximal arch of FDS transverse carpal ligament (carpal tunnel)
It is important to continue to challenge the patient, but build in __________ along the way
successes
this condition is usually a result of inflammation compression, external fixators, or ganglion cysts
superficial radial nerve syndrome (Wartenberg's Neuropathy)
______________ is a systematic or informal approach to examination and treatment planning in which you observe or inquire about tasks/activities that cause cumulative trauma.
task/activity analysis
this is the most common delivery method of radiation therapy beams of radiation go to cells with high O2 content and cells with high metabolic activity (damages DNA) (can damage other tissues besides cancer)
teletherapy
_______________ is systematic performance or execution of planned physical movements or activities intended to enable the patient or client to remediate or prevent impairments of body functions and structures, enhance activities and participation, reduce risk, optimize overall health, and enhance fitness and well-being (APTA definition)
therapeutic exercise
this term refers to axoplasm flowing better when the nerve is moved (via gliding)
thixotropy
this type of cancer is fairly common and is one of the few cancers that is increasing in incidence in the US relatively survivable Common signs/symptoms: neck lump, voice changes, swollen lymph nodes, throat/neck pain, swallowing/breathing problem
thyroid
A TOS test that is + for pec minor would include the scapular postural impairment of a ______ scapula
tipped
with an injury to the spinal accessory nerve causing sternocleidomastoid dysfunction, what condition could potentially result
torticollis (neck twisting to one side causing head tilt)
stretching neural tissue; may co-exist with compression, constriction, or entrapment
traction
what are common MOIs to the brachial plexus
traction, (mechanical) compression, (mechanical) entrapment (TOS)
with an injury to the spinal accessory nerve causing trapezius dysfunction, what does this do the the scapula
translated laterally (ABD), downward rot (as well as shoulder droop, scapular winging, asymmetric neckline, and/or weakness of forward arm elevation)
Friction massage involves the application of pressure ________________________ to the involved tissues, with movement directed ____________________ across scar tissue.
transverse/perpendicular perpendicularly
what muscles does the spinal accessory nerve innervate
trap, sternocleidomastoid
what are the mechanical interfaces / potential areas of entrapment/compression for the *radial* nerve
triceps (lateral head) subscap b/w brachioradialis and brachialis ECRB origin supinator origin (Arcade of Frohse) distal supinator
_______________ are usually found within a taut band of skeletal muscle that is painful on compression and that can give rise to characteristic referred pain, tenderness, and autonomic phenomena.
trigger point
____________________ is a hyperirritable focus of soft tissue
trigger point
Myofascial Release (MFR) Direct Technique •Directly loading the fascia at the__________________ •Best applied to one to three TP's per treatment, followed by _____________ and _______________ •Palpate and treat the most active trigger points, starting with the one that most closely recreates the ___________ that the person is experiencing.
trigger point modalities and stretching pain
(T/F) The adaptations used with clients are limited only by the creativity and imagination of the therapist
true
T/F Always prescribe at least one stretch for the muscle(s) you treated
true
T/F: ROM exercises can help decrease swelling and can help with pain control
true
T/F: peripheral nerves can regenerate even following a complete transection (laceration)
true
T/F: there are currently no clinical practice guidelines for treating thoracic outlet syndrome (TOS)
true
this condition of the ulnar nerve can co-exist with carpal tunnel syndrome common MOI's: fracture of hamate, ganglion cyst, repetitive wrist injury, cycling (riding down hard on handle bars)
ulnar tunnel (Guyon's canal)
Treating Thoracic Outlet Syndrome: teach patient how to stretch _____________ and strengthen for __________ correction
unassisted postural
What spinal nerve roots innervate the deltoid, biceps, brachioradialis, supinator, and flexor mm of the forearm?
upper roots C5-C6
what roots are affected in erb's palsy
upper roots C5-C6
studies have shown another effect of surgery combined with radiation is weakness in the _____________ which can cause: "dropped shoulder" - scap on involved side is depressed at rest altered overhead biomechanics (scap upward rot not initiated --> impingement and pain) problems with ECCentric control on the return of the arm from overhead to neutral over time, impingement can lead to a rotator cuff pathology, pain, and/or GH joint immobility
upper trap
EMG studies found largest changes in muscle activity for what two mm after breast cancer neither of these mm are directly affected by surgery or radiotherapy, these are secondary effects caused by altered biomechanics
upper trap, rhomboids
SAN Injury: Biomechanical problems with Overhead Movement •The _______________ cannot initiate scapular upward rotation along with the serratus anterior •The _____________cannot continue scapular upward rotation after about 90 degrees of overhead movement •Both can cause impingement & pain --> Over time, impingement can cause _______________ pathology, GH joint ______________ •Also problems with _______________ control to return arm from an overhead position to neutral.
upper trapezius lower trapezius rotator cuff immobility. ECCentric
Treatment for superficial radial nerve syndrome
usually no splint needed, address inflammation by removing irritating structure
compression MOI of anterior interosseous syndrome =
usually repetitive pronation
this type of training creates resistance or assistance vectors to retrain muscle focused on specific muscle/muscle group line of action
vector training
Corticosteroid Injections: The Downside the potential for tendon ______________ and subsequent rupture is (increased/decreased) with repeated injections around the tendon (corticosteroid)
weakening increased
gravity torque around joint is dependent on __________ and _________
weight and lever arm
when applying Wolf's and Davies' Law to healing tissues, consider: ________ to introduce tension to the tissues the ______ and _______ of tension how to progress the tension such that the tissue can tolerate the demands of the patient's various activities
when magnitude type
•Therapist should listen, validate pain, act as a support in order to facilitate return to_________. •Evaluate activities that are ___________ the symptoms and make modifications •Educate patients about "___________" •For ___________ and/or __________ pain, consider Therapeutic Neuroscience Education / Cognitive Behavioral Therapy
work provoking safe pain severe/chronic
Splinting for Lateral Epicondylitis - Acute phase: - After acute pain is resolved: - Chronic, non-healing: elbow-wrist immob with elb (_____) and wrist (______) _______________
wrist cock-up counterforce cuff 90 15-30/extension
Splinting for Medial Epicondylitis - Acute phase: - After acute pain is resolved: - Chronic, non-healing: elbow-wrist immob with elb (___) and wrist (_______) ________
wrist cock-up (neutral wrist) counterforce cuff 90 10-15 flex
Orthotics should be _______ the circumference of the part supported. If circumference is too high, the extremity "__________" below the straps—orthotic shifts. If circumference is too low, the orthotic causes _____________
½ floats pressure
What are contraindications to friction massage?
•Acutely inflamed tissue, acute strains, hematomas, calcifications, and peripheral nerves should not be directly massaged. •Tissues that have been torn and/or surgically repaired should not be treated with friction massage until sufficient healing has occurred. •A good rule of thumb: if active movement is more than mildly uncomfortable, don't perform a friction massage.
how do we locate an active trigger point?
•Find a palpable tender spot in the muscle •Mildly reproduce the person's pain with pressure You will typically observe a jump sign characterized by vocalization by the patient or withdrawal
common signs of thyroid cancer
•Neck lump •Voice changes •Swollen lymph nodes •Throat/ neck pain •Swallowing/ breathing problem
what are the prescriptions for stability exercises?
•No known ideal parameters •Be task specific •Develop progressive challenge
Muscle Performance Edurance Intensity ____% of _________
≤50% 1RM