Week 1
outcome
"Outcome" defined: ...end result of therapy, ...clients' ability to function, health perceptions, and satisfaction of care (AOTA,2008) Client-centered (often self-rated) Give "big picture" re: occupational performance Objective score of performance, participation, activity level survey, patient reported
inflammation/acute phase-features related to assessment
*inflamed tissue hurts when: palpated elongated actively contracted Mechanically compressed (nerve)* Use above information to assess individual tissues Principles of provocative tests
proliferation (fibroplasia) phase-features related to assessment
-assess ROM in protected arcs (repaired tendon/nerve/vessel) -assess provocation of symptoms
remodeling (scar maturation) phase-features related to assessment
-assess length of tissues (connective, contractile) -assess length and mobility of scar
what happens during the remodeling phase?
-collagen is "remodeled" or "matured" -type 3 replaced by type 1 -realignment along lines of tension can last 21 days- two years -length of time depends on patient and wound related complicating factors filled in wound is covered and strengthened scar tissue forms
closed pack position
-complete congruency between joint surfaces -*capsule and ligaments under max tension* -articular surfaces cannot be distracted (pulled apart) -minimal room within joint
during a bicep curl, what type of movement is this (open or closed chain?) what muscles are active? what muscles are passive?
-elbow flexion, open chain active: biceps with a concentric contraction (elbow flexors) passive: triceps
proliferation (fibroplasia) phase-intervention principles
-initiate protected ROM (repaired tendon/nerve/vessel) through limited ranges -preserve glide of neighboring tissues -initiate pain-free ROM -Reduce tension on tissue (orthotic, modified occupational performance)
open packed position
-minimal congruency between joint surfaces -capsule is most relaxed -articular surfaces can be distracted (pulled apart) -maximal room within the joint
joint accessory motion
-movement WITHIN the joint-occurs between the joint surfaces -can NOT occur in closed packed position because the ligaments are too tight
what causes abnormal wound healing generally?
-they never get a good fabrication/laying down of collagen adn then that collagen gets damaged -no proliferation/remodeling because of fibrosis (abnormal)
what are the 6 dorsal compartments and their contents? how do you test for them?
1-APL, EPB - hitchhike 2-ECRL, ECRB - grip 3-EPL - hitchhike 4-EDC, EIP - claw, point 5-EDM - point with small finger 6-ECU - ulnarly deviate
what are the approximate degree amounts with scapulohumeral rhythm?
180 deg = 120 deg GH + 60 deg ST
inflammation/acute phase-definition & characteristicds
1st 24-48 hours; can be acute, subacute (2 weeks), or chronic (months/years) -Prepare wound for healing; rid of debris (phagocytosis) -Cardinal signs: redness, swelling, heat & pain -2 reactions occurring concurrently: vascular & cellular -Vascular: vasoconstriction to preserve life-followed quickly by vasodilation and edema -Cellular: platelets->neutrophils->monocytes/macrophages->lymphocytes (helping to clean injured area out) pain=inflammation/acute
when we Put antagonist muscle on slack at neighboring joint... if AROM increases what does this mean? if AROM remains the same what does this mean?
AROM increases: antagonist muscle tightness AROM stays the same: joint stiffness
biomechanical FOR evaluation of motor skills:
Aligns Stabilizes Positions Reaches Bends Grips Manipulates Coordinates Moves Lifts Transports Endures Paces
alternative method of measuring outcomes
Alternate method = compare to unaffected side
assessment tools
Assessment tools - typically therapist-performed assessments Performance-based (observing the patient do something) Examples: 9 Hole Peg Test, grip strength testing with dynamometer, MMT, etc.
inflammation/acute phase-intervention principles
Avoid occupational behaviors that prolong inflammation (teach modifications) Prevent deformity (remember open-packed positions are positions of comfort AND often of deformity) Use RICE as a guide for interventions (rest, ice, elevate) -prevent open packed positioning
Some of the methods of provocative testing are... A. Passive contraction, passive elongation, vibration B. Palpation, elongation, active contraction C. open-packed positioning, elongation, palpation
B
Assume the client is lowering his Left leg down to the floor. Select the ONE BEST choice: (same pic) A-The client is demonstrating Left concentric hip extension B-The client is demonstrating Left eccentric hip extension C-The client is demonstrating active insufficiency of the Left rectus femoris at the hip D-The client is demonstrating passive insufficiency of the Left rectus femoris at the hip
B controlling descent against gravity
If suspect inflamed ECRB origin (tennis elbow): Palpate medial elbow Elongate ECRB Actively resist elbow flexion
B (flex the wrist) A-not correct because ECRB is on the lateral side C-not related to ECRB
inflammation when does it start, how long does it last, and what are the signs?
Begins immediately after wound and lasts 2-3 days Redness, warmth, swelling, pain begins when the would develops, lasts 4-6 days. marked by edema, erythema, inflammation, pain -healing process triggered -immune system works to prevent microbial colonization
Outcome measures - Benefits of use
Big picture focus on occupational performance (top-down) Client-centered Help with goal-setting - give objective score of function Medicare requirement for reimbursement Marketing - ex: FOTO Research
how to test for intrinsic tightness?
Bunnell-Littler Test -testing for intrinsic tightness
Client is 4 weeks out from stable, non-displaced fracture and has just had cast removed. What is the most appropriate type of exercise at this time? Weight-bearing Strengthening AROM Closed-chained
C 6-8 weeks to fully heal bone and perform weight-bearing activities
Assume the client is flexing the Left hip to don his sock. Select the ONE BEST choice: (see pic in notes-sitting on couch lifting up knee to don sock) A-The client is demonstrating active insufficiency of the Left rectus femoris at the hip B-The client is demonstrating passive insufficiency of the Left rectus femoris at the hip C-The client is demonstrating concentric contraction of the Left rectus femoris at the hip D-The client is demonstrating eccentric contraction of the Left rectus femoris at the hip
C is correct because shortening against gravity, not slow and controlled descent (eccentric) A-the knee is not extended B-the hip is not extended
aspects that indicate abnormal wound healing?
Chronic inflammation Abnormal fibrosis Combo of both! It's ABNORMAL
validity
Construct-how well it measures up to its claims, criterion-new tool vs gold standard, content-does it measure what it says its measures
middle (critical phase) muscles
Continued humeral head depression: subscap, infra, teres minor; upward scap rot: upper & lower trap *more musculature demands to overcome gravity
setting (pre-phase) and initial phase of scapulohumeral rhythm-which muscles?
Deltoid - superior (linear) force; subscap, infra, teres minor - depress humeral head initial-Rotator cuff muscles to depress humeral head and stabilize; scapula upward rotators
what can slow tissue healing?
Diabetes, tobacco use, infection; vascular insufficiency; malnutrition; certain medications; etc.
how to find compartment 4 surface anatomy
EDC claw hand EIP point index finger
how to find compartment 5 surface anatomy
EDM pinky up
sensitivity
How accurate a test is in identifying person WITH a condition
specificity
How accurate a test is in identifying person WITHOUT condition
biomechanical interventions
Improving AROM/PROM Protective ROM Increasing strength Joint mobilization Increasing endurance Tissue gliding Lengthening tissues Neural gliding Reducing, lengthening, softening scar Normalizing sensation Preventing deformity Muscle re-education Edema management Postural correction Functional mobility Modifying ADL Incorporating client factors and context Grading, modifying, discontinuing specific interventions Thorough understanding of anatomy: determine source of problem; must make applications
criterion-reference
Individual score compared to established standard Ex: NBCOT exam! you meet a certain score to pass
norm reference
Individual score compared to population score Ex: 9 Hole Peg Test, DASH
intrinsic muscles vs extrinsic
Intrinsic = muscles confined to the hand Extrinsic = muscles originating proximal to the hand but acting on the hand
when is joint tightness present?
Joint (capsular) tightness = present if PROM of a joint does not change despite repositioning of neighboring joint(s) same goniometric measure = contracture
biomechanical FOR evaluation of body functions: neuromuscularskeletal and movement-related functions
Joint mobility Joint stability Muscle power (MMT) Muscle endurance Coordination
when does lag occur? what is it usually in reference to? what can it indicate?
Lag = PROM>AROM usually in reference to problem at MCP (loss of active joint extension) trying to extend @ MCP, active lag of index finger can indicate mm weakness
what can loss of length of muscle/tendon units lead to?
Loss of length of muscle/tendon units can lead to joint tightness
MDC vs MDIC
MDC-strong change, client can tell if they are better MCID-smallest change not due to error (patient cannot always tell)
final phase muscles & clavicular cranking (final final)
More scapula upward rotation; Humeral head depressed due to gravity, less demand on rotator cuff Clavicle dorsally rotates on its long axis; lateral end of clavicle rotates upward = AC joint and scapula elevation
when is musculotendinous tightness (shortening) present?
Musculotendinous tightness (shortening) = present if PROM of a joint changes with *respositioning of adjacent joints that are crossed by that particular muscle-tendon unit*
other conditions with provocative testing
Other conditions: Mechanical compression (reducing space, internal/external pressure) Nerve or vascular structures Adhered tissue (pain with elongation - example: neural tension testing)
Measure AROM of joint If less than normal ROM, assess PROM in same direction If PROM>AROM what does this mean? If PROM=AROM what does this mean?
PROM>AROM=Weakness/adhesion of agonist muscle PROM = AROM: Could be Joint stiffness OR Antagonist muscle tightness (must keep testing)
principles of provocative testing (inflamed tissue hurts with): ****important to memorize
Palpation (Compression) Elongation Active Contraction (AROM, MMT/resistance)
how do we determine if it is joint stiffness or antagonist muscle tightness when PROM=AROM, but AROM is not normal?
Put antagonist muscle on slack at neighboring joint shorten antagonist mm at different joint than you are testing
outcome measure types
Quality of life (health status) -Example: SF-36 Regional (part of body) -Example: DASH Condition-specific -Example: AIMS DASH-disability of arm, shoulder, hand
remodeling (scar maturation) phase-intervention principles
Regain length of tissues (connective, contractile) Lengthen and mobilize scar Techniques: low load long duration (LLLD) stretch, heat and stretch, deep friction massage, joint mobilization, scar pad, mobilization splinting LLLD-low load long duration
sensitivity vs specificity
Sensitive test negative rule OUT disease-SNOUT specific test positive rule in disease-SPIN
scapulohumeral rhythm
Simultaneous glenohumeral & scapular movements that produce full shoulder elevation (abduction, flexion, scaption) Elevating shoulder: complex coordination of clavicle, scapula, & humerus; SC, AC, ST & GH
proliferation to remodeling phase for each type of tissue (memorize these)
Skin (7-10 days) Tendon (4-6 weeks) Ligament (8-10 weeks) Peripheral Nerve (varies - more later!) Bone (6-8 weeks) ligaments=longer to heal due to limited blood supply
standardized assessments
Statement of purpose Statistical confirmation of validity Statistical confirmation of reliability Description of equipment Normative data Specific instructions If performing standardized test for purposes of comparing results to norm or criteria - make sure you follow standardized procedures!
types of interventions
Therapeutic use of occupation Therapeutic use of exercise Therapeutic use of activity (purposeful activity) Therapeutic use of preparatory methods Education on compensatory strategies Education on environmental modifications Ergonomics Grading/adapting tools, materials, occupations
what are preparatory methods?
They are used in conjuction with or in order to prepare the client for puposeful activity and OT performance. They include sensory input, therapeutic exercise, physical agent modalities (PAMs), and orthosis/splinting modalities, orthoses, splinting
biomechanical FOR evaluation of body functions: sensory functions & pain
Touch Pain (e.g. diffuse, dull, sharp, phantom) Sensitivity to temperature and pressure
Measuring outcomes: Common features
What does the tool measure? What is the possible range of scores? What does the score mean? How long does it take to complete? Does tool measure function or disability? How much change shows improvement? How does the score compare to the norms? Time frame for rating/instructions What population? Self-rating? Performance-based?
what would active insufficiency look like for the biceps? passive?
active -flex elbow, shoulder, supine hand passive -extend elbow, shoulder, and pronate hand
what does active and passive insufficiency look like for the rectus femoris?
active -when the hip is flexed (shortened rectus femoris) the knee cannot be extended as far because it would further shorten the rectus femoris passive -when the hip is extended (lengthening the rectus femoris) the knee cannot be flexed as far because that would further lengthen rectus femoris
what does active and passive insufficiency look like for the hamstrings?
active -when the knee is flexed (shortened hamstrings) the hip cannot be extended as far (bc that would further shorten the hamstrings) passive -when the knee is extended (lengthened hamstrings) the hip cannot be flexed as far (bc that would further lengthen the hamstrings)
what does active and passive insufficiency look like for the EDC?
active -when the wrist is extended, (shortened EDC) the fingers cannot be extended all of the way passive -when the wrist is flexed (lengthened EDC) the fingers cannot be flexed all the way
what does active and passive insufficiency look like for the FDS/FDP?
active -when the wrist is flexed (shortened FDS/FDP), the fingers cannot be flexed all the way (cannot make a tight fist) passive -when the wrist is extended (lengthened FDS/FDP) the fingers cannot be extended all the way (claw hand)
which types of movements recruit more muscle fibers
active more than passive, eccentric more than concentric
assessment- outcome-
assessment-performance based outcome-survey or patient reported
proliferation (fibroplasia) phase-definition & characteristics
begins after inflammation; lasts days to weeks -formation of granulation tissue -angiogenesis -re-epithelialization -wound contraction -scaffolding or matrix established for further tissue healing
remodelating (scar maturation) phase-definition & characteristics
begins after proliferation and can last up to 2 years -Balance of tissue synthesis and degradation -Collagen conversion (type III to I): tensile strength=20% by week 3; at most will regain 80% of original strength -Wound contraction -Scar formation **important to educate clients on this process
proliferation-when does it begin? end time?
beings after inflammation stage; end time varies depending on tissue type -lasts another 4-24 days -granulation tissue fills in the wound
so with a bicep curl vs push up which is open chain and which is closed chain and why?
bicep curl: open chain because the distal hand is moving push up: closed chain because the body (proximal portion) is moving
what is our goal as therapists with abnormal wound healing?
break patients out of abnormal stage to normal. must start @ inflammation stage, so some patients may get worse before they get better -must use tools to break up scar tissue and put it back into the inflammation stage then doing exercises to appropriately realign the collagen matrix
close vs open pack and injury, ligament tightness
close -ligaments are tight -we put injured into closed pack-position of anti-deformity open -ligaments on slack -position of deformity
during a push up, what type of movement is this (open or closed chain?) what muscles are active? what muscles are passive?
closed chain (hands are fixed and body is moving) active: triceps, eccentric contraction (controlling descent) passive: biceps
which is more stable close packed or open packed?
closed-most STABLE position open -position of comfort following edema, maximal room within the joint
where does compartment 2 stop and what crosses over distally?
compartment 2 stops at the wrist and 3 crosses over distally
concentric, isometric, & eccentric contraction
concentric -length of muscle shortens -muscle force is greater than resistance isometric -no change in mm length -muscle force equal to resistance eccentric -muscle lengthens -muscle force is less than the resistance
closed chain movement
distal end (feet/hands) is fixed extremity planted, proximal portion moving "weight-bearing"
open chained movement
distal end is free to move, distal portion moving
what is the anatomical snuffbox the depression between?
dorsal compartemnts 1 and 3
when is there the least amount of stress/tension on a muscle?
during PROM
when are muscles working the hardest? why?
during eccentric contraction producing the most collagen
grading of therapeutic exercise program (easiest on mm to hardest)
easiest (less intense to muscle/tendons) PROM AAROM Isometric (place and hold) AROM Concentric Eccentric hardest (more intense)
during descent, what kind of contraction are active muscles performing?
eccentric on descent
how does glenohumeral movement compare to scapulothoracic movement?
gleno-2x as fast Scapulo-thoracic:GH movement = 1:2 (approximately!)
moving from squat-->stand what motion is occuring at the knee, hip, and ankle? what muscles are shortening? what muscles are lengthening? what muscles are active? contraction type? passive muscles?
hip extension extensors flexors extensors concentric flexors knee extension extensors flexors extensors concentric flexors ankle plantarflexion plantarflexors dorsiflexors plantarflexors concentric dorsiflexors
moving from stand-->squat what motion is occuring at the knee, hip, and ankle? what muscles are shortening? what muscles are lengthening? what muscles are active? contraction type? passive muscles?
hip flexion flexors extensors extensors eccentric flexors knee flexion flexors extensors extensors eccentric flexors ankle dorsiflexion dorsiflexors plantarflexors plantarflexors eccentric dorsiflexors
what muscles are active during passive insufficiency of rectus femoris?
hip extensors and knee flexors
what muscles are active during hamstring passive insufficiency?
hip flexors and knee extensors
what happens during the proliferation stage?
increased fibroblasts and increased collagen fibroblasts lead to collagen production (type 3) angiongenesis (growth of new blood vessels) also occurs fibroblasts lay collagen in the wound bed, strengthening the new granulation tissue -wound edges begin to contract -epithelial cells migrate from the wound margins
so what stage must therapists reset abnormal wound healing to?
inflammation stage -then use tools to break up scar tissue and put it back into the inflammation stage then doing exercises to appropriately realign the collagen matrix
3 main phases of normal would healing (what is it also known as)
inflammation-->proliferation-->remodeling aka acute-->fibroplasia-->maturation 4th stage in the beginning-hemostasis (when the bleeding stops)
if decreased PIP flexion compared to comp. fist, this could indicate
intrinsic tightness (interossei and lumbricals)
how can therapeutic exercise impact the wound healing process during the remodeling phase?
it can impact how the collagen is laid down
why is passive less stress/tension on mm?
its pushing mm tendons (less excursion) active is more excursion
what muscles would be impacted for intrinsic tightness?
lumbricals and interossei
how to find compartment 2 surface anatomy
make a fist to visualize and palpate ECRB and ECRL
responsiveness
minimal detectable change (MDC) & minimal clinically important difference (MCID)
why is the middle phase the critical phase?
mm work the hardest during this phase. -during this phase, the humeral head has to depress (purpose of all rotator cuff mm except supraspinatus) -upper and lower trap + serratus anterior upwardly rotate scapula so these mm must be strong in the middle phase to prevent *shoulder impingement*
mobilizations, assessment and intervention uses of joint accessory motion
mobilization -distraction, rolling, gliding assessment -to determine if stiffness is present (could be one cause of decreased ROM) intervention -to stretch capsule to increase ROM; pain management -different grades of motion for different purposes if joint accessory motion in an eval is limited, we can use joint mobilization using joint accessory motion as an intervention
AROm can increase ____ or ______
motion or strength
does resting position=open packed position?
no. all muscles that cross the joint are naturally relaxed. does not necessarily equal open packed
open or closed chain-where is the joint most stable and why?
open chain-joint less stable -shearing forces at the joint closed chain-joint more stable -joint compression=stability
joint accessory motion must occur in what position?
open packed -can NOT occur in closed packed position because the ligaments are too tight
3 principles of provocative testing
palpation (compression) elongation active contraction (AROM, MMT/resistance)
what phase happens after inflammation?
proliferation
provocative testing
provokes symptoms! -making them hurt for the purpose of assessment and treatment
In what wound healing stage is deep tissue massage an appropriate intervention? Inflammation Proliferation Remodeling
remodeling -you must have a collagen matrix laid down -not fully healed in proliferation yet, so deep tissue massage could re-injure
so when we move from squat to stand, the ____ muscles are active, but now they are______
same muscles are active, but now it is concentric contractions
what is the role of the intrinsics?
straighten the IPs
the Bunnell-Littler test is looking for intrinsic tightness. what other joints would be tested to see if they are the culprit and are stiff?
testing for lumbrical and interossei stiffness, but also considering PIP stiff joints possibly
for muscle insufficiency to occur, what must it do?
the muscle MUST cross at least 2 joints -ex. brachialis only crosses one joint, so it cannot be insufficient
what does muscle insufficiency mean?
the muscle cannot perform all jobs at the same time if it crosses more than 1 joint
process of abnormal wound healing
tissue strain micro trauma-->scar tissue formation-->tissue tightness decreased strength changes in blood flow altered biomechanics loss of flexibility or microtrauma-->strain, tear, or crush injury-->pain or loss of function *re-injury between the inflammation and fibrosis stage*
what type of collagen is produced in the proliferation stage?
type 3
which types of collagen are in the proliferation vs remodeling phase and which is stronger?
type 3-proliferation type 1-remodeling type 3-wimpy type 1-strong type 3 converted to type 1 during the remodeling phase
time frame of proliferation to remodeling phase depends on _______. why does this matter?
type of tissue injured guides evaluation and intervention
psychometric properties
validity, reliability, responsiveness, sensitivity, specificity
what would we observe if we had instrinsic tightness? what other joint are we also keeping our eye on?
we wouldn't be able to flex the IPs as much or extend the MCPs (bc this is when they are on length, they contract to extend the IPs and flex MCPs) trouble making a fist PIP joints-is it just the stiffness in the PIP joints why we can't make a fist or intrinsic tightness?
active insufficiency
when the muscle becomes shortened to the point it cannot generate or maintain active tension -cannot shorten over every joint -active: trying to shorten
passive insufficiency
when the opposing muscle becomes stretched/elongated to the point it can no longer lengthen and allow movement (cannot lengthen over every joint) trying to lengthen too much
what muscles are active during passive insufficiency for FDS/FDP?
wrist and finger extensors
what muscles are active during passive insufficiency for EDC?
wrist and finger flexors
