Ptha 2409 - Therapeutic Exercise - Bandy & Sanders Book, Daniels And Worthingham Book, And Stetz Lecture - Exam 4

Front 1

What is coordination? ***

Back 1

the ability to use the right muscles at the right time with appropriate sequencing and intensity

Front 2

What is balance? ***

Back 2

process of controlling the body’s COG over the BOS, or within the limits of stability

Front 3

What are the two types of balance? ***

Back 3

- static

- dynamic

Front 4

What are the components of balance? ***

Back 4

- biomechanical
- sensory
- musculoskeletal

Front 5

What is the BOS? ***

Back 5

- base of support

the area within the perimeter of the contact surface between the feet and the support surface.

Front 6

What are the limits of stability? ***

Back 6

- a.k.a. cone of stability

- the greatest distance a person can lean away from midline vertical (in any direction) without falling, stepping, or reaching.

Front 7

What are the anterio-posterior limits of stability? ***

Back 7

- about 12 inches (combining anterior and posterior)

- more range anteriorly (about 7 inches) than posteriorly (about 5 inches)

Front 8

What are the lateral limits of stability? ***

Back 8

- about 16 inches

- roughly 8 inches to either side

Front 9

What is the COG? ***

Back 9

- center of gravity

- central point within the limits of stability area

Front 10

What is the center of mass? ***

Back 10

where weight of body is said to be concentrated.

Front 11

Where is the center of mass in a human standing erect? ***

Back 11

- near the 2nd sacral vertebra

- about 5 cm (2 inches) below navel

Front 12

When standing upright, the _____ is centered over the _____. ***

Back 12

- COG

- BOS

Front 13

What are the sensory components of balance? ***

Back 13

- proprioceptive
- visual
- vestibular

Front 14

What is proprioception? ***

Back 14

- info about orientation of body and body parts relative to each other and support surface

- info from skin, joint, & muscle receptors, deep pressure (Pacinian/Meisner corpuscles, etc.)

Front 15

What does the visual sensory system do? ***

Back 15

provides info about physical surroundings relative to position

Front 16

Describe the vestibular system. ***

Back 16

- sensory and motor functions

- sensory system detects position of head in space, angular velocity and linear acceleration of head

- motor system is responsible for postural control

Front 17

What does the vestibulospinal reflex do? ***

Back 17

- stabilizes head

- upright posture

Front 18

What does the vestibulo-ocular reflex do? ***

Back 18

- stabilizes vision while head and/or body is moving

Front 19

When do the vestibulospinal and vestibulo-ocular reflexes develop? ***

Back 19

early in life (preference for upright head and eyes level with horizontal plane)

Front 20

How is the sensory system organized/integrated? ***

Back 20

- proprioceptive, visual, and vestibular systems provide redundancy

- normal response involves selection, suppression, or combination of appropriate input

Front 21

What are the musculoskeletal components of balance? ***

Back 21

- paraspinals
- abdominals
- hamstrings
- quadriceps
- gastrocnemius
- tibialis anterior

Front 22

What are the autonomic postural reactions? ***

Back 22

- occur before voluntary movement and after reflexes

- similar to reflex--quick response and similar in all people

- similar to voluntary--require some coordination

- 5 reactions/strategies

Front 23

What are the five autonomic postural reaction strategies? ***

Back 23

- ankle strategy
- weight-shift strategy
- hip strategy
- stepping strategy
- suspension strategy

Front 24

Describe ankle strategy? ***

Back 24

- small, slow-speed perturbations on large supporting surface

- anterior sway - control with gastrocs >> hamstrings >> paraspinals
- posterior sway- control with anterior tib >> quads >> abdominals

- muscles recruited distal to proximal

Front 25

Describe weight-shift strategy. ***

Back 25

- lateral (frontal?) plane
- hips and ankles

- control of mediolateral perturbations
- shifting weight from one leg to the other

- hips are key
- abductors and adductors, some contribution from ankle invertors and evertors

Front 26

Describe hip strategy. ***

Back 26

- for greater disturbances
- use of hip flex or ext to correct balance

- moderate or large postural disturbance; uneven, narrow or moving surface
(e.g., when bus quickly accelerates)

- recruit muscles from proximal to distal

Front 27

Two types of sway associated with hip strategy ***

Back 27

anterior sway
- contraction of abdominals (“catch” you)
- then quads assist
- (FYI - a response to posterior displacement of support surface)

backward sway
- contraction of paraspinals (“catch” you)
- then hamstrings assist
- (FYI - a response to anterior displacement of support surface)

Front 28

Describe stepping strategy. ***

Back 28

- greater disturbance

- large-amplitude forces displace COG
- a step is used to enlarge BOS
- new postural control re-established

- posterior displacement results in backward step
- anterior displacement results in forward step

Front 29

Describe suspension strategy. ***

Back 29

- when one quickly lowers the body COM by flexing knees

- causes associated ankle and hip flexion

Front 30

Describe combined strategies. ***

Back 30

- most of us use combination of strategies to maintain balance

- individual strategies only help clarify

Front 31

How is sensory organization assessed? ***

Back 31

- Sensory Organization Test performed on SMART Balance Master
- Clinical Test for Sensory Interaction and Balance (CTSIB) or “Foam & Dome”

- Romberg Test
- one-leg stance test

- functional reach test
- timed up and go test (TUG)

Front 32

How is the Sensory Organization Test performed? ***

Back 32

- on SMART Balance Master

Front 33

How is the Clinical Test for Sensory Interaction and Balance (CTSIB) or “Foam & Dome” performed? ***

Back 33

assesses balance under 6 different conditions (normal, blindfolded, & head in box while standing on floor; then same three while standing on foam)

Front 34

Describe the Romberg test. ***

Back 34

stand with feet shoulder width apart
- 30 sec – eyes open
- 15 sec – eyes closed -- sway is normal, LOB is not

Front 35

Describe the one-leg stance test. ***

Back 35

- cross arms and stand on one leg as long as possible; then switch to other leg.

Front 36

Describe the functional reach test. ***

Back 36

stand parallel to wall, shoulder at 90˚ reach and measure

Front 37

Describe the timed up-and-go test. ***

Back 37

- patient seated, stands, walks 3 meters, turns around, returns, sits

Front 38

What difficulties can biomechanical deficits cause? ***

Back 38

impairments can cause distorted input by changing COG
- reduced ROM
- decreased BOS
- muscle weakness - limits of stability
- pain

LE injury (e.g., ACL), stroke, arthritis, LBP

Front 39

What difficulties can sensory deficits cause? ***

Back 39

- proprioception, vestibular, and visual
---- neuropathy
---- inner ear
---- vision changes

Front 40

What difficulties can musculoskeletal deficits cause? ***

Back 40

- strength
- ROM
- muscle tone
- coordination

- CVA, head injury, Parkinson's disease

Front 41

What is BPPV? ***

Back 41

- Benign Paroxysmal Positional Vertigo

- Vestibular disorder that causes dizziness with changes in the position of the head.

Front 42

How does the acronym BPPV break down? ***

Back 42

- benign- not serious, self-limiting

- paroxysmal- sudden, unpredictable onset

- positional- comes with change of head position

- vertigo- sense of room spinning

Front 43

Causes of BPPV? ***

Back 43

- due to debris collected within part of inner ear.
- otoconia, otoliths, or “ear rocks”, - small crystals of calcium carbonate in saccule and utricle of ear

- more common in the elderly with degenerative changes of the vestibular system of the inner ear

- minor strokes
- head trauma

- viruses affecting the ear
- associated with migraines

Front 44

Purpose of the saccule and utricle of ear? ***

Back 44

- help determine direction of gravity

Front 45

Theory behind BPPV (disease state)? ***

Back 45

- in disease state, the otoconia loosen and can migrate into the semicircular canals (SSC)
- causes abnormal fluid (endolymph) displacement and resultant vertigo

- posterior canal most commonly affected
- known as canalithiasis

Front 46

Symptoms of BPPV? ***

Back 46

- dizziness usually short term (seconds to few minutes)
- nausea
- vomiting
- nystagmus
- visual disturbance - may be difficult to read or focus

Front 47

How is BPPV triggered? ***

Back 47

- tilting head
- rolling over in bed
- looking up or under
- sudden head motion

Front 48

What worsens BPPV? ***

Back 48

- changes in barometric pressure
- lack of sleep
- stress

Front 49

What test is commonly done for BPPV? ***

Back 49

Dix-Hallpike

Front 50

Describe the Dix-Hallpike test. ***

Back 50

- person is brought from sitting to supine with head turned 45 degrees to one side and extended about 20 degrees backward.

- once supine, the eyes are typically observed for about 30 seconds.

- if no nystagmus, the person is brought back to sitting.
- wait about 30 seconds
- test other side

- know that it is a test for determining BPPV (whichever ear is to the ground is the “bad” side)

Front 51

How is the Epley maneuver performed? ***

Back 51

- long sit in bed
- rotate head 45 deg toward side causing symptoms
- hold position 60 sec

- keep head in this position and gently lie down
- hold 60 sec

- rotate head 90 deg to other side
- hold 60 sec

- maintain head position and roll body to “good side”
- sit up with head flexed to 45 degrees
- hold 60 sec

Front 52

What other maneuver is used for BPPV? ***

Back 52

Semont

(no text description, but a picture of someone short sitting, then lying with head rotated on each side)

Front 53

Home treatment program for BPPV? ***

Back 53

- Epley maneuver 3 cycles before going to bed

- sleep semi-recumbent for 2 nights (45 deg), then graduate to 2 pillows

- avoid sleeping on “bad side”

- do not turn head quickly

Front 54

What is gait? ***

Back 54

manner or style of walking or running

Front 55

What is gait training (gt. tng.)? ***

Back 55

instructing a person to walk with the use of an assistive device (or ambulation aid)

Front 56

When is gait training with assistive devices needed? ***

Back 56

when a patient has:

- decreased ability to bear weight secondary to damage to skeletal system

- muscle weakness, or paralysis of trunk or LE

- poor balance and/or coordination

- absence of LE, with or without prosthesis

Front 57

Name some types of ambulation aids. ***

Back 57

- parallel bars (most supportive)
- walker (second most)

- crutches 2, crutch 1
---- axillary (under arms)
---- Lofstrand, Canadian (around forearm)

-cane 2, cane 1
---- single prong (J, offset, T)
---- quad, hemi, crab cane

Front 58

Rank assistive devices from most to least supportive. ***

Back 58

- parallel bars – most supportive
- walker

- bilateral crutches
- single crutch

- bilateral canes
- crab cane
- single cane – least supportive

Front 59

How much coordination (muscular, etc.) does the patient need for various assistive devices--rank least to most. ***

Back 59

- parallel bars – least coordination required
- walker
- cane
- crutches – most coordination required

Front 60

List and describe some of the most common WB statuses. ***

Back 60

NWB - non-weight-bearing
PWB - partial-weight-bearing

% WB - % of the person’s weight; show with scale
(also, a poundage might be listed instead)

WBAT - weight-bearing as tolerated
PWBAT - partial weight-bearing as tolerated

TTWB - toe touch weight-bearing
TDWB - touch down weight-bearing
(last two are just for balance, but don’t keep foot plantar flexed; from the book, I think this means have them use a heel-strike or foot flat with no weight behind it, because plantar flexion "toe touching" is not natural gait)

Front 61

Who determines a patient's WB status? ***

Back 61

the physician

Front 62

What is assumed if WB status is unknown? ***

Back 62

NWB

Front 63

How are assistive devices adjusted to fit? ***

Back 63

- initial estimate - usually done while seated

- final adjustment - done while standing with assistive device, then when using it

Front 64

How are parallel bars adjusted? ***

Back 64

estimate:
- stand erect, shoulders relaxed
- bars even with wrist crease (better estimate than measuring from greater trochanter to ground)

final
- 20-25 degrees elbow flexion when pt. stands erect and grasps the bars approximately 6 inches anterior to hips

Front 65

How are walkers adjusted? ***

Back 65

estimate
- stand erect, shoulders relaxed
- hand grip even with wrist crease
(if pt. is seated or lying down, could measure from greater trochanter to bottom of foot)

final
- patient stands inside walker
- 20-25 degrees elbow flexion when grasping handpiece
(rear feet of walker at mid-portion of shoe)

Front 66

How are axillary crutches adjusted? ***

Back 66

initial
- estimate length with patient lying or sitting, or
- X 77% of ht in inches, or
- subtract 16 in from ht, or
- with arms abducted; one flexed to 90; measure elbow to tip of long finger of opposite UE

final
- standing, tip 6” at 45 degree diagonal (or 2” lat and 4-6” ant)
- hand on handgrip; elbow with 20-25 deg flexion.
- 2-3 finger breadths between axilla and crutch (2 fingers if big fingers)

Front 67

How are forearm crutches adjusted? ***

Back 67

final
- tip 6 inches at 45 degree angle from toes (or 2 in lateral and 4-6 in anterior to toes)
- elbows at 20-25 degree flexion
- top of forearm cuff approx 1” – 1.5” distal to olecranon when grasping handpiece
- wrist in neutral

Front 68

How are canes adjusted? ***

Back 68

initial estimate
- pt. seated; length from greater trochanter to bottom of shoe
- pt standing; tip of cane on floor at lateral malleolus; hang arm down, and handgrip should be at ulnar crease or greater trochanter

final
- standing, tip 6” at 45 degree angle from toes
- hand on grip with elbow at 20-25 degrees flexion

Front 69

How do you take the patient seated to standing at parallel bars? ***

Back 69

- scoot to edge of chair
- stronger LE slightly posterior (lifts and lowers)

- push with both hands on WC arms, preferably
- once balanced, place hands on bars

Front 70

How do you take the patient standing to seated at parallel bars? ***

Back 70

- back up to chair
- feel chair at back of leg

- stronger leg slightly posterior (lifts and lowers)
- place both hands on chair arms to lower self

Front 71

How do you take the patient seated to standing at walker? ***

Back 71

- scoot to edge of chair
- stronger LE slightly posterior (lifts and lowers)

- push with both hands on WC arms, preferably
- once balanced, place hands on bars of walker

Front 72

How do you take the patient standing to seated at walker? ***

Back 72

- back up to chair
- feel chair at back of leg

- stronger leg slightly posterior (lifts and lowers)
- place both hands on chair arms to lower self

Front 73

How do you take the patient seated to standing with crutches? ***

Back 73

- scoot to edge of chair
- stronger LE slightly posterior and same side hand on chair (lifts and lowers)

- both crutches on side of involved LE
- stand and transfer one crutch to other side

Front 74

How do you take the patient standing to seated with crutches? ***

Back 74

- back up to chair until leg touching
- stronger leg slightly posterior and same side hand on chair

- both crutches on side of involved LE
- reach back for arm and lower self

Front 75

How do you take the patient seated to standing with a cane? ***

Back 75

- scoot to edge of chair

- both hands on chair, with cane on arm rest of stronger side

Front 76

How do you take the patient standing to seated with a cane? ***

Back 76

- back up to chair until leg touching
- both hands on chair, cane on arm rest of stronger side

Front 77

When is 4-point ambulation pattern used? ***

Back 77

when pt requires MAX stability or balance – not for limited weight bearing

Front 78

What is 2-point ambulation pattern? ***

Back 78

- progression of 4-point

- more rapid but gives less stability

- usually for balance

- not for limited weight bearing

Front 79

What is 3-point ambulation pattern? ***

Back 79

- 1 LE is NWB
- done either step-to or step-through

- involved limb goes forward with crutches, then step to or step through

Front 80

What is modified 4-point ambulation pattern? ***

Back 80

- 1 ambulation aid
- not for limited weight bearing
- aid on stronger side

Cane---bad foot---good foot – basically 4-point with 1 assistive device.

Front 81

What is modified 2-point ambulation pattern? ***

Back 81

- 1 ambulation aid
- not for limited weight bearing
- aid on stronger side

Bad foot & cane---good foot – basically 2-point with 1 assistive device

Front 82

What is modified 3-point ambulation pattern? ***

Back 82

- 1 LE is FWB; other is PWB

- may be step-to in tandem at first, then step-through as skill improves.

Front 83

How should patient be instructed to turn? ***

Back 83

- pt. taught to turn to either side (preferably to stronger side)

- pivot on stronger LE for more stability

- contraindicated to pivot on involved LE if recent THR

Front 84

How is patient taught to negotiate stairs? ***

Back 84

- ascend - stronger LE; then AA and weaker LE

-descend - weaker LE and AA; then stronger LE

- up with the good; down with the bad

Front 85

How is patient taught to negotiate a curb or ramp? ***

Back 85

curb with walker
- up: walker, strong, weak
- down: walker, weak, strong

ramp
- similar to stairs, but shorter stride

Front 86

How is patient taught to move backwards with assistive devices? (FYI) ***

Back 86

- four-point - crutch, opposite, crutch, opposite

- three-point - tips even with toes, back with LE, reposition and repeat

- modified three-point - stronger LE, crutch and weaker LE

Front 87

How should therapist perform guarding when patient is ambulating with assistive devices? ***

Back 87

- level surface - Pierson says therapist should guard on weak side, at least initially; however, best to guard where you assess is safest (if on strong side, can pull them away from the weak side easier)

** stairs, curb
- ascending- therapist below
- descending- therapist below
(you’re always below the patient on stairs/curb)

Front 88

What are some assessments of functional ability? ***

Back 88

- independent
- close guarding
- contact guarding

- minimal assistance
- moderate assistance
- maximum assistance

Front 89

What is close guarding? ***

Back 89

- position as if to assist
- hands raised but not touching pt.

- full attention on pt, with fair probability of pt requiring assistance

Front 90

What is contact guarding? ***

Back 90

- positioned with hand on pt, but not giving any assistance

- high probability of pt requiring assistance

Front 91

What is minimal assistance? ***

Back 91

pt able to complete majority of activity without assistance

Front 92

What is moderate assistance? ***

Back 92

pt able to complete part of activity without assistance

Front 93

What is maximum assistance? ***

Back 93

pt unable to assist in any part of activity

Front 94

Preparation for ambulation activities ***

Back 94

- review the patient's medical record for information to assist in planning the ambulation activities
- assess, examine, and evaluate the patient to determine limitations and capabilities to plan the preambulation activities and gait pattern
- determine the appropriate equipment and pattern based on the medical record, your assessment, and the goals of intervention
- prepare the patient for ambulation (e.g., obtain consent) and explain the pattern
- remove items in the area that may interfere with ambulation to maintain a safe environment
- confirm the initial measurement of the equipment to ensure a proper fit and determine the equipment is safe (e.g., tighten loose nuts and bolts, be certain spring adjustment buttons are secure, and examine rubber tips for dirt or cracks in the rubber
- apply a safety belt to the patient
- be certain the patient is mentally and physically capable of performing the selected gait pattern
- explain and demonstrate the gait pattern for the patient; require the patient to describe the pattern, how it is to be performed, and what is expected,
- use the safety belt and the patient's shoulder or trunk as points of control when guarding the patient
- maintain proper body mechanics for yourself and the patient

Front 95

Precautions for ambulation activities ***

Back 95

- be sure the patient wears appropriate footwear; do not allow the person to ambulate wearing loose-fitting shoes or slippers, or when barefoot; these conditions can lead to patient insecurity and injury
- monitor the patient's physiological responses to ambulation frequently and evaluate vital signs, general appearance, and mental alertness during the activity; compare your findings to normal values to determine the patient's reaction to the activity
- avoid guarding or controlling the patient by grasping clothing or an upper extremity
- anticipate the unexpected and be alert for unusual patient actions or equipment problems; anticipate that the patient may slip or lose stability or balance at any time
- guard the patient by standing behind and slightly to one side and maintain a grip on the safety belt until the patient is safe to ambulate independently
- do not leave the patient unattended while standing
- protect patient appliances (e.g., cast, drainage tubes, intravenous tubes, and dressings) during ambulation
- be certain the area used for ambulation is free of hazards, such as equipment or furniture, and the floor or surface is dry; maintain safe conditions to reduce the risk of injury to the patient

Front 96

What information is included in the SOAP note? ***

Back 96

- type of assistive device
- gait pattern (mod 4-point, 3-point, etc.)
- term of laterality and WB status
- distance ambulated
- level surface, curb, or stairs
- assistance with ambulation
- assistance with transfers (always include the transfer in gait training documentation)
- any other activities involving use of assistive device


- time?

Front 97

Example of SOAP note for:

Pt. is 30 y.o. male, S/P Fx. Left femur

Amb. 20 ft. yest. NWB,L

Pain constant at 4/10

Back 97

Date: 1/1/11 Sup. PT
S: Pt. says he only has leg pain when he moves. c/o ⇑pain LLE 6/10 after amb. From 4/10
O: Full-length cast LLE, with knee flexion at 45°
RX: gt. trng. w/ax. crutches, 3-pnt gait, NWB, left; amb. 30 ft. level surface w/mod. asst.
Transfers in/OOB w/mod asst.
A: ⇑ pain with amb; amb. 10 ft more than yest.
P: Con’t. gt. trng BID

J.Stegal, SPTA/co-sign

Front 98

Purpose of core exercises? ***

Back 98

- core awareness
- spinal stabilization
- back stabilization
- core strengthening
- lumbo-pelvic strengthening
- pilates

Front 99

What are core exercises? ***

Back 99

exercises that bring awareness, strength and endurance to the muscles of the trunk

Front 100

Who benefits from core exercise? ***

Back 100

- almost everyone.

- functional movement, kinetic chain– it’s all connected

- goal is to improve physical condition, decrease symptoms, make movement more efficient and comfortable.

- patients with spinal (LB) pain

Front 101

What is focus for patients with LBP? ***

Back 101

- spinal pain is a movement or postural disorder that has resulted in or perpetuated spinal dysfunction

- avoid getting caught up in guessing pathoanatomic diagnosis

- focus on improvement of function

- provide patient with stable foundation to allow greater freedom of movement.

Front 102

How can we help provide a patient with stable foundation to allow greater freedom of movement? ***

Back 102

- enhance movement awareness
- provide education on of safe postures
- work on strength, endurance, proprioception

Front 103

Where should the initial emphasis be for the PT patient? ***

Back 103

awareness

(before strength and endurance--don't be a motor moron!!)

Front 104

How does muscle activation in healthy persons differ from that in patients with LBP? ***

Back 104

- in a healthy person the trunk muscles precede limb muscles in order of recruitment

in pts with back pain (or potential pts), limb muscles activate before core muscles

Front 105

What is a neutral spine? ***

Back 105

- places spine in natural alignment
- neutral spine most equipped to absorb shock
- optimal position within which spine functions most efficiently

- pubic bone and ASIS are in same plane ***

- the in-between spot that is most comfortable and/or least painful for patients, until they can work up to ideal neutral spine.

Front 106

How can one achieve the ideal neutral spine? ***

Back 106

- hook-lying position

- feet, knees hip width apart
- arms down by your side, palms down

- cervical and lumbar spine not in contact with support surface

Front 107

For many patients, the ideal neutral spine is not attainable (at least initially) what compensations are possible/likely? ***

Back 107

- least painful position for some is a flexion bias - some posterior pelvic tilt (PPT)

- for some, may be extension bias and some slight anterior pelvic tilt (APT)

- these biases may change as pathology changes

Front 108

How does one find the neutral spine? ***

Back 108

- hook-lying position
- go to extreme APT and PPT
- somewhere in between
- position in which spine is asymptomatic or least symptomatic

- varies among individuals and pathologies

Front 109

How is core exercise progressed? ***

Back 109

- by adding slow, controlled limb movement in increasingly complicated postures

- supine (easiest)
- prone
- side-lying
- quadruped
- kneeling
- standing

Front 110

What should the patient be mindful of when beginning core exercises? ***

Back 110

- make time to learn movements well

-do not be sloppy early on, as this starts new habits -- does not help reduce pain or change pathology

- muscles are “on call” and recruited as needed to control spinal movements with safe range

- only after learning spinal stabilization the person can begin to strengthen the core mm

Front 111

Name the superficial stabilizers. ***

MUST KNOW THESE!!

Back 111

- gross movements of the spine; have little or no direct attachment to vertebrae

- external/internal obliques
- rectus abdominis
- quadratus lumborum - lateral portion
- erector spinae
- psoas major
- latissimus dorsi

Front 112

Name the deep stabilizers. ***

Back 112

- smaller movements; direct origin or insertion onto spinal segment

- multifidus
- rotatores (deep to multifidis)
- transversus abdominis

- hard to focus on them

Front 113

Which structures comprise the pelvic triangle? ***

Back 113

- multifidis
- pelvic floor
- transverse abdominals

Front 114

Pelvic floor muscles ***

Back 114

- puborectalis muscle (contracted at rest)
- anal sphincter (closed at rest)
- anorectal junction (compressed by puborectalis muscle when at rest

Front 115

When we were doing core exercises, what were the two points she repeatedly emphasized? ***

Back 115

- keeping a neutral spine

- contracting abdominals 20%

Front 116

Purpose of ACL? ***

Back 116

- ACL and PCL stabilize the knee from front-to-back during normal and athletic activities

- these ligaments help to balance weight, reducing the amount of wear and tear on the cartilage inside the knee.

Front 117

Injuries to the ACL usually occur in the _____ of the ligament. ***

Back 117

middle

Front 118

Grade I ACL sprain ***

Back 118

- fibers are stretched - no tear

- slight tenderness and swelling

- knee is stable

Front 119

Grade II ACL sprain ***

Back 119

- fibers are partially torn

- slight tenderness and moderate swelling

- knee is unstable or gives out during activity

Front 120

Grade III ACL sprain ***

Back 120

- fibers are completely torn (ruptured)

- tenderness but not a lot of pain

- swelling varies

- ACL no longer controls knee movement

Joint is unstable or gives out

Front 121

Etiology of ACL sprain. ***

Back 121

- 70% of ACL injuries are due to non-contact mechanisms

- attempting a quick change in direction causes the knee to “give out” (deceleration while cutting, pivoting, or sidestepping)

- remaining cases - direct contact and include other ligaments

Front 122

Signs and symptoms of ACL sprain? ***

Back 122

- pain
- swelling
- limited weight bearing
- instability
- feel/hear “pop” when injury occurs

Front 123

Diagnostic methods for ACL sprain? ***

Back 123

- physical exam

- MRI (definitive test)

Front 124

Treatment of ACL sprain ***

Back 124

- rehabilitation - PT

- surgery

Front 125

Describe surgery for ACL sprain. ***

Back 125

- arthroscopic surgery

- ACL surgery uses replacement graft
- harvested from tissue (patellar region, hamstring, or allograft)

- graft tissue is removed w/small piece of bone (bone block-patellar only)
- graft is pulled through the two tunnels that were drilled in the femur and tibia

- secured with screws or staples

Front 126

Difference between aggressive rehab and traditionally conservative rehab for ACL sprain? ***

Back 126

aggressive rehab
- immediate mvt.
- full passive ext.
- immediate weight bearing
- early muscle strengthening
- crutches 2-4 weeks
- return to activity 5-12 months

traditionally conservative rehab
- immobilization 6-8 weeks
- crutches 3-4 months
- return to activity 9-12 months

Front 127

Types of exercise for HEP for ACL sprain? ***

Back 127

- heel slides
- straight leg raises
- stationary bike
- quad sets
- standing knee bends
- mini wall squats
- step ups

Front 128

How common is PCL sprain? ***

Back 128

about 3-20% of all knee injuries

Front 129

Etiology of PCL sprains ***

Back 129

- motor vehicle accidents

- falling with knee bent usually with proximal tibia taking most impact

- severe trauma to knee

Front 130

Signs and symptoms of PCL sprains ***

Back 130

- swelling
- knee giving out when walking

- mild pain behind the knee usually when kneeling
- pain in front of knee when running or slowing down

- most athletes continue participating until showing S&S 2-3 weeks after injury has occurred.

Front 131

How is PCL sprain diagnosed? ***

Back 131

- knee MRI
- knee X-ray to see if ligament has detached from bone
- ligament test

Front 132

How can PCL sprains be prevented? ***

Back 132

- warm up and stretch before athletic activities
- do exercises to strengthen the leg muscles around your knee.

- don't increase the intensity of your training program suddenly, make it gradual
- wear comfortable, supportive shoes that fit your feet and fit your sport.

Front 133

Treatment of PCL sprain ***

Back 133

- R.I.C.E
- anti-inflammatory medication (NSAIDS)

- Grade I and Grade II PCL sprains — knee may be splinted in a straight-leg position, and begin intense rehabilitation program to strengthen the muscles around the knee

- Grade III PCL sprains — If the PCL has been pulled away from the bone, surgery may be done to reattach it with a screw. If the PCL is torn completely, it can be reconstructed surgically using either a piece of your own tissue (autograft) or a piece of donor tissue (allograft). After surgery, pt. wears a long-leg knee brace and gradually begin a rehabilitation program to strengthen the leg muscles around the knee

- recovery usually 4-12 months.

Front 134

Rehabilitative exercises for PCL sprain ***

Back 134

- varied, but

- lots of quad strengthening

Front 135

Definition of patellofemoral syndrome ***

Back 135

- pain in the patellofemoral joint caused by abnormal tracking of the patella (pulled too far laterally in knee ext)

- damage to articular cartilage of patella which ranges from a softening (chondromalacia patella) to complete destruction

Front 136

Etiology of patellofemoral syndrome ***

Back 136

- unknown

- injury - trauma to kneecap (dislocation or fx)

- age - extremely common in adolescents and young adults, OA is usually the cause of knee problems in older age

- sex - females 2X more than men possibly due to the fact that a woman’s wider pelvis increases the angle at which the bones in the knee joint meet

- certain sports - direct association with activity level - running and jumping sports, “runner’s knee”

- misaligned bones - bones in knee or foot not properly aligned, knock-kneed or flat footed; patella tracking towards lateral side of femur

- patella alta - small, high-riding patella

- insufficient lateral femoral condyle - not prominent anteriorly which results in loss of abutment effect (trasmit loads) normally provided to prevent lateral movement

- weak vastus medialis obliquus (VMO) - distal fibers originate on medial femur and run horizontally to insert on medial patella; horizontal fibers allow them to prevent excessive lateral movement of patella during loaded knee ext

- increased Q angle - formed bw line of pull of quads and patellar tendon; also associated with increased foot pronation as well as excessive knee valgus (knock knee)

- tightness in LE muscles- esp IT band, hamstrings, gastroc, vastus lateralis

Front 137

What is patella alta? ***

Back 137

- small, high-riding patella

(the more superiorly the patella moves on femur during knee ext, the less time it is in the deep portion of the patellar groove where it is more stable)

Front 138

Signs and symptoms of patellofemoral syndrome ***

Back 138

- gradual onset of anterior knee pain, located behind patella
- most common - pain when walking up or down stairs

- kneeling, squatting, running increase PF compressive forces
- prolonged static position (sitting with knee flexed in car, plane, “theatre sign”)

- tightness in PF joint
- point tenderness over lat border of patella and crepitus

- visible quad atrophy, esp along VMO
- mild swelling

Front 139

Testing for patellofemoral syndrome ***

Back 139

- X-rays - to rule out fx, see configuration of PF joint, identify possible osteophytes, joint space narrowing, patella alta, and arthritic changes

- arthrogram and arthroscopy used to examine articular cartilage

Clarke’s sign - pt. supine, PT presses patella inferiorly while pt is asked to contract quads. (+) if pt cannot complete contraction w/o pain

- Q angle in males = 13, females = 18; measured using ASIS, midpoint of patella, and tibial tubercle

- tests are designed to rule out: referred hip pain, Osgood-Schlatter, neuroma, patellar tendonitis, plica syndrome, or infection of knee

Front 140

Management of patellofemoral syndrome ***

Back 140

- conservative measures successful, surgery rare

- NSAIDS and steroid injections into joint

- PT goals: control edema, stretching, strengthening, increase ROM, activity modification

- patellar taping - improve position and tracking during dynamic activities; can be useful to limit irritation

- Pt’s that undergo conservative management may be able to return to previous function within 4-6 wks

Front 141

Strengthening exercises for patellofemoral syndrome ***

Back 141

- quad sets

- SLR - “set” quads before lifting; progress to add adduction (with femur ER) or long sit

- short arc quad progress to long arc quad (knee ext)

- descending stairs - involved leg on top step while pt steps down and then back up slowly, may progress by increasing height of step or adding resistance

- squats - not deep!

- hip/knee adduction exercises

Front 142

HEP for patellofemoral syndrome ***

Back 142

- focus on ROM, strength, stretch, functional activities

- active pt’s must decrease level of activity in order to relieve additional stress placed on PF joint

- proper footwear and/or orthotics may be recommended to improve alignment and decrease aggravation of symptoms, esp pain

- brace - provide support, avoid direct pressure on patella, prevent lateral subluxation

Front 143

Surgical procedure for patellofemoral syndrome ***

Back 143

- rare

- surgery - loosening tight lateral retinaculum or reducing the Q angle by moving the attachment of the patellar tendon medially, rare

- long term effects - failure to address the cause will result in pt’s condition further deteriorating… pt may experience irritation of PF joint that will further impact their ability to participate in certain ADL’s

Front 144

Describe meniscus tear. ***

Back 144

- tear of the fibrocartilage C-shaped medial meniscus or the semicircular lateral meniscus

- occur in different ways and are noted by how they look and where the tear occurs in the meniscus

types of tears:
- longitudinal
- bucket handle
- flap
- transverse
- parrot beak

Front 145

Healing prospects for meniscus tear ***

Back 145

- tears that occur in the red zone (the outer edge) tend to heal better because of blood supply that proliferates from the synovial capsule

- tears that occur in the white zone (the inner area) do not heal due to a lack of blood supply to trigger an inflammatory response

Front 146

Which meniscus is injured more often? ***

Back 146

- medial meniscus is injured more often than the lateral meniscus because it is fixed to the walls of the joint capsule and the medial collateral ligament making it less mobile

Front 147

In what ways may the meniscus be torn? ***

Back 147

- most common - sudden change of direction (e.g., an abrupt start, stop, pivot, turning or twisting too quickly with foot planted and knee bent)

- landing from a jump with the knee in hyperflexion or hyperextension

- trauma
- overuse
- degeneration

Front 148

Signs and symptoms of torn meniscus ***

Back 148

- joint line pain and swelling
- joint locking
- giving way of the knee

- inability to flex or extend knee completely
- pain when going up or down stairs, squatting, and getting up from a low seat

- clicking sound when you move your knee (sound of the cartilage moving against the bone in an abnormal way)
- antalgic gait pattern

Front 149

How is torn meniscus diagnosed? ***

Back 149

- physical examination

- MRI (test of choice) – gives a good picture of location and extent of a meniscus tear and provides images of the ligaments, cartilage, and tendon

- McMurray’s test – patient supine; ankle is turned while the leg is bent and straightened this twists and compresses the meniscus, presence of pain, resistance or clicking will alert your doctor to a tear

Front 150

How is a torn meniscus managed in acute phase (non-operative)? ***

Back 150

- RICE & NSAIDs to alleviate pain, inflammation and speed healing

- crutches are indicated until pain decreases and inflammation subsides

- relieving pressure is important at this stage to avoid further damage to the cartilage

- NWB AROM of the affected knee if tolerated (no pain should be felt)

Front 151

How is a torn meniscus managed in sub-acute and beyond phases (non-operative)? ***

Back 151

- start with open kinematic chain exercises then gradually progress to closed kinematic chain exercises

- SLR
- step-up
- passive knee extension
- heel slide
- wall squat with a ball
- standing calf stretch and hamstring stretch on wall
- knee stabilization exercises

Front 152

How is a torn meniscus managed surgically? ***

Back 152

- for significant tears - rehab 1-3 months or longer depending on type of surgery

- suturing - repaired by sewing the two sides together, mending the tear

- debridement/arthroscopic partial menisectomy (most common procedure) – the part of the meniscus that has ripped is cut or shaved off and any loose pieces of cartilage that have broken free are cleaned out of the joint; surface is left smooth

- total meniscectomy (not very common) – when the meniscus has been damaged in a number of places and cannot be repaired, most of the meniscus has to be removed

Front 153

What is degenerative spondylolisthesis? ***

Back 153

- Latin for “slipped vertebral body”

- diagnosed when one vertebra slips forward over the one below it

- typically occurs in the lumbar region of the spine
---- L4-L5 (most common location)
---- L3-L4

Front 154

Etiology of degenerative spondylolisthesis ***

Back 154

- consequence of aging process in which the bones, joints, and ligaments in the spine become weak and less able to hold the spinal column in alignment

- in adults, most common cause is degenerative disease such as arthritis or osteoporosis

- facet joints (which guide and limit motion of the spine) degenerate and allow too much flexion, allowing one vertebral body to slip forward on the other.

Front 155

Signs and symptoms of degenerative spondylolisthesis ***

Back 155

- commonly the same as spinal stenosis because as the facet joints degenerate they often get larger and cause a narrowing of the spinal canal

- main symptoms include:
---- lower back pain
---- pain, numbness, tingling or weakness in the legs due to nerve compression (sciatic pain)
---- muscle spasms
---- tight hamstrings with decreased ROM of the lumbar spine
---- pain with activities such as standing and walking or extension of the spine

- more severe symptoms include:
---- disc herniation
---- cauda equina syndrome
---- loss of control of the bladder and bowel caused by severe compression of the nerves.

Front 156

How is degenerative spondylolisthesis diagnosed? ***

Back 156

- medical history - review of the patient’s symptoms such as back & leg pain

- physical examination - physical symptoms such as ROM, flexibility, muscle weakness or neurological issues are examined

- diagnostic tests - lateral x-ray and MRI if necessary for confirmation

Front 157

Degenerative spondylolisthesis grading ***

Back 157

- spondylolisthesis is graded according to the percentage of slip of the vertebra compared to the neighboring vertebra:

---- Grade I- slip of up to 25%
---- Grade II- between 26%-50%
---- Grade III- between 51%-75%
---- Grade IV- between 76%-100%
---- Grade V- (spondyloptosis) vertebra has completely fallen off the next vertebra

Front 158

How is degenerative spondylolisthesis managed? ***

Back 158

- prevention and early detection are very important!
- initial treatment is conservative and based on the symptoms

- for immediate relief of discomfort:
---- ice pack or heat pad
---- NSAIDs
---- short period of rest (1-2 days of bed rest)

Front 159

Long-term management of degenerative spondylolisthesis ***

Back 159

- avoid standing or walking for long periods of time--upright position accentuates the stenosis

- avoid active exercises--activity in the sitting position should be tolerable (e.g., stationary bike)

- avoid activities that require bending backwards

- chiropractic manipulation - to mobilize painful joint dysfunction

- physical therapy - to stretch and strengthen muscles

- hyperextension brace - to stabilize the spine

- epidural injections - to alleviate inflammation

- surgery - (rarely used) only considered if there is an acute neurologic deficit

Front 160

How is physical therapy used for treating degenerative spondylolisthesis? ***

Back 160

- the most acceptable physical therapy protocol includes activity & exercise that reduces extension stress.

- exercise goals should be to improve abdominal strength, increase flexibility of the hamstrings & increase ROM of the lumbar spine

- aquatic therapy proves to be the most beneficial option as it allows the patient to exercise in a flexed forward position

- pelvic tilt exercises will help strengthen abdominal muscles and stabilize the spine in a neutral position

Front 161

Other facts about degenerative spondylolisthesis ***

Back 161

OF COURSE…it’s far more common in females than males
More common in people over the age of 50, and increasingly more common in those older than 65.
It can occur at any level of the spine (even all three at once) but most commonly occurs in the lumbar region.

Front 162

Precautions for exercise/physical therapy with spondylolisthesis ***

Back 162

- stabilize the pelvis when lengthening muscles at the hip

- if flexion of the spine causes a change in sensation or pain to radiate down the legs, the exercise must be reassessed & the pelvis must be placed back into a functional position

Front 163

What is spinal stenosis? ***

Back 163

- narrowing of the spinal canal occurring in the cervical and lumbar area

- occurs when the growth of bone or tissue or both reduces the size of the openings in the spinal bones

- narrowing can squeeze and irritate the nerves that branch out from the spinal cord.

Front 164

Etiology of spinal stenosis ***

Back 164

- aging - cushioning and facet joints deteriorate, causing narrowing of spine; common in those > 50 y.o.; F > M
- arthritis - OA & RA

- heredity - born with a small spinal canal.
- instability of the spine - (a.k.a. spondylolisthesis)

- tumors - inflamed abnormal growths of ST on the spinal canal displacing bone and eventually collapsing the spine’s supporting framework

- trauma - accidents and injuries may either dislocate the spine and the spinal canal or cause burst fractures that produce fragments of bone which penetrate the canal

Front 165

Signs and symptoms of spinal stenosis ***

Back 165

- chronic LBP
- pain & stiffness in LE’s resulting in difficulty walking

- pinched nerve(s) which control muscle power and cause numbness, tingling, hot and cold feelings in UE/LE’s
- balance and coordination problems; frequent falling

- bladder incontinence in severe cases
- nerve damage resulting in paralysis (varies in each case)

Front 166

How is spinal stenosis diagnosed? ***

Back 166

- physical exam to identify areas of pain, numbness, and weakness

- MRI, CT, or X-ray recommended to view bone, tissue, and narrowing of spinal canal

- blood test to rule out MS or vitamin B-12 deficiency anemia for brain and nerve damage

Front 167

How is spinal stenosis managed in the acute stage? ***

Back 167

during first 3 months of having localized or referred intermittent pain via compressed spinal nerve

- physical therapy to enlarge the space available to the nerves
(SKTC, DKTC, prayer pose, cervical stretches, nerve mobilities, pelvic tilts)

- NSAIDs & oral steroids to reduce nerve compression

- rest

Front 168

How is chronic spinal stenosis managed? ***

Back 168

> 3 months of having symptoms evolved to include pain, weakness, tingling, loss of feeling, and possible muscular paralysis.

- epidural steroid injections to reduce nerve compression

- stenosis surgery where excess bone, ligament, and soft-tissue is removed to allow more room for the nerves
---- laminectomy (removal of the bone behind the spinal cord)
---- foramenotomy (removing bone around the spinal nerve)
---- discectomy (removing the spinal disc to relieve pressure)

- spine fusion surgery to fuse 2 or more vertebrae directly together reducing motion that may be causing pain

Front 169

What is whiplash? ***

Back 169

- an acceleration-deceleration mechanism of energy transfer to the neck exerting a “lash-like effect”

- may result from the impact of motor vehicle accidents, but also through other mishaps

- impact may result in bony or soft tissue injuries, which in turn may lead to a variety of clinical manifestations

Front 170

Proper terms for whiplash ***

Back 170

- cervical acceleration-deceleration (CAD) describes the mechanism of the injury

- "whiplash associated disorders" (WAD) describes the injury sequelae and symptoms

Front 171

Etiology of whiplash ***

Back 171

- most frequent cause of whiplash is a car accident

- contact sport injuries and blows to the head
- falls
- heavy lifting

- child abuse, particularly the shaking of a child, can also result in this injury as well as in more serious injuries to the child's brain or spinal cord
- pulls and thrusts on the arms

- repetitive stress injuries or chronic neck strain (such as using your neck to hold the phone) are a common, non-acute causes

Front 172

Most frequent cause of whiplash ***

Back 172

car accident

Front 173

Extend of WAD depends upon what three factors? ***

Back 173

- head’s position at the point of impact

- amount of force involved

- direction of the forces

Front 174

Mechanism of whiplash in car accident ***

Back 174

- the mechanism includes hyper-extension of the neck as the seat pushes the person's torso forward and the unrestrained head and neck fall backwards

- after a short delay the head and neck then recover and are thrown into a hyper-flexed position

- the sudden strain on the tissues causes injury to the surrounding soft tissues and joints

Front 175

Epidemiology of whiplash ***

Back 175

- rates of whiplash are higher in persons using a seatbelt with shoulder restraint than with no restraint, but seatbelts often prevent more serious injuries

- poor posture
- poorly-fitted head restraints

- women sustain higher rates of whiplash injuries
- narrowing of the cervical spine canal due to acquired or congenital disorders predisposes to spinal cord damage with these types of injuries

Front 176

Signs and symptoms of whiplash ***

Back 176

- neck pain
- neck swelling
- back pain

- headache
- visual disturbances
- TMD
- tinnitus

- tenderness along back of neck
- muscle spasms (in side or back of neck)

- difficulty moving neck; if patient is unable to move the neck even slightly, fractured dens is likely

- radiating pain from neck into either shoulder or arm
-weakness, tingling, or loss of function in extremities

Front 177

How are WAD classified? ***

Back 177

- whiplash-associated disorders (WAD) can be classified by the severity of signs and symptoms: (Based on Quebec Task Force)

- grade 0: no complaints or physical signs
- grade 1: indicates neck complaints but no physical signs
- grade 2: indicates neck complaints and musculoskeletal signs, decreased ROM
- grade 3: neck complaints and neurological signs that include decreased or absent deep tendon reflexes, weakness and sensory deficits
- grade 4: neck complaints and fracture/dislocation

Front 178

Where do fractures primarily occur in WADs? ***

Back 178

cervical spine fractures occur primarily at 2 levels:

- 1/3 of injuries occur at the level C2 (these tend to be the most fatal injuries either at cranio-cervical junction C1, or at C2)

- 1/2 of injuries occur at the level of C6 or C7

Front 179

How are WADs diagnosed? ***

Back 179

- X-rays
- CT scans
- MRI
- EMG/NCV
- medial branch block
- discography

Front 180

How are WADs treated? ***

Back 180

no single treatment has been scientifically proven as effective for whiplash; patients have found the following helpful:

- pain relieving medications
- traction
- massage
- heat
- ice
- TENS
- patient education
- injections (i.e.: Botox, lidocaine, saline)
- ultrasound
- MFR
- early range of motion exercises to restore flexibility
- avoidance of excessive neck strain for the next week and then increased activity as tolerated in the following weeks

- when all the above no longer aid in subsiding symptoms some patients opt for surgery:

Front 181

Surgeries for WADs? ***

Back 181

when all the above no longer aid in subsiding symptoms some patients opt for surgery:

- Anterior Cervical Decompression and Interbody Fusion

- Cervical Disc Replacement

Front 182

How does current tx of WADs differ from that in the past? ***

Back 182

whiplash injuries were often treated with immobilization in a cervical collar, however, the current trend is to encourage early movement instead of immobilization

Front 183

Prognosis for WADs ***

Back 183

- some patients recover within days of the accident while for others, it may take several months and occasionally years

- depends on the severity of the injury

- fortunately, whiplash is typically not a life threatening injury, but it can lead to a prolonged period of partial disability

- majority of people who sustain a whiplash injury make a full recovery with no limitations

- research has shown that it is better to maintain your normal daily activities in order to speed up recovery

Front 184

What is fibromyalgia? ***

Back 184

- a chronic, idiopathic, nonarticular, noninflammatory pain syndrome with generalized tender points

- characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias & anxiety

- current theory: imbalance of neurotransmitters could cause pain amplification, rather than suppression

- pain can be organic (real) or psychogenic

Front 185

Etiology of fibromyalgia ***

Back 185

unknown, however may be triggered by:

- single event trauma (ex: car accident, surgery)
- continuous trauma (ex: job w/heavy lifting & poor body mechanics)

- autoimmune disease
- infections, esp. viral

- severe emotional stress
- withdrawal from meds, esp steroids
- hormonal abnormalities

Front 186

Systems affected by fibromyalgia ***

Back 186

- systemic
- CNS (esp sensory/vision)
- muscular
- skeletal (joints/TMJ)
- digestive

- integumentary
- urinary
- reproductive

Front 187

Comorbid conditions of fibromyalgia ***

Back 187

- IBS
- TMJ pain
- noncardiac chest pain
- migraine headaches
- irritable bladder
- Raynaud’s phenomenon
- Sicca syndrome (dry mouth & eyes)

Front 188

Diagnosis of fibromyalgia ***

Back 188

- many other diseases have symptoms similar to Fibromyalgia, however the main components of diagnosis are:

- widespread pain involving both sides of the body, above and below the waist as well as the axial skeletal system, for at least 3 months

- presence of 11 tender points among the 9 pairs of specified sites (18 points)

Front 189

Prevalence of fibromyalgia ***

Back 189

- 3.4% of women, 0.5% of men in US
- affects women 10 times more than men

- considered a disease of women 20 to 50 yrs, however has also been observed in males, children and older people
- patient is usually deconditioned

Front 190

Management of fibromyalgia ***

Back 190

- if identified early and managed properly, patients usually improve (harder to get better if therapy is delayed more than 5 years)

- pharmacological treatment (responds poorly to NSAIDs)
- cognitive behavior therapy
- EXERCISE!

(Combination of all 3)

Front 191

Connection between fibromyalgia and exercise ***

Back 191

- 83% of Fibromyalgia pts do not exercise regularly & 80% are not considered physically fit.

- exercise increases sense of well-being, allows restful sleep, releases serotonin & endorphins, which reduces pain.

Front 192

Exercise progression in pts with fibromyalgia ***

Back 192

- WALKING is the 1st step toward a general conditioning & toning program (gradually add swimming or cycling)

- isometric exercises (work up to isotonic)

- stretching & deep breathing--many fibro pts have shallow, jerky breathing patterns; deep breathing promotes relaxation


- pain is accentuated by: weight lifting, rowing, jogging, tennis, golf or bowling early in rehab

- patients will NEVER improve unless they have GOOD POSTURE--bad posture aggravates musculoskeletal pain & creates tight, stiff, sore muscles

Front 193

Other treatment options for fibromyalgia patients ***

Back 193

- gentle massage, manipulation, MFR
- moist heat, ultrasound, iontophoresis
- e-stim (TENS)
- traction

- posture & gait training
- choice of footwear
- relaxation techniques

Front 194

Other considerations (psychological) for patients with fibromyalgia ***

Back 194

Patients who know what the condition is & are motivated to improve do better than passive individuals.

Those with psychiatric & emotional problems will not improve until those issues are addressed first.

Front 195

What does CRPS stand for? ***

Back 195

- complex regional pain syndrome

- previously known as reflex sympathetic dystrophy

Front 196

What is CRPS? ***

Back 196

- multi-symptom, multi-system syndrome that in most cases affect the extremities but can affect any body part

- nerve or soft tissue injury that doesn’t follow the correct healing pattern (e.g., broken bone, herniated disc of the spine, carpal tunnel syndrome, heart attack)

- injury can be minor to severe, causing extreme pain, swelling to affected area, movement disorder.

Front 197

Types of CRPS ***

Back 197

- CRPS type 1 and type 2 - signs and symptoms are the same

- type1 - injured nerve not identified or no known injury to the nerve

- type 2 - partial injury to nerve can be identified

Front 198

Etiology of CRPS ***

Back 198

- the exact prevalence of CRPS is unknown, occurs most often in females (especially pediatric population)

- trauma (often minor) leading cause
- ischemic heart disease and myocardial infarction
- cervical spine or spinal cord disorders
- cerebral lesions
- infections
- surgery
- repetitive motion disorder or cumulative trauma

Front 199

Diagnosis of CRPS ***

Back 199

- history of trauma

- bone scans
- nerve conduction studies

- x-rays
- thermogram

Front 200

Signs and symptoms of CRPS ***

Back 200

- pain - that is abnormal with the healing cycle of a injury; described as severe, constant, burning, and/or deep aching pain; associated with pressure stimulation (e.g., wearing clothing, a light breeze, tapping on skin)

- skin changes
---- may appear shiny (dystrophy- atrophy), dry or scaly
---- hair grows coarse and then thin
---- nails become brittle, grow fast and then slow
---- rashes, ulcers, and pustules
---- may become either cold or warm to touch
---- feeling cold or warm sensations without touching skin
---- increased sweating
---- skin color can range from white to blue or red

- swelling - pitting or hard edema to the painful and tender region

- movement disorder
---- difficulty moving due to pain and swelling in affected region
---- decreased movement leads to wasting away of muscles (disuse atrophy)

Front 201

Treatment of CRPS ***

Back 201

- educate about therapeutic goals

- primary goal of PT is to teach pt how to use affected body part with ADL; encourage normal use of the limb

- minimize pain
----TENS unit (stimulates surface of the skin)
---- muscle cramps can be relieved by heat applications and/or pressure message
---- exercise and ROM activities depends on body area affected; teach pt weight-bearing vs. non-weight-bearing exercises

- swimming pool exercises are beneficial
---- cardiovascular
---- weight bearing
---- helps improve mood/confidence
---- improve mobility

Front 202

Medications for CRPS ***

Back 202

- analgesics - helps reduce pain
- NSAIDs
- coricosteroids - reduce local inflammation and pain

- anticonvulsants - used for neurogenic pain

- anesthetics - sympathetic nerve blockers

Front 203

What is the Tinetti Assessment Tool used for? ***

Back 203

to assess balance

(and risk of falls)

Front 204

What is the Berg Balance Test? ***

Back 204

measurement of balance, transfers, etc.

Front 205

What is BAPS? ***

Back 205

Biomechanical Ankle Platform System

Front 206

What is FIMS? ***

Back 206

Functional Independence Measure

Front 207

What are Frenkel's exercises? ***

Back 207

- coordination exercises
- typically cross midline

- a system of slow repetitious exercises of increasing difficulty developed to treat ataxia in multiple sclerosis and similar disorders