Therapy Exercise

PTA 130:Fundamentals of Treatment IDay 2 Orthopedic Management, Tissue ResponseConcorde Career College1Movement as medicineStructure determines functionFunction will change structure over timeHuman body can adapt to load/stress over timePT and PTAs as experts in arranging, sequencing, organizing movement progressions and regressions over time.Not all movement is created equalMovement that is functionalMovement that is single plane that contributes to tri-planar movementFoundational Concepts of Musculoskeletal RehabilitationPTA as movement assessorA successful PTA will understand what normal movement looks like and how each component part contributes to the functional movement patterns orchestrated by the CNS to accomplish a functional taskA successful PTA will know how to identify inadequate movement patterns and effectively communicate the pattern to the PTA successful PTA will progress and regress the procedures within the plan of careRole of the PTA in Assessment and Treatment of the Orthopedic PatientSequenced process and procedures for maximum impact and effectivenessPrep - Ice/MHP/CPM/US/Relax STM, Stretching, ROM, Manual TechsMovement Restoration/InstructionStrengthening PNF, resistance training, Fx movtCoordination PNF, functional movementCalm ModalitiesLearning ConsolidationHEPConcorde Career College Plan of Care FrameworkLesson ObjectivesDescribe the major classifications of musculoskeletal injuries

Discuss orthopedic diagnoses to include surgical repairs

Describe therapeutic interventions to include precautions and contraindications

Concorde Career CollegeNEED TO ADD!5Common Orthopedic Soft Tissue InjuriesStrainsSprainsDislocationSubluxationMuscle/tendon rupture or tearTendinopathySynovitisHemarthrosisGanglionBursitisContusionOveruse SyndromeConcorde Career College6Common Orthopedic Soft Tissue InjuriesStrainOverstretchingOverexertionOveruse of soft tissue. Generally refers to disruption of the musculotendinous unit.

Concorde Career CollegePg 295- 296 K&CClue- T= Tendon; P= pulled 7Common Orthopedic Soft Tissue InjuriesSprainSevere stress, stretch, or tear of joint capsule, ligament, tendon, or muscle. Generally refers to disruption of a ligament.Graded 1st degree - mild2nd degree - moderate3rd degree - severe

Common Orthopedic Soft Tissue InjuriesDislocation- Displacement of a part, usually the bony partners of a joint. Leads to soft tissue damage, inflammation, pain and muscle spasmSubluxation- Incomplete or partial dislocation of the bony partners. Involves secondary trauma to surrounding tissueRupture or Tear- Either partial or complete Partial tear- pain upon stretching or contractionComplete- no pain with stretching or contraction

Dislocation of the A-C JointConcorde Career College

Dislocation of the UlnaConcorde Career College

Common Orthopedic Soft Tissue InjuriesTendinopathies Tendinitis- inflammation of a tendonTenosynovitis - inflammation of the synovial membrane covering a tendonTendinosis- degeneration of the tendon due to repetitive microtrauma

Synovitis- Inflammation of a synovial membrane

Concorde Career CollegePartial tear = Pain with MMT Reference article on tendinitis vs tendinosis- kpTenovaginitis or tendosynovitis 12Common Orthopedic Soft Tissue InjuriesHemarthrosis- Bleeding into a joint, usually due to severe trauma

Ganglion- Ballooning of the wall of a joint capsule or tendon sheath

Bursitis- Inflammation of a bursa

Contusion- Bruising from a direct blow

Concorde Career CollegeCommon Orthopedic Soft Tissue InjuriesOveruse SyndromesA term used to describe a group of disorders that occur due to excessive stress on an anatomic area of the body. Typically, microtrauma occurs as a repeated injury usually not noticed initially because the injury is microscopic in magnitude. Over time, the cumulative trauma leads to inflammation and pain.

Concorde Career CollegeOther Clinical ConditionsDysfunctionJoint dysfunctionContracturesAdhesionsReflex muscle guardingIntrinsic muscle spasmMuscle weaknessMyofascial compartment syndromesConcorde Career College

Clinical ConditionsDysfunctionLoss of normal function of a tissue or regionJoint DysfunctionMechanical loss of normal joint play in synovial jointsContracturesAdaptive shortening of skin, fascia, muscle or a joint capsule that prevents normal mobility or flexibility of that structure AdhesionsAbnormal adherence of collagen fibers to surrounding structuresConcorde Career College

Clinical ConditionsReflex muscle guardingProlonged contraction of a muscle in response to a painful stimulus

Intrinsic muscle spasmProlonged contraction of a muscle in response to the local circulatory and metabolic changes that occur when a muscle is in a continued state of contractionConcorde Career CollegeClinical ConditionsMuscle weaknessA decrease in the strength of a muscle

Myofascial compartment syndromeIncreased interstitial pressure in a closed, nonexpanding, myofascial compartment that compromises the function of the blood vessels, muscles, and nerves. Concorde Career CollegeJoint, Connective Tissue, and Bone Disorders and ManagementConcorde Career CollegeArthritis/ArthrosisArthritis - Inflammation of a joint

Arthrosis -Limitation of a joint without inflammation

Common signs and symptoms:Impaired MobilityImpaired Muscle PerformanceImpaired BalanceFunctional Limitations

Concorde Career College20Arthritis/ArthrosisOsteoarthritis (Degenerative Joint Disease) A chronic degenerative disorder primarily affecting the articular cartilage of synovial joints, with eventual bony remodeling and overgrowth at the margins of the joints

Rheumatoid ArthritisAn autoimmune, chronic, inflammatory, systemic disease primarily affecting the synovial lining of joints as well as other connective tissueConcorde Career CollegeConcorde Career College

Pg 314 fig 11.5 K&CWhite arrows= narrowed joint spaceLg arrow= osteophyte formationSmall black arrows= sclerotic subchondral bone22Concorde Career College

Pg 311 fig 11.2 K&CAdvanced rheumatoid arthritis of the hip joints. Destruction involves the entire joint space and bony regions on either side of the joints space23Rheumatoid Arthritis

Fibromyalgia & Myofascial Pain SyndromeChronic pain syndromesFibromyalgia- Individuals process nociceptive signals differentlyMyofascial Pain Syndrome- localized changes in the muscleConcorde Career CollegeCovered more thoroughly in 180- Chronic Pain YES in 18025FRACTURESA structural break in the continuity of a bone, an epiphyseal plate, or a cartilaginous joint surface. Classified according to their character and location.

Symptoms and Signs of a possible fracture:History of fall, direct blow, twisting injury, accidentLocalized pain aggravated by movementMuscle guarding with passive movementDecreased function of the partSwelling, deformity, abnormal movementSharp, localized tenderness at the siteConcorde Career CollegeFRACTURESFractures defined bySiteExtentConfigurationRelationship of the fragmentsRelationship to the environment (closed/open)Complications

Concorde Career CollegeConcorde Career College

K&C pg 321, fig 11.11

28Concorde Career College

K&C pg 321, fig 11.1229Concorde Career College

K&C pg 321, fig 11.13

30Common Orthopedic Surgical ProceduresApproaches:Open, Arthroscopic, Arthroscopically Assisted ProceduresTissue Grafts:Autograft, Allograft , Synthetic graftsSoft Tissue Repair or Reconstruction:Muscle, Tendon, Ligament, Capsule Stabilization, Tendon transferSoft Tissue Release, Lengthening or Decompression

Common Orthopedic Surgical ProceduresJoint Procedures:Synovectomy, debridement, microfracture, osteochondral auto/allografts, arthroplasty, arthrodesis

Extra-Articular Bony Procedures:ORIF- Open Reduction and Internal FixationOsteotomy

Concorde Career CollegeHOMEWORK- Write a short paragraph (definition) of one common orthopedic problem- soft tissue injury or surgical procedure32Concorde Career College

Example of Hip ORIF33Bone Healing Following FractureStages:Inflammatory phase- hematoma formation and cellular proliferationReparative phase- callous formation uniting the breach and ossificationRemodeling phase- consolidation and remodeling of the boneConcorde Career CollegeInflammation and repair- next- very similar- kpBone fracture also covered in PTA 120 pathoLooking for types of immoblization- CAM, Cast, bivalve cast, etc- so far not seeing anything in K&C or houglum- kp

34Tissue Inflammation & RepairConcorde Career College35Concorde Career CollegeWhy is it important to understand the healing process? Understanding the healing process is vital to developing safe and effective therapeutic exercise programs

Not understanding can result in therapeutic exercise programs that impede healing and cause additional injury

Concorde Career College37Types of HealingPrimary healing:Separation is smallBridge of cells binds ends of wound togetherMinor wounds, sutured tissues

Secondary healingSeparation is largeTissue must fill spaceMore scarring, longer healing time

38Injury ClassificationConcorde Career CollegePrimaryDirectAcute direct traumaSuperficial epidermis & or dermisPrimary intention : typically small separation of tissue [IE:- surgical wounds]Bridge of cells binds wound stump ends togetherSecondaryInflammatoryChronic overuseDeep involving deeper structuresSecondary intention:Typically more severe Stump ends farther apartTissue produced from bottom & sides to fill in Longer to heal & larger scarHouglum pp35-3639Healing PhasesPhases:Inflammation (Acute)Protection PhaseProliferation (Subacute)Repair and Healing PhaseRemodeling (Chronic)Maturation and Remodeling Phase

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Concorde Career CollegeHouglum, pg 39, fig 2.341Inflammatory (Acute) Phase: Protection PhaseLasts 4-6 daysComplex chemical & cellular interactions occurNecessary, but should not be prolonged or extensive Chronic InflammationTreatment goal: Allow movement, but minimize excessive movementRest, Ice, Compression, Elevation (RICE)Minimize and contain damageModalities blood flow when circulation becomes stable from injury, pain and spasmConcorde Career College42Movement?Inflammatory Phase: Acute InjuriesP.R.I.C.EProtection: Using splinting or wrappingRest: Avoid further activityIce: Reduce inflammation, decrease acute effusion, use cool to prevent reflex vasodilatation Compression: Minimize the amount of swelling/effusionElevation: Decrease pooling of blood by elevating. Improve lymphatic drainage Proliferation (Subacute) Phase: Repair & Healing PhaseControlled Motion Phase 10-17 days longSynthesis and deposition of collagen characterize this stageFibroblasts are presentThe immature connective tissue that is produced is thin and unorganizedKeloid scars may form secondary to uncontrolled collagen production

44Proliferation SignsSwelling: fluid from fibroblast activity

Redness: new capillaries

Sensation: pressure-sensitive nerves and tension-sensitive nerves are hypersensitive

Concorde Career College45Remodeling (Chronic) Phase: Maturation & Remodeling PhaseReturn-to-Function Phase May last 6 months to one yearBe aware of Chronic Inflammation or Overuse SyndromeIncreased pain, swelling, and muscle guarding that lasts more than several hours after activityConcorde Career CollegeComment on overuse syndrome- precaution- notify PT46Chronic InflammationCaused by inability to move from inflammation phase to proliferation phaseMay be due to: Lack of proper growth factorsDisturbed immunity Poor nutritional support Not enough quality rest Continued low grade functional or environmental irritants

47Chronic Pain SyndromePersists longer then 6 monthsPain cannot be linked to irritation or inflammation Functional limitations and disability including physical, emotional and psychological parametersConcorde Career CollegeFactors that affect HealingTreatment modalitiesDrugsSurgical repairAgeDiseaseWound size infectionNutritionMuscle spasmSwellingTissue Specific HealingLigamentTendonMuscleCartilageBoneConcorde Career College

Ligament Healing Time InflammationFirst few hrs: Ligament stumps and becomes progressively more friable24 hrs: Fibroblasts begin to appearHealing and Repair1-2 wks: Vascular buds appear in the wound and begin to communicate with existing capillaries.2d-6wk: Matrix structures replace the blood clot during inflammationRemodelingUp to 12 mo: Ligament becomes more normal40-50 wks: Near-normal tensile strength is restoredCheck the terms Houglum- pg 45 Table 2.4

51Tendon Healing TimeInflammation5 days: Wound gap is filled by phagocytes1 wk: Collagen synthesis is initiated and placed in a random disorganized way.Healing and Repair (Proliferation)4 wks: Collagen is fully oriented with the tendons long axisRemodeling2 mo: Collagen is mature and realigned along tendons axis 40-50 wks: Strength is 85-95% normal Houglum pg 46; table 2.552Muscle Healing TimeInflammation6 hrs: Fragmentation of injured muscle fibers begins1 wk: Muscle tension is progressively reduced, scar tissue is seen in large muscle injury, muscle is able to produce near normal tensionHealing and Repair13 days: Regenerating myotubes are seen18 days: Cross-striated muscle fibers appearRemodeling6wks to 6mo: Contraction is 90% normal.Houglum pg 47, Table 2.6 (Inflammation at 1 wk- inconsistent???) kp 8/18/1153Articular Cartilage Healing TimeInflammation48 hr: Clot is formed to fill the defect5 d: Fibroblasts in the area, combine with collagen fibers to replace the clotHealing and Repair2 wks: Fibroblasts differentiate, islands of chondrocytes appearRemodeling2 mo: Defect resembles cartilage in appearance6 mo: Type I and type II calcified cartilage has a normal appearanceHouglum pg 49; Table 2.754Bone Healing TimeInflammation3 - 4days: Fractured edges become necrotic. Osteoclasts mobilize in the areaHealing and RepairUp to 4 wks: Osteoblasts proliferate to form soft callus3-4wks: Hard callus develops 4-6 wks: External blood supply dominatesRemodeling3-4 mo:Fracture is healed, but remodeling continues12 wks:Near-normal strength is attainedHouglum pg 51, Table 2.855Tensile StrengthThe maximal amount of stress or force a structure is able to withstand before tissue failure occurs

Once injury occurs, normal tensile strength seldom returns to 100% of its prior level

Concorde Career College56Houglum pg 51

Therapeutic Exercise & HealingInflammation (acute) phase- ProtectionNo exerciseRelief of pain, spasm, and edemaRepair and Healing (subacute) phase- Controlled MotionRange of motion (ROM) exercisesPain reliefMaturation & Remodeling (chronic) phase- Return to FunctionStrength, coordination, power, agilityRestoration of optimal function

57Treatment Through the PhasesInflammation phaseModalities for pain, edema, spasm reliefNo stretchingNo resistanceMaintenance of conditioning of cardiovascular system and uninjured segments

Concorde Career College58Treatment Through the PhasesRepair and Healing phase (Early)Easy ROMActive assistive ROM (AAROM) Passive ROM (PROM) Isometrics ProprioceptionExercises for cardiovascular system and other segments 59

Treatment Through the PhasesRepair and Healing Phase (Late)AROM, PROMIsotonic, proprioception, balanceContinuation of exercises for Cardio Vascular system and other segments

Concorde Career College60Not sure about this?? of special considerations of delayed healing, physician prescription, age, general health of the individual ??Treatment Through the PhasesMaturation and Remodeling phaseReturn to function phaseIncrease strength and alignment of scarOK for progressive stretching, strengthening, endurance training, functional exercise and specificity drills

Concorde Career CollegeInterventions That Affect The Healing Of TissuesCold packs for inflammatory regulation Electrical stimulation for pain control, enhanced protein synthesis in repair phase, facilitated muscle contraction for mechanical edema pumping and increased muscle tone. Ultrasound for deep mechanical and thermal effects Drugs as pain suppressors, muscle relaxants, and NSAIDs Therapeutic exercise for flexibility, strength and tissue loadingConcorde Career College62Rehabilitation Progression1st:Correct deviations & reduce pain2nd:Range of motion and flexibility3rd:Strength and endurance4th:Proprioception and balance5th:Agility and coordination6th:Performance

Treatment Enhancement FactorsMake the program challenging but appropriate for the healing phaseMake the program interesting and fun; use your imaginationKeep short-term and long-term goals in mindPsychological encouragement

Concorde Career College64Treatment Enhancement FactorsObserve closely for exercise responsesDont assume patient knows the correct way to perform an exerciseWatch continuously for substitutionsAssess, assess, and assess

Concorde Career College65QuestionsConcorde Career College