Final Revision Notes - Physiotherapy PDF

**FINAL REVISION NOTES -- EVERYTHING YOU NEED TO KNOW ABOUT PHYSIO** A screenshot of a computer Description automatically generated **1. Wrist (6 movements)** - **Flexion: Flexor carpi radialis** - **Extension: Extensor carpi radialis longus** - **Radial Deviation (abduction): Flexor carp...

**FINAL REVISION NOTES -- EVERYTHING YOU NEED TO KNOW ABOUT PHYSIO** A screenshot of a computer Description automatically generated **1. Wrist (6 movements)** - **Flexion: Flexor carpi radialis** - **Extension: Extensor carpi radialis longus** - **Radial Deviation (abduction): Flexor carpi radialis** - **Ulnar Deviation (adduction): Flexor carpi ulnaris** - **Pronation: Pronator teres** - **Supination: Supinator** **2. Elbow (4 movements)** - **Flexion: Biceps brachii** - **Extension: Triceps brachii** - **Pronation: Pronator teres** - **Supination: Supinator** **3. Shoulder (6 movements)** - **Flexion: Anterior deltoid** - **Extension: Latissimus dorsi** - **Abduction: Supraspinatus** - **Adduction: Pectoralis major** - **Medial/Internal Rotation: Subscapularis** - **Lateral/External Rotation: Infraspinatus** **4. Cervical Spine (C Spine) (4 movements)** - **Flexion: Sternocleidomastoid** - **Extension: Trapezius (upper fibers)** - **Lateral Flexion: Sternocleidomastoid** - **Rotation: Semispinalis capitis** **5. Thoracic Spine (T Spine) (4 movements)** - **Flexion: Rectus abdominis** - **Extension: Erector spinae** - **Lateral Flexion: Quadratus lumborum** - **Rotation: External oblique** **6. Lumbar Spine (L Spine) (4 movements)** - **Flexion: Rectus abdominis** - **Extension: Erector spinae** - **Lateral Flexion: Quadratus lumborum** - **Rotation: Internal oblique** **7. Hip (6 movements)** - **Flexion: Iliopsoas** - **Extension: Gluteus maximus** - **Abduction: Gluteus medius** - **Adduction: Adductor longus** - **Medial/Internal Rotation: Tensor fasciae latae** - **Lateral/External Rotation: Gluteus maximus** **8. Knee (4 movements)** - **Flexion: Hamstrings (e.g., biceps femoris)** - **Extension: Quadriceps (e.g., vastus lateralis)** - **Medial Rotation: Semitendinosus** - **Lateral Rotation: Biceps femoris** **9. Ankle (4 movements)** - **Dorsiflexion: Tibialis anterior** - **Plantarflexion: Gastrocnemius** - **Inversion: Tibialis posterior** - **Eversion: Peroneus longus** **SUBJECTIVE ASSESMENT** Introduction + consent -Hello my name is Alice and I am a student physiotherapist -Please can you confirm your name and date of birth -Now I\'m going to be asking you some questions regarding your condition and symptoms to provide me with a bit of insight would this be okay? Open questions, affirmations, reflections, summary -Can you tell me about the reason why you're here today? -ICE- **I**mpression --what is the patient's impressions/understanding of what's going on? **C**oncerns --does the patient have any concerns/worries? **E**xpectations -- what does the patient hope or expect to happen/any goals? -Can you explain how this is affecting your everyday life? -Are you using any coping strategies History of presenting condition (SOCRATES) -Site; Where is pain -On set; What happened and when -Character; describe symptoms -Severity; Rate pain on scale of zero to 10 how severe is it -Radiation/referral - Pain felt away from the tissue in which it originates; pain site body chart -Association; swelling/ bruising/ deformity/paresthesia, pins and needles? -Time; pain over 24 hour time frame, activity dependent, morning/night +SLEEP -Exacerbating or relieving factors; rest, heat -Severity; Rate pain on scale of zero to 10 how severe is it Past medical history and/or family history -- THREADSOCSSS PA T: thyroid H: hypertension/ heart conditions pacemaker, bleeding disorders and clots/ anticoagulants R: rheumatoid conditions E: epilepsy A: asthma/ other breathing difficulties D: diabetes S: stroke \[any other neurological conditions\] O: osteoporosis/ any fractures C: cancer \[personal/ family history closed bracket S: surgery S: steroid S: smoking/ vaping P: Pregnancy A: Alcohol use OR - **Broken** **Heart**ed **Thy Strokes Bleeding, Hyper Baby** **Ost**rich **In AlDi,** **CheSter** - **Can Smoking Surge** **Anti-Age** at **Epi**c **Pace?** Broken (fractures) - Has the patient had any previous broken bones? - Has it left any deformity or weakness or loss of function? - Might this suggest an issue with falls? - Might this indicate any underlying osteoporosis? **Heart**ed conditions - **Has the patient had a previous myocardial infarct (MI)?** - **Does the patient have angina?** - **Will this limit their ability to exercise and how will this be risk assessed?** - **Do they carry a GTN spray?** **Thyroid** - **Disorders of the thyroid are linked to some conditions such as 'carpal tunnel syndrome', 'trigger finger' and 'frozen shoulder'** **Stroke or other neurological conditions** - **A previous stroke (cerebrovascular accident CVA) may have left the patient with physical or cognitive deficits which may present as weakness, memory loss, loss of sensation, reduced balance, altered gait and many other potential symptoms.** - **Other neurological conditions like Parkinson's or Multiple Sclerosis may also cause such symptoms** - **It is important to understand the patient's baseline capabilities** **Bleeding disorders & clots** - **Haemophilia may be a contraindication to some assessment and treatment techniques** - **A previous history of deep vein thrombosis & pulmonary embolisms means there is a greater risk of others occurring in the future** - **Patients may be on longterm anti-coagulants (blood thinners) after a previous clot** **Hypertension (high blood pressure)** - **Hypertension is a risk factor for stroke and heart attacks** - **Hypertension is important when considering potential vascular causes of symptoms, such as peripheral vascular disease, cervical artery disorders, abdominal aortic aneurysms, popliteal aneurysm** - **If you are going to be using exercise as part of an intervention it is important to ascertain whether blood pressure is stable or not** - **Many patients are on medication for hypertension and some may monitor their blood pressure at home.** **Baby (Pregnancy)** - **If the patient is pregnant it could mean that some aspects of your assessment or treatment might be contraindicated** - **It may also contraindicate x-rays and many medications** **Osteoporosis (reduced bone mineral density)** - **If a patient has osteoporosis they are at greater risk of a fracture. This may only come to light if they have had a previous fracture which has triggered an assessment of their bone quality.** - **Post menopausal females are most at risk** - **Patients who have rheumatoid arthritis and patients treated with long term steroids are also at risk** - **Other risk factors for fracture include smoking and high levels of alcohol intake** **Inflammatory conditions** - Conditions such as rheumatoid arthritis and axial spondyloarthritis are chronic inflammatory autoimmune conditions - The presence of a pre-existing rheumatoid arthritis or axial spondyloarthritis will mean we may need to be more cautious with handing and palpating some joints (for instance in rheumatoid arthritis erosion of the cervical dens can lead to upper cervical instability) - Gout is a recurrent condition, so a previous history of gout means that a recurrence is likely **Al**cohol - Excessive alcohol use can predispose to avascular necrosis & fractures - May indicate a coping mechanism **Di**abetes - Can impair healing - Associated with conditions such as 'Frozen shoulder' - May have symptoms of diabetic neuropathy - Need to consider how well controlled it is - Is there a risk of hypoglycaemic episode whilst under your care & how will that risk be managed? **Chest** - Are there any respiratory conditions such as asthma or COPD - How well controlled are the symptoms? - Will this impact on your assessment/treatment options? - Will the patient need to bring their inhaler to appointments? - Has there been any long term steroid use in the treatment of the condition? - Has there been a history of tuberculosis (TB)? TB can spread to the spine after lying dormant for many years. **Ster**oids - Has the treatment been treated with steroid such as prednisolone for other health issues? - Steroids can cause osteoporosis which can pre-dispose to fractures as well as making the skin more fragile - Does this person use anabolic steroids for bodybuilding ? which can predispose to tendon ruptures **Can**cer - Has the patient had any previous cancer? - Some cancers have a tendency to metastasize to bone along with breast cancer, prostate, kidney, lung and thyroid, therefore a history of cancer should raise the suspicion of metastases - Primary cancer can also present as pain - Consider this history of cancer alongside other screening questions such as the nature of pain, night pain, weight loss, general health, age **\50 years** **Smoking** history - Smoking is a risk factor for many chronic health conditions - There are strong links with lung cancer (which can masquerade as neck/arm pain) - Increased risk of developing vascular pathologies like blood clots and heart disease - Increased risk of developing rheumatoid arthritis - May indicate a coping mechanism Surgery - Has there been any previous surgery? - If there has been surgery, is there any metalwork within, for instance pins and plates for a fracture or a joint replacement? These could be the source of an infection - Potential complications after surgery include infection & blood clots - Maybe there has been previous arthroscopic (keyhole) surgery to a joint- this can lead to earlier progression of osteoarthritis in a joint - Has there been a caezarian section which has weakened abdominal muscles or other surgery which has cut through muscle - Has there been surgery which can suggest other conditions, for example, a stent for the heart condition or a mastectomy for breast cancer. **Anti** coagulants - Medications such as aspirin, warfarin & apixaban may contraindicate some assessment and treatments techniques **Age** - Age of greater than 50 years of age is associated with increased risk of cancer and fractures - Musculoskeletal pain in children is rare and cancers need to be considered **Epi**lepsy - How well controlled is it? - Do they carry an epipen? - How can you manage the risk when the patient is with you? **Pace**maker - This could be a contraindication to any electrotherapy modalities & MRI scans - How do you feel in yourself? (**tiredness and fatigue/malaise** is a common symptom in many conditions including inflammatory, neurological and malignant conditions - **Fever & night sweats** are suggestive of infection - **Has your weight changed recently?** (unexplained weight loss 5-10% loss of body weight in 3-6 month period is suggestive of malignancy and systemic diseases) - **Unremitting night pain**, is non-mechanical and suggestive of inflammation or malignancy - Consider asking about **intravenous drug use** (IVDU) if infection is suspected - Does the patient have an **impaired immune system** through HIV or immunosuppressive medications which could increase the risk of infection Are there any other conditions I haven't listed that you would like me to be aware of? Medication/drug history -CURRENT OR PAST DRUG USE -How long for and how often -Special attention to steroids, anticoagulants and painkillers Social What does the average day look like for you? -Hobbies/activities -Employment -Living circumstances e.g. stairs -Psychological impact -Family history Special questions For cervical vascular pathology 5 D's -- neck and shoulder -Dizziness -Dysarthria (difficulty speaking) -Dysphagia (swallowing problems) -Drop attacks (sudden fall/ loss of consciousness) -Diplopia (double vision) 3 N's -Nausea (sick) -Nystagmus (involuntary eye movement) -Numbness (facial) Cauda equina syndrome (CES) -- asked for lower back and legs as starts from L1 -Pins and needles in legs -Saddle anaesthesia or pain -Bladder/bowl dysfunction -Changes in sexual sensation/ function -Loss of function Joint questions -- Did the patient hear a pop/click at time of injury? Give way? (instability/rupture of ligaments) Locking? (meniscus, true locking associated with bucket handle tears) Swelling? How quickly? Where is the swelling? (Intra articular/ extra articular; immediate swelling usually indicates trauma within the knee such as ligament damage) Was there bruising? (Immediate bruising indicates significant trauma -Infection-fever -Fracture- trauma, osteoporosis, deformity, lumps/bumps -Neurological deficits- foot drop Summary Summarise and present info SIN: Severity -- pain score, Irritability -- how easily/ quick does pain come on, Nature -- type of pain; atherogenic (joints), myogenic (muscles), neurogenic (nerves) **FLAGS** To look for in assessment- Age over 50 years Progressive symptoms Thoracic pain Past history of cancer Weight loss Drug abuse Night pain Systemically unwell (fever) Night sweats   OBJECTIVE ASSESSMENT Observation + state at rest - Ensure, that with consent-that the patient is adequately undressed to be able to observe sufficiently - Posture (Standing/Sitting & or other)- view from different planes - Deformity - Wasting, spasm, swelling, colour, rashes, cuts/skin marks - 'State at rest' ascertained Clearing adjacent joints -- ROM with overpressure - First 'clear' any adjacent joints which could be implicated through a pattern of 'referred pain' - Pain usually refers distally - For example, pain in the hip can often refer to the knee. Pain from the cervical spine often refers to the thoracic or shoulder regions Active ROM Passive ROM - Performed by the therapist - Normally achieve more ROM than active movements - If significant difference between active and passive ROM likely to be a contractile tissue accounting for the reduction in active ROM (ie loss of strength) - If no further ROM is achieved passively than actively then joint/capsule likely to be cause of the stiffness - May also be limited by pain and therefore limiting the ability to take the movement to end range Strength (resisted tests)/length testing Special Tests and Neurological tests - The validity of special tests is highly variable and rarely can a test do this in isolation-it sits in context with the subjective history and rest of the clinical assessment - Spine -- neurological assessment (myotomes, dermatomes, reflexes, UMN tests) - Upper limb neurodynamic tests if considering a nerve-related disorder - Peripheral joints- ie, Hawkins-Kennedy test for shoulder - Ruling in or ruling out certain potential diagnoses - Consider the 'sensitivity' and 'specificity' of these tests Neurodynamic tests - evaluates the length and mobility of various components of the nervous system. They are performed by the therapist placing progressively more tension on the component of the nervous system that is being tested - Lower limb -- Straight leg raise (SLR), Slump test, Prone knee bend test - Upper limb -- Upper Limb Neurodynamic (ULND) tests 1, 2a, 2b, 3. Functional test - Consider any aggravating factors which the patient reported which you may now want to observe/re-create. - Consider person-specific activities relating to specific aspects of their job/hobbies/day to day life - PERSON-SPECIFIC Palpation and accessory movements What you are looking for in accessory movement -- palpating hard - Patient response (local or referred pain, reduced or increased pain) - Quality of movement - Range of movement - Resistance - Muscle spasm - Here are some guides on 'normal' ranges of ROM values of the lower limb, please note there can be a wide variation of values recoded from 'normal' subjects: **Hip** Degrees ------------------ --------- Flexion 120-125 Extension 15-30 Lateral rotation 40-50 Medial rotation 25-40 Abduction 30-50 Adduction 20-30 **Knee** Extension 0 Flexion 130-140 **Ankle** Dorsiflexion 15-20 Plantarflexion 50-60 **Subtalar** Inversion 30-40 Eversion 15-20 Here are some guides on 'normal' ranges of ROM values of the upper limb, please note there can be a wide variation of values recoded from 'normal' subjects: **Shoulder** Degrees ------------------ --------- Flexion 160-180 Extension 50-60 Lateral rotation 80-100 Medial rotation 70-90 Abduction 170-180 **Elbow** Extension 0 Flexion 140-150 **R/U joint** Supination 80-90 Pronation 80-90 **Wrist** Extension 70-80 Flexion 60-80 Radial deviation 15-25 Ulnar deviation 30-40 THEORY TOPICS Stress and inactivity Homeostasis - "A property of cells, tissues, and organisms that allows the maintenance and regulation of the stability and constancy needed to function properly. Homeostasis is a healthy state that is maintained by the constant adjustment of biochemical and physiological pathways." (Stoppler, 2018) Sympathetic Nervous System - Fight or Flight - Stress induced - Arousal/alertness - Energy Parasympathetic Nervous System - Inhibited by stress - Rest and digest - Recovery Sympatheticoadrenomedullary system (SAM) -- acute stress regulation HPA Axis-chronic stress regulation  Allostasis - An enhanced response to that of the asymptomatic response of homeostasis.....when the threat requires a behavioural response to prevent harm or preserve the body's equilibrium. i.e. pain &/or stress. (Porter, 2017). General Adaptation Syndrome- Initial flight or fight response (SAM & HPA)-\> Resistance Reaction- (HPA) longer lasting response- release of CRH-if stress is short term, body can return to normal-can continue after the stressor as been removed-\> Exhaustion -- cannot sustain resistance stage leading to stress related disease Allostatic load-the long term wear and tear on the stress response  Rumination + Magnification + Helplessness = Catastrophizing Magnified perception of pain as threatening or dangerous- amygdala 'If exercise was a pill\...' Coronary heart disease​ High blood pressure​ Stroke​ Metabolic syndrome​ Type 2 diabetes​ Breast cancer​ Colon cancer​ Depression​ Falls​ Increased cardiorespiratory and muscular fitness​ Healthier body mass and composition​ Improved bone health​ Increased functional health​ Improved cognitive function -Sleep Sleep involves the brain\'s regulation of the sleep-wake cycle, primarily controlled by the hypothalamus. The **suprachiasmatic nucleus (SCN)**, located there, is the master clock that responds to light and dark signals. It influences the production of melatonin, a hormone from the pineal gland that promotes sleep. Sleep is divided into two main types: 1. **Non-REM (Rapid Eye Movement)** sleep: This has three stages (N1, N2, N3). N3, also called deep sleep, is where the body focuses on repair and growth, and the immune system is strengthened. 2. **REM sleep**: This is where most dreaming occurs, and the brain is highly active. It supports memory consolidation and emotional regulation. Physiologically, during sleep, your heart rate, blood pressure, and breathing slow down in non-REM stages but become more irregular during REM sleep. The body uses this time for cellular repair, toxin clearance (especially in the brain via the glymphatic system), and memory integration. Inflammation Innate defence systems (non-specific) 1. Epithelial barriers 2. Phagocytes 3. Anti-microbial chemicals 4. The inflammatory response 5. Immunological surveillance - Natural Killer Cells 1. T-cells and B-cells- lymphocytes 2. Specific response targeted at particular antigens based on memory 1. **Redness** (increased movement of blood through dilated vessel) 2. **Heat** (increased movement of blood through dilated vessel & metabolic reactions) 3. **Swelling**(passage of fluid from dilated and permeable blood vessels into the surrounding tissue) 4. **Pain** (\*nociception\*)- sensory nerves due to oedema and chemical mediators 5. **(Loss of function)** Inflammatory mediators released (histamine, prostaglandins, cytokines) Vasodilation of blood vessels (redness/heat) & Increased permeability of vessels walls Exudate (plasma) into surrounding tissue (swelling) Healing phases - Inflammation (hours/days)  Bradykinin, prostaglandins can sensitize nerves (nociception) Neutrophils (& later monocytes turn into macrophages)  To remove dead tissue-phagocytosis  BONE HEALING++ I **Acute Inflammation**: - It\'s short-term and occurs immediately after injury. - Signs include redness, heat, swelling, pain, and loss of function. - Key players: White blood cells, especially neutrophils, migrate to the site of injury, releasing chemicals like histamine and cytokines to promote healing.  **Chronic Inflammation**: - Happens when inflammation persists over time, leading to tissue damage. - It\'s associated with conditions like arthritis, cardiovascular disease, or autoimmune disorders. - Macrophages and lymphocytes are more involved here.  **Phases of Inflammation in Healing**: - **Inflammatory Phase**: First seventy-two hours. The body cleans the injured area and sets the stage for repair. - **Proliferation Phase**: Fibroblasts produce collagen, creating new tissue. - **Remodeling Phase**: Lasts weeks to months, where tissue regains strength and flexibility. Pain Lorimer Mosley Pain is a complex experience that involves both sensory and emotional components. It's often divided into two main types: 1. **Acute Pain**: This is short-term pain that arises from tissue damage or injury. It usually goes away once the injury heals. It\'s sharp, localized, and often signals that something is wrong. 2. **Chronic Pain**: Pain that persists beyond the usual healing time (usually longer than three months). It may occur even without an obvious injury and can be linked to conditions like arthritis, nerve damage, or fibromyalgia. **Ascending Pathway (Pain Transmission to the Brain)** 1. **Nociceptors** (Pain Receptors) - These are specialized nerve endings found in the skin, muscles, joints, and organs. They detect harmful stimuli like heat, pressure, or chemical changes. - When activated, nociceptors generate electrical signals (action potentials). 2. **Primary Afferent Neurons (First-Order Neurons)** - These neurons transmit the signal from the nociceptors to the **dorsal horn** of the spinal cord. - The cell bodies of these neurons are located in the **dorsal root ganglion** outside the spinal cord. 3. **Dorsal Horn of the Spinal Cord** - The signal enters the dorsal horn of the spinal cord, where it synapses with **second-order neurons**. - The pain signal can also involve **substance P** and **glutamate**, neurotransmitters that enhance the pain signal. 4. **Spinothalamic Tract (Second-Order Neurons)** - The second-order neurons cross over to the opposite side of the spinal cord (decussation). - These neurons then ascend the spinal cord in the **spinothalamic tract** (a major pain pathway) toward the brain. 5. **Thalamus** - The second-order neurons synapse in the **thalamus**, which acts as a relay station. - From here, the signal is sent to the **somatosensory cortex** and other brain areas for interpretation. 6. **Somatosensory Cortex** - Located in the **parietal lobe** of the brain, this area is responsible for the conscious perception of pain. **Descending Pathway (Pain Modulation)** 1. **Periaqueductal Gray (PAG)** - Located in the midbrain, the **periaqueductal gray** plays a central role in pain modulation. - When the brain recognizes pain, it sends signals from the PAG to decrease pain intensity. 2. **Rostral Ventromedial Medulla (RVM)** - The PAG activates the **rostral ventromedial medulla** in the brainstem, which further sends signals down the spinal cord to modulate pain. 3. **Descending Pathways in the Spinal Cord** - These signals travel down the spinal cord via the **dorsal horn**, where they release **endorphins** (natural painkillers) and **serotonin** to inhibit the pain signal. - The descending pathways can either **inhibit** or **facilitate** the ascending pain signals, depending on the brain\'s assessment of the situation. 4. **Pain Modulation** - Inhibition of pain occurs through the activation of **opioid receptors**, leading to reduced pain perception. - The brain can \"turn down the volume\" of pain through this process, especially when it\'s not perceived as a threat. **Simplified Flowchart of Ascending Pathway:** 1. **Nociceptors** → 2. **Primary Afferent Neurons** → 3. **Dorsal Horn of the Spinal Cord** → 4. **Spinothalamic Tract** → 5. **Thalamus** → 6. **Somatosensory Cortex** **Simplified Flowchart of Descending Pathway:** 1. **Periaqueductal Gray (PAG)** → 2. **Rostral Ventromedial Medulla (RVM)** → 3. **Descending Pathways in the Spinal Cord** → 4. **Pain Modulation** Biopsychosocial model -- George Engel **1. Biological Factors** - These are the **physical** aspects of a patient's condition, such as anatomy, physiology, and any underlying medical conditions. - In physiotherapy, this includes evaluating **musculoskeletal function**, **movement patterns**, **injuries**, and **diseases** (e.g., arthritis, neurological conditions). - **Assessment**: Physiotherapists assess muscle strength, joint mobility, posture, pain levels, and other clinical signs related to the patient's physical health. **2. Psychological Factors** - These relate to how a person's **thoughts, emotions, and mental health** affect their experience of pain, injury, or illness. - **Psychological factors** can influence how a patient perceives their condition, their stress levels, and their coping strategies. - **Assessment**: In physiotherapy, a psychological assessment might include understanding the patient's **pain beliefs**, **fear-avoidance behaviors**, **stress levels**, **motivation**, and **emotional state**. Psychological factors like **anxiety, depression**, or **catastrophizing** can impact recovery and affect how a person manages their condition. **3. Social Factors** - These are the **social and environmental influences** that affect a person's health, including family dynamics, work, culture, and socioeconomic status. - For instance, a patient\'s ability to **access healthcare**, maintain a **healthy lifestyle**, or recover from an injury may be affected by their **social support** or **workplace demands**. - **Assessment**: In physiotherapy, assessing **social factors** could include looking at the patient's **living situation**, **work environment**, family support, and whether they have the resources or time to engage in rehabilitation or exercise programs. ANATOMY For each I want to know - All movements each limb does - Normal Rom - What to clear - The muscles responsible for those - Bones in the area +joint type - Special tests Wrist Clear the elbow Movements -- Flexion, Extension, Radial deviation (abduction), Ulnar deviation (adduction), Pronation, Supination Elbow Clear should and wrist Movements -- Flexion, Extension, (pronation and supination) Shoulder Clear C spine and elbow Movements -- Flexion (forward), extension, abduction, adduction, external rotation, internal rotation (consider scapular movements) One simple move to loosen up your shoulders - Sequence Wiz Cervical spine Clear Shoulder and T spine Movements -- Flexion, Extension, Lateral flexion, Rotation Thoracic spine Clear C spine and L spine Movements -- Flexion, Extension, Lateral flexion, Rotation Lumbar spine Clear T spine and hip Movements -- Flexion, Extension, Lateral flexion, Rotation? Hip Clear L spine and knee Movements -- Flexion, Extension, Abduction, Adduction, External rotation, Internal rotation Knee Clear hip and ankle Movements - Flexion, extension, internal rotation, lateral rotation Ankle Clear knee Movements- dorsiflexion, plantar flexion, inversion, eversion, COMMON CONDITIONS KEY FINDINGS - Following the subjective and objective assessment you should now be able to identify some of the most important aspects of the assessment -- these are your 'key findings' - As part of your OSCE, you will be asked to identify your 'key findings' in a list whilst demonstrating an understanding of what makes them a 'key findings' - Learning outcome 4. - 'Utilise the assessment process to identify key findings that will inform clinical reasoning'. - Marking rubric: - 'communication of ideas' - 'knowledge of relevant theories supported by research' - Examples from subjective history: - "The patient is worried about her pain and how it may affect her ability to look after her children. Engel, 1977 proposed the biopsychosocial model which identifies how mental and social factors can also impact pain. In this case, her worries could be a stressor, which would activate her sympathetic nervous system through the HPA axis. This would increase the production of cortisol. The increased levels of cortisol can lower your nociceptive threshold, which means her worry could be contributing to her pain" - "She has avoided her normal activities of knitting and baking due to fear of pain. The fear avoidance model (Vlaeyen 2016) suggests this can become cyclic where pain leads to fear, increased fear leads to reduction in activity which leads to deconditioning this leads to increased pain and loss of function" - "No cauda equina symptoms were reported by the patient. They described normal bowel and urinary sensation and function and normal sensation was reported in the saddle area. This was necessary to screen for cauda equina which is a red flag which requires urgent care due to the threat of permanent loss of function/sensation occurring- (Petty & Ryder 2018)" - "She avoided moving or using the right arm by independently, she would use the other arm a bit more to help move it into position-she reported she was scared to do so. Fear avoidance can lead to increase in pain as it affects the perception of pain and the likelihood that a noxious stimuli will be perceived as painful (Vlaeyen, 2016). This is based also based upon the neuromatrix model (Melzack) and the involvement of different areas in the brain having multiple roles with pain and roles such as emotion (insula), executive function (pre-frontal cortex), and fear (amygdala). - "Lumbar spine was cleared for concern through active and passive movements which did not reproduce the patient's symptoms, therefore it is not likely that the pain is referred pain from lumbar spine- Petty & Ryder, 2018) - "Talar tilt test was positive for reproduction of pain with a recording of 8/10 on the pain scale (up from 6/10 at rest) This is important to consider during diagnosis of the presenting condition as the lateral ligaments tested in the region reproduced this pain and may be a source of nociception, however no signs of laxity suggests that there has been no rupture of the calcaneofibular ligament- Petty & Ryder , 2018" ANTOMY FUNDIMENTALS  A screenshot of a computer Description automatically generated  - Compact bone - Periosteum - Bone marrow - Long bones (epiphyses and diaphysis) - Short bones - Flat bones - Irregular bones - Sesamoid A diagram of a person\'s body Description automatically generated Fibrous joints - The articulating surfaces of bones that form fibrous joints fit closely together. The different types and amount of connective tissue joining bones in this group may permit very limited movement in some fibrous joints, but most are fixed. Cartilaginous joints - - The bones that articulate to form cartilaginous joints are joined together by either hyaline cartilage or fibrocartilage. Joints characterized by the presence of hyaline cartilage between articulating bones are called synchondroses, and those joined by fibrocartilage are called symphyses. - Cartilaginous joints permit only very limited movement between articulating bones in certain circumstances (symphysis pubis in childbirth). Synovial joints -- - 1\. Joint capsule. - 2\. Synovial membrane. - 3\. Articular cartilage. Thin layer of hyaline cartilage covering and cushioning the articular surfaces of bones. - 4\. Joint cavity. Small space between the articulating surfaces of the two bones of the joints - 5\. Menisci. Pads of fibrocartilage located between the articulating ends of bones in some joints. - 6\. Ligaments. - 7\. Bursae facilitate movement of tendons and reduce friction.  Cartilage 1. Hyaline-found in articular joints -- shock absorbing/smooth; connecting ribs to sternum; trachea/nose 2. White fibrocartilage -- high tensile strength, IV discs, symphysis pubis, labrum, TMJ 3. Elastic cartilage - Cartilage is avascular and is not innervated. - Chondrocytes receive nourishment via diffusion from the surrounding environment. - Type 2 collagen - Collagenous fibrous tissue - Tendons attach muscle to bone - Flexible but possesses great tensile strength - Type 1 collagen, water & elastin - Greater collagen content - Collagenous fibrous tissue - Ligaments attach bone to bone - Flexible but possesses great tensile strength - Type 1 collagen, water & elastin - Greater elastin content Skeletal muscle structure A diagram of the muscles of the human body Description automatically generated Sliding filament theory Muscle terms - Agonist/Prime mover - Synergist - Antagonist - Concentric - Eccentric - Isometric Nerve anatomy - research further - Central Nervous system - Peripheral nervous system The Oxford scale -- Porter (2013) - Grade of Muscle contraction 0 No contraction 1 Flicker of a contraction 2 Full-range active movement with gravity eliminated (counterbalanced) 3 Full-range active movement against gravity 4 Full-range active movement against light resistance 5 Normal function/full-range against strong resistance Anatomy cervical and Upper Limb Bony landmarks from posterior Spine of scapula - The inferior angle of the scapula - The medial and lateral borders of the scapula - Acromion - Spinous processes of cervical spine Bony landmarks from lateral and anterior - Manubrium - Sternum - Sternoclavicular joint - Clavicle - Acromioclavicular joint - Corocoid process - Lesser tuberosity of the humerus - Greater tuberosity of the humerus - Intertubercular groove --long head of biceps  Superficial muscle observation - Trapezius - Supraspinatus - Infraspinatus - Deltoid - Pectoralis major - Latissimus dorsi - Biceps - Triceps Elbow - Bony landmarks - Lateral epicondyle - Medial epicondyle (and location of the ulnar nerve) - Olecranon process  Elbow/forearm - Soft tissue landmarks - Distal biceps tendon - Triceps tendon - Common extensor attachments at the lateral epicondyle - Visualise the superficial forearms flexors -- thenar eminence of one hand onto the opposite medial epicondyle: Thumb: pronator teres Index: flexor carpi radialis Middle: palmaris longus Ring: flexor digidorum superficialis  Little: flexor carpi ulnaris Wrist/hand- bony landmarks - Styloid process of radius - Styloid process of ulna - Metacarpals - Phalanges - Radio-carpal joint line - Metacarparpo-phalangeal joints - Proximal interphalangeal joints - Distal interphalangeal joints Inspection-landmarks - Identify the anatomical snuffbox --what are the tendons? - Identify the thenar and hypothenar eminences - Identify Palmaris Longus - flex wrist & oppose LF (absent in 7% population) - Identify Flexor Carpi Radialis -- flex & RD, radial to PL - Identify Flexor Carpi Ulnaris -- resist flexion, proximal to pisiform - Identify Extensor carpi ulnaris -- extend & UD, distal to ulnar styloid - Identify Extensor carpi radialis longus-- clench fist,  Motivational interviewing -- podcast (Open questions, Affirmation, Reflection, Summary +-----------------------------------+-----------------------------------+ | Clavicle | Cervical and thoracic | | | Zygapophyseal joints | |  | | +===================================+===================================+ | Lateral epicondyle of the humerus | Cervical and thoracic Transverse | | | processes | | Humerus: Anterior view | | +-----------------------------------+-----------------------------------+ | Medial epicondyle of the humerus | | +-----------------------------------+-----------------------------------+ | Spine of the scapula | | | | | |  | | +-----------------------------------+-----------------------------------+ | Coracoid processScapula: Anterior | | | view | | +-----------------------------------+-----------------------------------+ | Acromion | | +-----------------------------------+-----------------------------------+ | Greater tuberosity/tubercle | | | | | |  | | +-----------------------------------+-----------------------------------+ | Lesser tuberosity/tubercle | | +-----------------------------------+-----------------------------------+ | Glenoid fossa | | | | | | Scapula: Anterior view | | +-----------------------------------+-----------------------------------+ | Bicipital/intertubercular groove | | | | | |  | | +-----------------------------------+-----------------------------------+ | Radial tuberosity | | | | | | undefined | | +-----------------------------------+-----------------------------------+ | Coracoid process | | | | | |  | | +-----------------------------------+-----------------------------------+ | Olecranon | | | | | | undefined | | +-----------------------------------+-----------------------------------+ | Capitulum-elbow | | | | | |  | | +-----------------------------------+-----------------------------------+ | Trochlea - elbow | | +-----------------------------------+-----------------------------------+ | Cervical and thoracic Vertebral | | | bodies | | +-----------------------------------+-----------------------------------+ | Cervical and thoracic | Disc thickness | | intervertebral discA diagram of a | generally increases from rostral | | human spine Description | to caudal. The thickness of the | | automatically generated with | discs relative to the size of the | | medium confidence | vertebral bodies is highest in | | | the cervical and lumbar regions. | | | This reflects the increased range | | | of motion found in those regions. | | | | | | In the cervical and lumbar | | | regions, the intervertebral discs | | | are thicker anteriorly. This | | | creates the secondary curvature | | | of the spine -- the cervical and | | | lumbar lordoses | | | | | |  | +-----------------------------------+-----------------------------------+ | Cervical and thoracic transverse | | | foramen | | +-----------------------------------+-----------------------------------+ | Cervical and Thoracic Spinous | | | processes | | +-----------------------------------+-----------------------------------+ | Cervical and thoracic Vertebral | | | canal- | | | | | | The vertebral canal comprises the | | | vertebral foramen located in the | | | cervical, thoracic, and lumbar | | | vertebrae. The vertebral or | | | spinal cord typically ends at the | | | level of the L2 vertebra, where | | | the spinal cord gives off | | | multiple branching spinal nerves | | | and nerve rootlets known as the | | | cauda equina | | +-----------------------------------+-----------------------------------+ A diagram of the spine Description automatically generated  Lower limb, upper limb and spine anatomy - bones, joints, muscle and nerves Lower limb, upper limb and spine kinesiology Normal movement and development Normal gait A range of MSK presentations including acute, chronic, and adult and paediatric conditions, which will include Osteoarthritis, Rheumatoid Arthritis, Acute Trauma, soft tissue Injuries, Fractures/dislocations and other bone and nerve injuries. Physiology and psychology of stress Bodies' response to pain Collaborative service user engagement within physiotherapy Motivational interviewing (MI), mainly MI spirit for engagement -- reflective listening Biopsychosocial model and related non-biomedical models of health Inflammation, infection and tissue healing Appropriate use of walking aids Measurement including muscle and joint testing Myotomes, dermatomes and deep tendon reflexes Subjective and objective assessment