SKEB 2513 Basic Rehabilitation 2023/2024 PDF

SKEB 2513 Basic Rehabilitation 2023/2024-2 Rehabilitation of z Common Musculoskeletal Conditions Siti Ruzita Mahmod, PhD  z Topic outline: ▪ General Considerations, Pathogenesis, Clinical Findings, Treatment and Rehabilitation in: Shoul...

SKEB 2513 Basic Rehabilitation 2023/2024-2 Rehabilitation of z Common Musculoskeletal Conditions Siti Ruzita Mahmod, PhD  z Topic outline: ▪ General Considerations, Pathogenesis, Clinical Findings, Treatment and Rehabilitation in: Shoulder impingement Ankle sprain Discogenic low back pain  z Intended Learning Outcomes 1 To be able to describe the general pathogenesis and findings in different musculoskeletal conditions 2 To be able to use the knowledge in musculoskeletal rehabilitation and relate the suitable biomedical engineering solution for addressing the functional limitation or disability in the persons. z Part I External Impingement of the Shoulder  Recall >>> rotator cuff anatomy & function z The rotator cuff is a group of flat tendons, which fuse together and surround the front, back, and top of the shoulder joint like a cuff on a shirtsleeve.  Shoulder Impingement z General Consideration ▪ Primary causes: subacromial or subcoracoid impingement of the rotator cuff. ▪ Secondary causes: abnormal glenohumeral and scapulothoracic motion.  Shoulder Impingement z General Consideration Static stabilizers of the shoulder include the glenoid labrum and glenohumeral ligaments. Dynamic stabilizers of the shoulder include the rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) Glenohumeral and scapulothoracic motion  Shoulder Impingement z General Consideration The undersurface of the acromion can be a cause of impingement. Type I acromion impingement is flat Type II acromion impingement is concave Type III acromion impingement is hooked * A greater prevalence of Type III, or hooked acromion in patients with impingement  Shoulder Impingement z Pathogenesis The deltoid & supraspinatus muscles provide superior translational forces to the humeral head Infraspinatus, teres minor, and subscapularis provide inferior translational forces. Normally, these opposing forces are balanced. # Supraspinatus impingement occurs when there are unopposed superior translational forces of the humeral head in 30–60 degrees of shoulder abduction. Figure. Force couples in the shoulder joint  Shoulder Impingement z Pathogenesis # Partial-thickness tears of the rotator cuff tendons → decrease overall power of the shoulder muscles → superior migration of the humerus under the acromion → further impinges the rotator cuff. The impingement typically occurs in the tendon’s hypovascular zone (2–6 cm proximal to the insertion) → leads to full- thickness tears.  Shoulder Impingement z Pathogenesis # repetitive overhead activity → supraspinatus tendon degeneration→causes tendon thickening and erosion under the coracoacromial ligament. # humeral instability caused by microtrauma to the static stabilizers of the glenohumeral joint → secondary impingement # weakness of the static stabilizers → increased demand for the dynamic stabilizers →muscle fatigue →subluxation of the humeral head occurs anteriorly and superiorly → impingement on the coracoacromial arch  Shoulder Impingement Clinical Findings z A. Signs and symptoms resisted initial shoulder abduction causing pain in the deltoid muscle. a positive finding (i.e. pain on resisted motion) in the following special test/examination : 1. Neer sign Shoulder impingement is detected as examiner passively induces 160 degrees of shoulder flexion while stabilizing the scapula 2. Hawkins sign Shoulder impingement is detected examiner passively induces 90 degrees of shoulder flexion with maximal internal rotation 3. Empty can test examiner resists shoulder abduction with the patient’s shoulder flexed to 90 degrees in the plane of the scapula + forearms maximally pronated. 4. Speed’s test the examiner resists shoulder flexion at 90º while the patient’s elbow is extended and forearm is supinated  z Hawkins Test to detect shoulder Empty can test impingement.  Shoulder Impingement Clinical Findings z B. Imaging studies 1. Radiographs Able to show the narrowing of the subacromial space to 6–7 mm that may indicate impingement. 2. Magnetic Able to demonstrates both bony and soft tissue resonance imaging abnormalities. (MRI) 3. Computed Can shows muscle atrophy with fatty infiltration tomography (CT) scans 4. Ultrasonography Able to confirm the supraspinatus tendinosis secondary to subacromial impingement and bicipital tendinosis  Shoulder Impingement Treatment and Rehabilitation z 1. nonsteroidal anti-inflammatory Subacromial subdeltoid steroid injection drugs →relieving pain →allow greater gains with (NSAIDs) therapy 2. Physical therapy strengthening the inferior rotator cuff muscles 3. Surgery May be indicated in a later stage if impingement causes a full thickness tears of rotator cuff muscles z Part 2 Ankle Sprain  Lateral Ankle Sprain General Consideration z Lateral ankle sprains comprise up to 21% of sports-related injuries. Medial ankle and syndesmotic sprains account for 10–15% of ankle sprains. Trauma to the structures that make up the ankle joint may have serious consequences for both athletes and non-athletes due to the joint complexity.  Lateral Ankle Sprain Pathogenesis z # Forced ankle plantar flexion, supination, and inversion → sprained the lateral ligaments (85%of ankle sprain injuries) The anterior talofibular ligament- ATFL (one out of 3 lateral ligaments of the ankle) is prone to injury following excessive ankle inversion  Lateral Ankle Sprain Clinical Findings z A. Signs and symptoms ✓ Assessment of any ankle injury should begin with inspection for Swelling Ecchymosis (a bruise) gross deformity ROM of the ankle Vascular Motor and sensory Special orthopaedic Test Description ✓ a positive finding (i.e. pain on resisted motion) in the following special 1. Anterior drawer test A positive test is indicated by a dimple sign at the anterior talocrural joint. test/examination could be sign of the ankle sprain. 2. Talar tilt test A positive test is when the affected ankle translates into greater inversion (compared with the unaffected side) →signifies a tear of the calcaneofibular ligament. 3. External rotation test If pain is elicited by induced external rotation of the ankle, or abduction and eversion. 4. Squeeze test Tibia & fibula are compressed just above the midpoint of the calf. Pain elicited = injury to the syndesmosis  Lateral Ankle Sprain Clinical Findings z A. Signs and symptoms Anterior drawer test assesses anterior Talar tilt test to assess lateral ligamentous talofibular ligament stability. stability.  Lateral Ankle Sprain Grades of Ankle Sprains z ▪ Grade I sprains (mild) - does not demonstrate ligamentous laxity using the previously mentioned tests. ▪ Grade II sprains (moderate) - unstable with increased laxity caused by a tear of anterior talofibular ligament. ▪ Grade III sprains (severe) - unstable, with increased laxity as a result of tears of the anterior talofibular + calcaneofibular ligaments.  Clinical Findings Lateral Ankle Sprain z B. Imaging studies 1. Radiographs to rule out a fracture because the symptoms are quite similar to severe ankle sprains. 2. Magnetic resonance provide insight into osteochondral defects, bone bruises, and imaging (MRI) scan stress or occult fracture 3. Ultrasound scan view ligament directly but not as sensitive as an MRI scan  Shoulder Impingement Treatment and Rehabilitation z A program of rehabilitation is important for prevention of recurrent injuries or chronic instability. Phases of ankle sprain rehabilitation (1) pain control, including reduction of edema and protection of ligaments (2) gait normalization (3) return to daily activities (4) return to sport A grade 3 ankle sprain showing swelling and bruising  Shoulder Impingement Treatment and Rehabilitation z Phases of ankle sprain rehabilitation (1) pain control, including reduction of edema and protection of ligamentous structures (2) gait normalization (3) return to daily activities (4) return to sport 1. nonsteroidal anti-inflammatory drugs Control pain and swelling (NSAIDs) 2. RICE –rest, ice, compression, and subside the swelling and pain some days after the injury elevation. 3. Early mobilization within the first week Restore patient’s functional outcome and prevents atrophy (weight bearing as tolerated) related 4. Active ROM exercises to immobilization. 5. Taping protects the ankle from reinjury by restricting ROM 6. Osteopathic manipulative Benefit for redirection of fluid back into the lymphatic system (↓ edema)/ peroneal muscle relax ROM: Range of Motion  z Kinesio® Taping in chronic ankle sprain Ankle ROM exercise z Part 3 Discogenic Low Back Pain  Discogenic Low Back Pain z General Consideration ▪ Discogenic low back pain - cause of pain for almost 40% of chronic low back pain sufferers. ▪ Discogenic: the disc is the source of the patient’s pain ▪ In some cases, anatomic changes occur → disc to compress adjacent neural structures → pain (radiculitis) or radiculopathy ▪ Radiculopathy symptoms also include numbness, weakness, or electrical sensations such as pins and needles, burning, or shock that travel down one extremity  Discogenic Low Back Pain z ▪ Radiculopathy area of symptoms vary depending on the affected spinal nerve root  Discogenic Low Back Pain Pathogenesis z 1 degenerative disc disease intervertebral disc 2 displacement/ disruption 3 disc herniation  Discogenic Low Back Pain Pathogenesis z 1 degenerative disc disease Caused by the normal aging process, or by excessive or repetitive trauma → disc dehydration and an increase in the collagen concentration Changes in intervertebral discs may affect neighboring structures thus eliciting pain indirectly. * Aging (strongest factor), obesity, smoking, and excessive axial loads can accelerate the degeneration of the intervertebral discs  Discogenic Low Back Pain Pathogenesis z 2 intervertebral disc disruption Is a breakdown of the internal architecture of the disc →back and limb pain (without signs of disc degeneration and disc protrusion@bulging) presence of isolated radial fissures penetrating from the nucleus pulposus into the annulus fibrosis (MRI).  Discogenic Low Back Pain Pathogenesis z 3 disc herniation a) ? also known as slipped disc, prolapsed disc, bulging disc, or herniation of the nucleus pulposus 3 specific types of disc herniation They are differentiated based on the integrity of the posterior longitudinal ligament that reinforces the back of the disc  Discogenic Low Back Pain Clinical Findings z A. Signs & Symptoms ▪ complaint of axial low back pain with or without radiation to the limb. ▪ The pain may be progressive and longstanding in the case of degenerative disc disease, or acute, in the case of internal disc displacement. ▪ Particular positions or activities → pain by increasing intradiscal pressure e.g. jumping, coughing, twisting, or flexing the spine. ▪ Tenderness over the spinous processes and paraspinal muscles. ▪ Pain is often exacerbated with trunk flexion and relieved with extension of the spine.  Discogenic Low Back Pain Clinical Findings z A. Imaging 1. Radiographs Only show structural changes, such as loss of disc height, that could be suggestive of a herniated or degenerative disc. 2. Magnetic resonance ? imaging (MRI) scan 3. Ultrasound scan ?  Discogenic Low Back Pain Treatment and Rehabilitation z 1. nonsteroidal anti-inflammatory drugs 1st line agents but may be contraindicated in some (NSAIDs) cases because of their side effects 2. Opiates and muscles relaxants Frequently prescribed for severe pain 3. Physical therapy (conservative @ non - Stabilization of core muscles invasive measures) - Emphasize neutral to extension bias position - Physical/ therapeutic modalities: alleviating localized back pain - Proper spinal bracing: help relieve pain by preventing painful movement or further spinal deformities but does not alter the natural course of the disease. - Traction: reduce intradiscal pressure→relieve radicular pain  z Lumbar traction Ultrasound therapy for muscle spasms in low back pain  Discogenic Low Back Pain Treatment and Rehabilitation z 4. Epidural steroids injections Providing symptomatic relief of radicular pain (patients who have not responded to conservative measures) 6. Surgery (discectomy/ fusion) for progressive or worsening neurologic symptoms. 7. Regenerative treatment administration of growth factors, autologous or allogenic cells, gene therapy, and the introduction of biomaterials, Spinal fusion: https://www.youtube.com/watch?v=WID1p_UJZIM z