Week 2 - Examination and Assessment PDF

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StupendousSpatialism

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Charles Sturt University

Tim Miller

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healing tissue engineering rehabilitation

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This document is a set of lecture notes on examination and assessment, focusing specifically on the concepts of healing. The material details the stages of tissue healing, while also discussing the role of progressive controlled mobility and how exercise enhances recovery.

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WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright u...

WARNING This material has been reproduced and communicated to you by or on behalf of Charles Sturt University in accordance with section 113P of the Copyright Act 1968 (Act). The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice EHR520 – Week 2 Examination and Assessment Tim Miller (ESSAM AES AEP) E: [email protected] Ph: (02) 6338 4442 Examination and Assessment CONCEPTS OF HEALING Concepts of Healing Week 2 - Assessment and Examination 4 Primary and Secondary Healing Dependent upon: The extent of the injury Approximation of the wound’s end sites Healing by primary intention: If the separation between tissues is small, then a bridge of cells binds the ends together Examples include minor wounds and smaller surgical incisions Week 2 - Assessment and Examination 5 Primary and Secondary Healing Healing by secondary intention More severe wounds where the stump ends are further apart and cannot be bridged Wounds heal by the formation of scar tissue that fills the space An example is a grade II ligament sprain The tissue is torn, but is not surgically repaired Healing takes longer and results in a significant scar Week 2 - Assessment and Examination 6 Healing Phases 1) Haemostasis Phase A short, necessary stage Damage to local blood vessels causes vasoconstriction (5 – 10 minutes) Vasodilation – Platelets arrive to create a blood clot/plug that stems the bleeding Lymph vessels are damaged and formation of a fibrin plug prevents the usual drainage of fluid away from the site, causing swelling The plug is broken (fibrinolysis) 2-4 days post-injury Week 2 - Assessment and Examination 7 Healing Phases 2) Inflammation Phase Without inflammation, the body would be unable to completely heal after injury If inflammation didn’t occur, proliferation, maturation and final resolution would not take place. On the other hand, inflammation becomes harmful when it is prolonged beyond the normal healing time The goal is to control, but not eliminate swelling PRICE – Protect, Rest, Ice, Compress and Elevate Characteristics include pain, tenderness, swelling, redness and increased temperature ROM is limited by pain or direct tissue damage The body begins to ‘clean-up’ the injury site within 5 – 6 hours using WBCs and phagocytes The extent of the swelling is proportional to the extent of the injury Week 2 - Assessment and Examination 8 Healing Phases – Summary Table Week 2 - Assessment and Examination 9 Healing Phases 3) Proliferation (Fibroplastic) Phase There is an overlap of phases as the injury site heals There is no clear-cut delineation between one phase and another. Rather, as the body steadily accomplishes the tasks in one phase, the next phase evolves The proliferation phase begins 3 – 4 days after the injury and continues for 2 – 4 weeks Active scar formation Signs and symptoms will subside Endothelial capillary buds form, which allow for aerobic healing There is increased blood flow for nutrient delivery Granulation tissue develops Collagen is deposited at day 6 or 7 ROM and gentle resistance exercises begin Week 2 - Assessment and Examination 10 Healing Phases 4) Re-Modelling (Maturation) Phase Re-alignment of collagen Transition from Type III to Type I collagen, which increases tensile strength Increased stress and strain causes an increase in collagen re-alignment A non-vascular, contracted, firm scar is present after 3 weeks Maturation of scar tissue may require several years to be complete Week 2 - Assessment and Examination 11 Healing Phases – Summary Table Week 2 - Assessment and Examination 12 Healing Phases – Summary Table Week 2 - Assessment and Examination 13 Role of Progressive Controlled Mobility Wolff’s Law Bone and soft tissue respond to the physical demands placed upon them Initial immobilisation is necessary Subsequent controlled mobilisation enhances Scar formation Revascularisation Muscle regeneration and fibre orientation Tensile properties Controlled activity allows for a gradual return to function SAID principle Week 2 - Assessment and Examination 14 Ligament Sprains Ligaments Inelastic bands of connective tissue that join bone to bone Provide joint stability, control bone position during joint motion and provide proprioceptive input Common sprain sites include the ankle (ATFL and CFL) and the knee (MCL, LCL, ACL, PCL) Week 2 - Assessment and Examination 15 Ligament Sprains Grade I – Some pain, minimal loss of function, no abnormal motion and mild point tenderness Grade II – Pain, moderate loss of function, swelling and instability Grade III – Extremely painful, inevitable loss of function, severe instability and swelling. May also present with a joint subluxation Week 2 - Assessment and Examination 16 Ligament Sprains Week 2 - Assessment and Examination 17 Tendons – Tendon Rupture and Tendinopathy Macrotrauma Repetitive microtrauma Week 2 - Assessment and Examination 18 Muscle Strains Occur due to: Overstretch Being forced to contract against too great a resistance Damage can occur to: Muscle Tendon Musculotendinous junction Tendon-bone interface Precipitating factors include: Lack of flexibility Inadequate warm-up Insufficient strength/endurance Poor coordination Week 2 - Assessment and Examination 19 Muscle Strains Muscle tissue contains unique structures, known as satellite cells, that enable it to regenerate Satellite cells are muscle stem cells that fuse with adjacent myofibres to repair and regenerate muscle tissue Satellite cells restore and replace muscle cells routinely damaged during activity When a small muscle injury is revascularized and reinnervated and occurs in a muscle type that can regenerate, satellite cells replace injured muscle tissue with new muscle tissue Larger injuries, however, such as ruptures or severe lacerations, heal with scar tissue Week 2 - Assessment and Examination 20 Muscle Strains Grade I – Some fibres stretched or torn. Tenderness and pain on active ROM Grade II – A number of fibres are torn and active contraction is painful. There is often a palpable divot and swelling Grade III – Complete rupture with immense immediate pain. This causes significant impairment Week 2 - Assessment and Examination 21 Muscle Strains Week 2 - Assessment and Examination 22 Articular Cartilage Articular cartilage has limited healing capacity and regenerates more slowly than scar tissue is deposited Healing is variable and depends upon damage to the cartilage and/or the sub-chondral bone Articular cartilage fails to undergo clot formation or a cellular response The defective region remains defective When subchondral bone is involved, the inflammatory process proceeds as normal Week 2 - Assessment and Examination 23 Articular Cartilage Restore ROM and address mechanics, then strengthen muscles Land- or water-based rehabilitation may be appropriate Week 2 - Assessment and Examination 24 Bone Fractures Acute vs. stress fractures Immobilisation and sometimes surgical repair Treat with joint mobility, stretching and then strengthening exercises Address any identifiable underlying cause/s of stress fractures Week 2 - Assessment and Examination 25 Bone Fractures Week 2 - Assessment and Examination 26 Tensile Strength During Healing Tensile Strength – The maximum amount of force that a structure can withstand prior to breaking 12 months post-injury – Tensile strength reaches near-normal levels Inflammation Phase Tensile strength declines to 50% within 24 – 48 hours (dependent on tissue type) Proliferation Phase Day 5+ tensile strength begins to increase Remodelling Phase Bone strength returns to 83% of normal by 12 weeks post-injury Ligaments and tendons return to near-normal strength after 4 - 12 months Muscle returns to 90% of pre-injury strength after 1.5 – 6 months Week 2 - Assessment and Examination 27 Factors That Affect Healing Oxygen Tissues need oxygen to survive. When an injury occurs, not only is the oxygen supply locally disrupted but the metabolically active cells need increased levels of oxygen Because of these factors, temporary hypoxia occurs at the wound site. If this hypoxia persists, the wound does not heal A person whose vascular status is compromised may develop chronic, unhealed wounds. Chronic hypoxia leads to acidosis and inadequate ATP production, which prevent the wound from advancing in the normal healing process Factors that cause vasoconstriction, such as smoking, stress and diabetes, delay or restrict normal wound healing Treatment modalities: Ice: Limits swelling, especially recently developed swelling due to exercise Heat: Increases circulation, removes waste products and relaxes muscles Week 2 - Assessment and Examination 28 Factors That Affect Healing Medications: Reduce pain and swelling NSAIDs reduce oedema and pain, allowing earlier commencement of rehabilitation exercise (but possibly delay some healing, especially with fractures) Some other medications may delay the healing process. These include antibiotics, antineoplastic drugs, heparin, nicotine and corticosteroids Surgical repair: Less swelling and shorter immobilisation, which results in a quicker recovery Age, disease, size of wound, infection, surgical repairs, nutritional status, muscle spasm and swelling all have an impact on healing times Week 2 - Assessment and Examination 29 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Week 2 - Assessment and Examination 30 Advances in Investigation – Stem Cells Stem cells are unique, non-specific cells that can differentiate, or change, into different cell types that become specialised in their appearance and function When stem cells divide, they can either become new stem cells or differentiate into specialised cells such as bone cells, muscle cells, nerve cells or blood cells All human cells start as stem cells, but as they continue to divide and mature under the right conditions, they differentiate into specific kinds of cells to perform specific functions Because of the ethical concerns that arise from using embryonic stem cells in research, adult stem cells, sometimes called somatic stem cells, are harvested and re-programmed in laboratory settings, allowing those cells to develop into different types of cells Future uses in stem cell applications to healing go beyond scar tissue healing and involve regeneration of new tissue. This is an exciting and promising prospect of stem cell therapy for injuries and disease Week 2 - Assessment and Examination 31 Advances in Investigation – Tissue Engineering Tissue Engineering – An interdisciplinary and multidisciplinary field that aims at the development of biological substitutes that restore, maintain or improve tissue function A variety of substances are used in tissue engineering in addition to the body’s cells, including plastic and other polymers and proteins Polymers used in tissue engineering can be synthetic, inorganic materials, but they are more often composed of organic molecules that have been synthesised by living organisms. These polymers are called biopolymers and come from plants in the form of starches, cellulose and natural rubber; animals in the form of collagen and hyaluronic acid; and smaller animal and plant forms such as bacteria, algae and fungi Week 2 - Assessment and Examination 32 Advances in Investigation – Tissue Engineering As part of the engineering process, these polymers are used to build scaffolds that create an environment that is conducive to new tissue formation Cells from the body are then inserted into these porous, mesh-like scaffolds, which produce interactions with other cells and ultimately form new tissue There are many research avenues currently investigating scaffold development through tissue engineering Studies of ways to restore tissue of injured muscle, tendon, bone, articular cartilage and intervertebral discs are well underway Week 2 - Assessment and Examination 33 Role of Therapeutic Exercise in Healing Exercise can enhance recovery, but only if applied appropriately at each specific stage of healing You need to consider the healing phases and timing for each injury Signs of too much stress include: Increased pain Increased oedema Decreased function Week 2 - Assessment and Examination 34 Role of Therapeutic Exercise in Healing Week 2 - Assessment and Examination 35 Examination and Assessment SUBJECTIVE AND OBJECTIVE EXAMINATION Subjective Examination Systematic, yet flexible approach to information gathering Establish a level of comfort and trust with the client Information to gather: General demographics (age, sex, race, primary language) Occupation (current and prior) History of injury, client’s report of pain, onset and pattern of symptoms Past medical history (including medications and surgery, as well as any other medical conditions and their associated medications) Previous and current rehab/treatment Additional information (physical activity history, changes in physical activity levels, sport, work, any test/imaging results, client goals and expectations, living arrangements) Red and yellow flag questions Week 2 - Assessment and Examination 37 Subjective Examination Your subjective examination helps you to determine the extent of the injury, how the injury affects the patient’s function and quality of life, what you should include in the objective examination and how aggressively you can perform the objective examination Pain Profile: Where is the pain? Is it referring? Is it constant or intermittent? What is the nature of the pain? Intensity? VAS? Aggravating and easing factors? Are there variations throughout the day? Does the pain wake the client at night? How irritable is the pain? Week 2 - Assessment and Examination 38 Objective Examination Look for observable signs and effects of the injury Determine the structures involved and the extent of the injury Produce a comparable sign (reproduce the pain) Should be planned (even if just mentally) Remain open-minded Week 2 - Assessment and Examination 39 Observation and Visual Inspection Begins as soon as you first see the client – posture, movement and compensatory movements Assistive devices? For example, crutches – gait re-training Muscle guarding, “carrying” an injury Postural assessment Patterns of muscle tightness and weakness Signs of trauma Oedema Discolouration Rash Wound Deformity Muscle atrophy Week 2 - Assessment and Examination 40 Active ROM Movement of a joint produced by the patient without assistance Affected by pain, strength and available joint ROM Active ROM can be useful to obtain information regarding oedema, a tightened joint capsule/ligaments, muscle spasm, fracture/osteophyte and apprehension Can have the patient perform the movement across gravity if they are too weak to move the injured body part against gravity Quality of movement? Pain? Use of a goniometer Week 2 - Assessment and Examination 41 Passive ROM Movement of a joint produced by the clinician – no muscle contraction from the patient Pain? PROM should be greater AROM Pain is typically caused by stretch of a ligament, a joint capsule or a muscle End-feel (next slide) can be assessed using a moderate over-pressure This will not cause pain in normal tissue Week 2 - Assessment and Examination 42 End-Feel of Movement End-Feel – The nature of the resistance you feel at end-ROM Capsular – Firm, but not hard Bony – Hard Soft – Muscle approximation or oedema Week 2 - Assessment and Examination 43 ROM The ROM or mobility of a joint can be normal, hypermobile (excessive) or hypomobile (less than normal) Keep in mind that athletes may demonstrate mobility patterns that fall outside the normal expected ranges For example, baseball players (and other throwing athletes, such as javelin throwers) tend to have a decreased amount of glenohumeral joint internal rotation (and greater external rotation) in their throwing shoulder Gymnasts tend to demonstrate an excessive amount of joint mobility at a number of joints Joints that are hypomobile may be so because of either muscle spasms or capsular restrictions Week 2 - Assessment and Examination 44 Muscle Strength – Manual Muscle Testing Manual muscle testing is used to test contractile tissue – muscle, tendon and nerve Mid-range, end-range and full range strength testing Can be done both eccentrically and concentrically Week 2 - Assessment and Examination 45 Special Tests Avoid special tests if a fracture or dislocation is suspected, or if the patient is in a lot of pain Special tests help to distinguish muscle, ligament, tendon, joint surface and nerve injuries Joint stability tests, such as Lachman’s Test Manual force applied to put strain on the joint capsule or ligament Compression tests assess the articular cartilage and menisci, such as Apley’s Test Week 2 - Assessment and Examination 46 Neurological Tests Neurological testing includes examination of sensory, motor and reflex parameters These testing procedures can be used if you suspect nerve root impingement, peripheral nerve entrapment, nerve compression syndromes or central nervous system damage Neurological testing can be performed if the patient experiences radicular symptoms extending into the upper or lower extremities or complains of numbness or tingling Week 2 - Assessment and Examination 47 Touch/Palpation Touch/palpation is performed last to avoid irritating the tissue before the other tests Skin Temperature Tone Oedema Fascia, muscles, ligaments and tendons – tenderness, trigger points and crepitus Start superficial and progress deeper as needed Compare the injured and uninjured sides Can determine which structures and which type of tissue is involved Week 2 - Assessment and Examination 48 Functional Testing Not always performed during the initial consult, but is an important follow-up measure to track a patient’s progress Determines painful activities, the injured part’s ability to perform an activity and quality of movement (compensation strategies) Can assess agility, coordination and proprioception – smoothness of movement, ROM and quality of performance Should ideally be activity- or sport-specific Overhead or single leg squat, jumping, running, etc. Advanced functional tests include performance-specific skills such as serving in tennis or bowling in cricket Compare to pre-injury scores or norms if possible Week 2 - Assessment and Examination 49 Outcome Measures Check the research and recommendations behind each outcome measure before electing to use it (ie. validity, accuracy and reliability) https://www.sralab.org/rehabilitation-measures Physitrack app ESSA’s Outcome Measures for Exercise Physiologists – Can be purchased through the ESSA site Week 2 - Assessment and Examination 50 Assessment – Interpreting the Results Differential diagnosis (list of potential problems used to plan specific treatment) Based on subjective and objective findings Tests your ability to recognise signs and symptoms, and then utilise your problem-solving skills If in doubt, always seek the advice of a diagnostic clinician The assessment, whilst strictly non-diagnostic as per the AEP Scope of Practice, is used to inform your course of treatment With the patient’s input, create SMART goals for each identified issue Week 2 - Assessment and Examination 51 Plan Goals for treatment – Create a goal for each problem identified Start with long-term goals and then generate short-term goals if required A treatment plan is then generated to achieve the goals Consider the frequency, duration and components of treatment As short-term goals are met, new ones are created Once long-term goals are achieved, the patient is ready to return to activities Week 2 - Assessment and Examination 52 Recording Examination Findings and Treatment Sessions For a number of reasons you should keep thorough but concise medical records They can be referred to later to determine progress They can be used to facilitate communication with other rehabilitation clinicians to provide consistent patient care They are legal documents and can be used to demonstrate compliance with all applicable regulations They may also be used for research and outcomes analysis Because medical records are legal documents, all records that are not typed must be recorded clearly and legibly in pen, not pencil. Recorded items should not be erased, blacked out, or covered with correction fluid or tape. An error should be corrected with one line drawn through it and your initials and the date next to it, indicating that you have altered the record. You should always sign or initial the record after completing documentation Week 2 - Assessment and Examination 53 Recording Examination Findings and Treatment Sessions A common method of treatment session record keeping is the SOAP (Subjective, Objective, Assessment and Plan) note SOAP notes are the most universally used system of problem-oriented record keeping in the medical profession Subjective Subjective notes are what the patient says. Direct quotes with quotation marks can be used A common mistake is to put the clinician’s impressions or assessments in this category Objective Objective notes record what is done in the treatment session that day. They also include any objective measurements or examination and test results Specific exercises can be noted, including weights and reps, or an exercise record sheet or grid can be used where that information is included Week 2 - Assessment and Examination 54 Recording Examination Findings and Treatment Sessions Assessment The assessment recorded for the treatment session is your interpretation of the problems being addressed and how the patient and the injury responded to the treatment that day. Here are some examples: – Patient continues to walk with an antalgic gait secondary to pain in the medial knee joint – Patient’s ROM and strength are improving but remain deficient Plan This is the near-future treatment plan. What will you do with the patient at the next treatment session? It may not always be adhered to during the succeeding treatment session, depending on the patient’s response to the previous treatment Week 2 - Assessment and Examination 55 Recording Examination Findings Week 2 - Assessment and Examination 56 Recording Examination Findings Week 2 - Assessment and Examination 57 Recording Treatment Sessions Week 2 - Assessment and Examination 58 Recording Treatment Sessions Week 2 - Assessment and Examination 59 Recording Treatment Sessions Week 2 - Assessment and Examination 60 Examination and Assessment CREATING THE REHAB PROGRAM Program Contents The contents of any rehabilitation program are dependent upon The type and severity of the injury The body part/s involved The patient’s health, age and activity level The patient’s physical, emotional and psychological response to the injury The patient’s goals Week 2 - Assessment and Examination 62 Examination Irritability of the injury Highly irritable – less demanding/active rehab initially Low irritability – can begin with more aggressive exercise rehab Continual assessment Monitor patient responses within and between sessions Observe the quality of their movements Re-assess outcome measures regularly to monitor progress Week 2 - Assessment and Examination 63 Maintenance of Conditioning Level Physical activity level may decline as a consequence of joint/limb immobilisation/rest Sedentary behaviour is an independent health risk factor for disease You may need to get creative – come up with ways to keep your patient active whilst adequately resting the injury Week 2 - Assessment and Examination 64 Phases of Rehabilitation and Therapeutic Exercise Phase 1: Inactive Phase Control inflammation, spasm, pain and oedema Maintain overall conditioning PRICE (Protect, Rest, Ice, Compression, Elevation) Short- and long-term goal planning and setting Patient education and instruction Week 2 - Assessment and Examination 65 Phases of Rehabilitation and Therapeutic Exercise Phase 1: Inactive Phase Exercise is not advised during the inflammation phase (remember this is only quite short: 2 – 3 days) During the inflammation phase, the strongest element protecting the injured microvessels is the tenuous fibrin clot. This structure is easily damaged by forces applied to it Any new bleeding restarts the inflammation process from the beginning, ultimately adding to the healing time Exercise applied to the damaged tissues during this time exacerbates the injury, resulting in additional tissue damage Week 2 - Assessment and Examination 66 Phases of Rehabilitation and Therapeutic Exercise Phase 2: Active Phase Pain and oedema are under control Focus on mobility – joint range of motion and tissue flexibility Mostly passive with some gentle active exercises – monitor symptoms Strength – isometric and light isotonic exercises Week 2 - Assessment and Examination 67 Phases of Rehabilitation and Therapeutic Exercise Phase 2: Active Phase If the clinician misjudges either the amount of stress applied by an activity or the tissue’s ability to withstand that stress, the patient will report increased pain or swelling from that rehabilitation session. There may also be a reduction in function This judgement error occurs to even the most experienced clinicians, but its outcome serves as an important tool for providing an indication of how much stress the tissues can tolerate The clinician now has a more accurate idea of the healing structure’s limits and can more accurately predict when to re-try this previously harmful activity Week 2 - Assessment and Examination 68 Phases of Rehabilitation and Therapeutic Exercise Phase 2: Active Phase The most effective gains in ROM are made during the first 3 – 8 weeks after injury Changes in ROM can be made relatively easily with new scar tissue because its higher water content and greater amount of glycosaminoglycans (GAG) restrict cross-link formations in the earlier stages of Type I collagen formation. This structural arrangement allows a stretch force to have a more effective impact on tissue lengthening during this time It is mechanically easier to change new scar tissue than it is to affect the length of older scar tissue As scar tissue becomes more mature with the passage of time, it becomes more resistant to change by external forces applied to it because of its reduced fluid and GAG content and its more numerous collagen cross-links Week 2 - Assessment and Examination 69 Phases of Rehabilitation and Therapeutic Exercise Phase 3: Resistive Phase Build strength, endurance and agility Single plane, progressing to multi-plane and functional movements Low load, high reps to begin with Proprioception Maintain ROM and flexibility Week 2 - Assessment and Examination 70 Phases of Rehabilitation and Therapeutic Exercise Phase 4: Aggressive / Advanced Phase Functional and performance-specific levels of training Restore power, coordination and agility Functional exercises – use a lower load, speed and force to begin with Performance-specific: competition-level training Week 2 - Assessment and Examination 71 Phases of Rehabilitation and Therapeutic Exercise The duration of each rehabilitation phase depends on many factors, including: Injury type and severity Age and condition of the patient Psychosocial factors Compliance with the rehabilitation program (both in-clinic and at home) Week 2 - Assessment and Examination 72 Phases of Rehabilitation and Therapeutic Exercise Week 2 - Assessment and Examination 73 Phases of Rehabilitation and Therapeutic Exercise Week 2 - Assessment and Examination 74 Phases of Rehabilitation and Therapeutic Exercise Week 2 - Assessment and Examination 75 Exercise Continuum Bayer et al. (2017). Early vs. Delayed Rehab After Acute Muscle Injury Patients who received early intervention had a median 21 days shorter time for return to play when compared with a delayed intervention group Mainly quadriceps and calf sports-related injuries Early rehab group commenced rehab 2 days post-injury, where-as the delayed intervention group commenced 9 days post-injury All patients followed a standardised 4-stage rehabilitation program over a 12- week period Week 2 - Assessment and Examination 76 Exercise Continuum Week 2 - Assessment and Examination 77 Individualisation of Rehabilitation Each client will progress at different rates and respond differently to rehab Re-assess continually (including outcome measures) Challenge the client, but do not over-stress and aggravate the injury Regularly discuss progression with the client in relation to their short- and long-term goals In situations of long-term injury and chronic pain, ideally progress to self- management “An individual’s ability to manage the symptoms, treatment, physical and psychological consequences and lifestyle changes inherent with living with a chronic condition.” Week 2 - Assessment and Examination 78 Concepts of Healing Week 2 - Assessment and Examination 79

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