Orthopedic Conditions & Assessment PDF

Orthopedic Conditions & Assessment We e k 1 4 Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives Screen and identify pertinent red flags Screen and identify pertinent yellow flags Discuss pain sensation and specific tissues Describe stages of injury and healing and the treatment goals at...

Orthopedic Conditions & Assessment We e k 1 4 Dr. Albert Iarz, ND, RMT BMS 150 Lab Learning Objectives Screen and identify pertinent red flags Screen and identify pertinent yellow flags Discuss pain sensation and specific tissues Describe stages of injury and healing and the treatment goals at each stage Compare and contrast normal end feels to pathologic end feels Define muscle spasm and guarding Red Flags Fractures Dislocations Infections Compartment syndrome You will learn about many more when we start discussing orthopedic adjustments Red Flags Fractures Hx of significant trauma? Older than 55? Dark black bruising? Four step test (4 steps without pain or altered gait?) Resisted isometric contraction Percussion – light palpation Pain with squeezing of the bone 128 Hz tuning fork or set your phone to vibrate and place on bone Inability to move damaged area? Dislocations *Neurovascular screen, ER Red Flags Compartment Syndrome Neurovascular screen, ER *5Ps pain, pallor (pale skin tone), paresthesia (numbness feeling), pulselessness (faint pulse) and paralysis (weakness with movements) *Vitals Labs: CBC, ESR, CRP I: erythema, streaking P: disproportional tenderness, increased warmth, spinal percussion Hx: IV drug use, steroid use, dental abscess, recent infection etc. Tissue Sensitivity to Pain Skin Most Sensitive Periosteum Fibrous Capsule Tendons ↓ Ligaments Subchondral Bone Cortical Bone ↓ Muscle Fascia Synovium Least Sensitive Fibrocartilage Articular Cartilage Pain & Specific Tissues Condition AROM PROM RROM Pain Muscle Injury ↓AROM WNL Pain Dull ache- sharp pain when (Strain or (Painful) (Pain at challenged tendinopathy) end ROM) Pain with palpation, stretching or contraction of damaged muscle (possible) weakness) Unidirectional pain with motion in muscle fibre direction Fascial Strain ↓AROM ↓PROM WNL May have palpatory (Painful) (Painful) (no subcutaneous adhesions, limited pain) ROM or non-dermatomal pain and posture changes Pain & Specific Tissues Condition AROM PROM RROM Pain Ligament Injury ↓AROM ↓PROM WNL Injured at full end ROM with (Sprain) (Painful) (Painful) (no tearing pain) Pain with palpation or stretching of ligament (passive over pressure) Instability due to full ligament rupture may show empty end feel, increase PROM or ‘clunk’ Capsulitis ↓AROM ↓PROM WNL Pain with direct capsule palpation (Painful) (Painful) (no or multidirectional pain with pain) motion – pain in a single direction indicates muscles or tendon damage Pain & Specific Tissues Condition AROM PROM RROM Pain Joint Injury ↓AROM ↓PROM WNL Mild loss of ROM or pain (arthropathy) (Painful) (Painful) (no Crepitus with scour test pain) AROM may show repeatable ‘snapping’ or ‘popping’ Pain may change with weather Joint WNL or Limited in WNL or Pain or point tenderness dysfunction limited specific weak Asymmetry/misalignment (subluxation) segmental ROM PROM abnormality or restriction ROM –joint ‘feels stuck’ Pain & Specific Tissues Condition AROM PROM RROM Pain Bone Injury ↓AROM ↓PROM ↓PROM Hx of trauma - perform fracture (fracture) (Painful) (Painful) (Painful) screen Pinpoint tenderness, dull ache but very sharp when challenged Nerve Injury ↓ or ↓ or ↓ or Numbness, tingling, or muscle WNL WNL WNL weakness & shooting electrical pain with compression of the nerve Tissue Stages of Healing Stages of Healing GOOD PAIN VS ACUTE PHASE (1-5 days) Main goals: BAD PAIN? Relieve pain Prevent muscle atrophy Re-establish pain-free ROM & normalize biomechanical function – support inflammation and the normal process of healing Low pain motion is key – the sooner you move the better the outcome will be Stages of Healing ACUTE PHASE (1-5 days) Treatment principles: METH – CI in compartment syndrome Protect – DO NOT re-injure damaged tissue (develop chronicity & delay healing) Relative Rest – short term cessation of use (1-2 days max)- continued excessive activity may cause further injury and delay healing Relaxation massage & breathing Stages of Healing POST-ACUTE PHASE (~2 days-6 weeks) Main goals: Normalize ROM & biomechanics, perform symptom free daily activities & improve neuromuscular control & muscle strength Prevent muscle atrophy Re-establish pain-free ROM & normalize biomechanical function – support inflammation and the normal process of healing Stages of Healing POST-ACUTE PHASE (~2 days-6 weeks) Treatment principles: Warm up prior to activity: key goal is restoring integrity & strength of dynamic & static stabilizers Isometrics progress to concentric exercises and then to eccentric exercises & finally to active/sport-specific exercises. AROM & mild strengthening activates: Massage Aquatic therapy **Pain free, submaximal exercise Stages of Healing FUNCTIONAL STAGE (2 week-6 months) Main Goals: Maintain a high level of ability Prevent tissue contracture & recurrence of injury Maintain normal biomechanical function Stages of Healing FUNCTIONAL STAGE (2 week-6 months) Treatment Principles: Normal gait pattern & fast walking If they can walk 20-30 minutes at a fast speed without pain or stiffness, short periods of jogging can be added to fast walking During later stages: sport massage and plyometric exercises to increase speed and power Importance of mental training/toughness, self talk & visualization cannot be overstated Stages of Healing REMODELING PHASE (3 weeks-12+months) Main goals: Maintain a high level of ability Prevent tissue contracture & recurrence of injury Maintain normal biomechanical function Stages of Healing REMODELING PHASE (3 weeks-12+months) Treatment Principles: Massage and IASTM – reduce scar tissue & promote healing Begin unilaterally with weights, using low weight and higher repetitions to monitor form & technique; slowly increase the weight as tolerated as long as pain/inflammation is not increased afterwards DO NOT increase weight or intensity too rapidly, can cause chronic injury (10% per week max) Warm up and post activity stretching are essential; address other compensations (posture, activations, imbalance, ergonomics)  Treatment Guideline Summary Phase Time Clinical Objective Course Acute 2-3 d (up Reduce pain: PRICE or METH as indicated to 7d) Emergency referral if required, prevent excess swelling/ ischemia Basic PFROM, activity as tolerated and relaxation massage Address psychosocial concerns (anxiety) Post- 2d – 6wk Pain reduction, prevent early scar tissue adhesion Acute Begin orienting repair tissue along line of tension Maintain normal muscle tone, ROM & functional capacity Basic stretch, strength, functional & proprioceptive training Chronic 2wks – Proper loading of repair collagen & myofascial tissue 12+mos Increase elasticity of scar tissue (increase ROM & strength Reduce fibrotic adhesion, relieve muscle spasms Advanced stretch, strength, functional & proprioceptive training Address psychosocial concerns (yellow flags) Yellow Flags – look familiar?! If the patient is not progressing as expected after 4-6 weeks (e.g. severe pain, pain is increasingly complex, multiple pain sites) Assess for biopsychosocial factors (Yellow Flags) that may indicate risk for developing persistent pain and disability Consider asking “How is the pain affecting the rest of your life?”  Yellow Flags Physical Factors Psychological Factors Social Context Lack of activity/prior Depression Injured at work; low job deconditioning Anxiety satisfaction; challenging Increasing age (levels out at Post-Traumatic Stress work relationships; age 60) Disorder (PTSD) awareness of work safety Early and high levels of Adverse Childhood issues disability Experiences On-going litigation or Duration or intensity of History of sexual abuse compensation issues pain, disproportional to Anger, fear, hypervigilance Poor support structure mechanism of injury Past/present history of (family and social) Family Multiple somatic substance use history of chronic pain complaints such as fatigue, Motor Vehicle Accident insomnia, anorexia Vulnerable populations Poor sleep (e.g., social determinants of Previous injury and/or health such as poverty, lack comorbid conditions, of stable housing, physical particularly if prolonged or mental/ cognitive recovery challenges, language and cultural barriers, frail  End Play (End Feel Types) NO End Play Definition (Example) RM Tissue Stretch Near end ROM hard/firm type of movement limited by AL tension in muscle & fascia i.e. cervical lateral flexion Soft Tissue Squeezing quality, near end ROM where soft tissue Approximation compression prevent further motion i.e. elbow flexion Ligamentous Hard, firm, painless ROM, limited by tension in ligament i.e. normal knee extension Bone to Bone Hard, non-giving, painless end ROM i.e. elbow extension  End Play (End Feel Types) AB End Play Definition (Example) NO Bone to Bone Painful, hard end feel RM i.e. osteophyte formation, ankylosis (fusion) AL Muscle Spasm Guarding or splinting feel caused by movement reduction secondary to reactive myoplasm to protect the injured tissues i.e. instability, trauma Capsular Firm, decreased ROM accompanied with pain, but not myospasm; synonym: boggy end feel i.e. edema, adhesions, synovitis, adhesive capsulitis Springy block Bouncing or springy, seen in joints with menisci (knee mainly), associated rebound effect i.e. internal derangement, meniscal lesion Empty Lack of normal end ROM resistance, usually associate with an increase ROM i.e. instability, hypermobility, ligament rupture Muscle Spasm and Guarding Following injury muscle within an affected area will contract to splint the area in an effort to minimize pain through limitation of motion. Involuntary muscle contraction in response to pain following an injury Spasm usually indicates increased tone due to upper motor neuron lesion in the brain  Exercise Medicine and Physical Activity Promotion Dr. Albert Iarz, ND, RMT BMS 150 Lab  Learning Objectives Identify barriers to physical activity (history and attitude towards it) Identify and utilize 2 models geared towards behaviour change Learn how to target exercise advice towards your patient Learn strategies to increase adoption and adherence to exercise prescriptions Please note that this information will be considered “Testable” material for your final BMS150 written exam  Topics that will be covered Foundations of behaviour change Socioeconomic Barriers to physical activity Strategies to increase adoptions and adherence to exercise prescriptions Cognitive and behavioural strategies  Models for behaviour Change Transtheoretical Model Health Belief Model TRANSTHEORETICAL MODEL Is a model that has integrated main principles of change and behaviour interventions from many different theories. It’s focus is on creating STAGES of change based on how ready an individual may be for that change It also takes into account a person’s openness to adopt healthier behaviour for the long term TRANSTHEORETICAL MODEL This model helps to specifically target those individuals that may have been non-compliant to former interventions and may be very reluctant to change This approach can help point out that long-term behaviour change is more of a long term process and allows for progress as well as regression between stages TRANSTHEORETICAL MODEL STAGES Pre-Contemplation Contemplation Preparation Action Maintenance  PRE-CONTEMPLATION STAGE Change may occur in the next 14 months Individual is NOT intending to take any action at the moment Individual may be uninformed or under informed about the POOR health effects that their continued lack of action is causing Individuals shy away from discussing their “high-risk” behaviours with other. Even go so far as to avoid reading or thinking about it  PRE-CONTEMPLATION STAGE INTERVENTION Do not push the idea of exercise Simply provide the Pros or Benefits to exercise for their situation Explore any mis-information Help your patients see how “doing nothing” could impact not just their health, but their children or spouse CONTEMPLATION STAGE Change is expected to occur in the next 6 months Individuals at this stage have mixed emotions about making the change They want to, they have been thinking about it, maybe even getting information about it. But still hesitant. This stage is all about “Can I do it” vs “What are the benefits”  CONTEMPLATION STAGE INTERVENTIONS Identify barriers to exercise and try to find solutions to them Looks into their self-efficacy and how to build that Discuss that starting out does NOT have to be all or nothing. It can occur with SMALL steps which will lead to gains and those gains can motivate to keep going.  PREPARATION STAGE The time for change is occurring within the month Individuals here already have an action plan and have taken steps to ensure they are ready They are willing to listen and put into action a treatment or exercise plan  PREPARATION STAGE INTERVENTIONS At this stage, helping the individual develop a plan that meets their goals Work on goal setting, short achievable goals and long term goals Look into rewards for each step or goal obtained Teach self monitoring techniques, as to avoid relapse of non-activity Build in reminders to keep active  ACTION STAGE This stage is over the next 6 months Change is occurring daily and must be kept into action for 6 months The change occurring must also be enough to warrant reduction in risks of disease or benefits to health overall  ACTION STAGE INTERVENTION Individuals at this stage need positive reinforcement and feedback Looks into different activities to avoid boredom or burnout Discuss relapse prevention Discuss rewards to maintain motivation  MAINTENANCE STAGE This is from 6 months to 5 years roughly At this stage, individuals are maintaining their action plan and working to prevent relapse Individuals are less tempted into relapse and is increasingly confident that they can sustain changes made  MAINTENANCE STAGE INTERVENTIONS Continued support HEALTH BELIEF MODEL Comprised of similar stages but more reliant on perception vs stages Focus is on convincing the individual that change will benefit their health without a doubt. Even better is benefit can outweigh the costs. The key here is that patients understand personal risk and health related benefits, thus strengthening their sense of self and self efficacy Self-efficacy is influenced by many factors and must be addressed HEALTH BELIEF MODEL 6 Categories that are all intertwined Perceived Susceptibility Perceived Severity Perceived Benefits Perceived Barriers Cues to Action Self Efficacy PERCEIVED SUSCEPTIBILITY This is the individuals belief that a health condition or disease can affect them How much at “RISK” does your patient believe they are in? Excuses or facts could be: Being to young Not being a smoker Or just ignorance to facts PERCEIVED SUSCEPTIBILITY INTERVENTIONS Educate them on specific populations and their risk levels Personalize the risk more, based on your patients individual characteristics or behaviours The goal is to help your patient perceive their actual risk or such and such of a condition  PERCEIVED SEVERITY This is the belief in the seriousness of a condition and the consequences attached to that condition Example could be Diabetes and Foot Amputation Or shoulder dislocation and the increased likelihood that it will happen again and easier  PERCEIVED SEVERITY INTERVENTION Simply educate patient on their specific condition and the factual consequences or ignoring it  PERCEIVED BENEFIT This is where the patient must believe that the advised action to reduce the risk or seriousness of their condition can be achieved. Example of exercise to stabilize GH capsule/ Shoulder girdle to prevent further dislocation  PERCEIVED BENEFIT INTERVENTION Focus here is describing exactly how to do the action/ exercise Clarify the positive effects that are expected and why Give a timeline of benefit  PERCEIVED BARRIERS The individual here needs to understand that the advised action is attainable and the cost (psychological, financial, social) is worth the benefit  PERCEIVED BARRIERS INTERVENTION At this point, try to identify any misinformation and barriers Also add in some reassurance, incentives, and assistance where needed.  CUES TO ACTION Here is where you discuss any strategy to help the patient get ready for the proposed action Provide information and a reminder system  SELF-EFFICACY By definition, it is the confidence in one’s own ability to take action This is key to help build and the force that keeps your patient going SOCIOECONOMIC BARRIERS TO PHYSICAL ACTIVITY Social characteristics Age Gender Race Socioeconomic status SOCIOECONOMIC BARRIERS TO PHYSICAL ACTIVITY Those that are more socially advantaged by having more resources or money are more likely to engage in physical activity because it would be easier to do so They would have more time Be able to pay for memberships or equipment With lower income, access may not be as simple as walking down the street. There may not be recreational facilities or green spaces where they could engage in physical activity SOCIOECONOMIC BARRIERS TO PHYSICAL ACTIVITY Thus as a practitioner, you MUST tailor make your physical activity plan to your patient’s social characteristics in order to be successful. Telling a patient who is living paycheque to paycheque to simply join a gym won’t help Or getting that same patient to buy gym equipment STRATEGIES TO INCREASE EXERCISE ADOPTION AND ADHERENCE Our job as practitioners is to support patients by strengthening their motivation and thus their capabilities in becoming more physically active We need to provide them with the tools to achieve that As practitioners, we have a lot of influence over our patients due to the inherent power dynamic or Doctor- Patient and thus we need to be aware that our words and advice carry a lot of weight.  MOTIVATIONAL INTERVIEWING A person-centered approach to providing support and advice It is used to enact changes in behaviours in a wide range of healthcare settings It looks into being more respectful towards your patient as a whole and thus less combative. It adopts a more guiding style vs direct style to encourage patient motivation and thus increase their success.  MOTIVATIONAL INTERVIEWING There are 3 factors to be mindful of when trying to engage in motivational interviewing 1. Adopt a “GUIDING” style vs an expert position 2. This is a collaborative process. All the patient to express their ideas on how they can adopt a healthier lifestyle 3. Engage in talk that focuses on change and try to direct that change into the patients own desires. Additional information may be required with permission from the patient  FITT-VP MODEL These factors are important to identify when prescribing Physical Activity to your patient Type of Activity Volume or Dose of activity (FITT-VP) Greatest effect on the target disease (Which exercises) Contraindications to a specific type or intensity of activity prescribed  FITT-VP MODEL Frequency Intensity Time Type Volume Progression of Activity  FITT-VP MODEL Frequency The # of training sessions within a week So 3 times per week or 7 times per week  FITT-VP MODEL Intensity (relative) For a certain activity, the intensity for that specific individual based on current aerobic fitness Strength training may be described based on 1 Rep maxes, where a % is taken from that max and translated into reps Or can be taken as a goal of strengthening and/or toning and thus higher weight for strength with less reps or lower weight with more reps for toning. Ask patient to lift a weight that you believe or feel that they can lift 15-20 times and gauge it off of that.  FITT-VP MODEL Time The total time of each session as a whole in minutes usually (Aerobic) Combine reps and sets for a total time (Strength)  FITT-VP MODEL Type Either aerobic or strength(resistance)  FITT-VP MODEL Volume Taking the intensity of the activity into account and multiplying by the number of session per week. Looking to see if high intensity with a lower number of session per week would be more beneficial or harmful vs lower intensity and more sessions.  FITT-VP MODEL Progression Keep in mind your patients current physical activity level Do not push a patient from 0 activity to 7 days per week. The risk of injury is too high. Take into account a slow progress and account for muscle soreness.  References 1. Canvas Website: Exercises and Change Module, accessed Feb 14, 2023