1
Q
Sensitivity Vs Specificity
A
Sensitivity is the rate of a true positive
Vs
Specificity is the rate of a true negative
2
Q
SnOut
A
Sensitivty/rule it out (negative)
- Highly sensitive test are good for ruling out a condition when the test for it is negative
3
Q
SpIN
A
Specificit/rule IN (positive)
Highly specific test are food for ruling in a condition when the test is positive
4
Q
+LR
A
Increases in the probability of a condition being present if the test is positive >1
The further above 1 the greater the odds they actually do have it
5
Q
-LR
A
Decrease in probability of a condition being absent if test is negative <1
The further below 1 the greater the odds they actually don’t have it
6
Q
CPT Category: Therex
A
- develop/restore strength, endurance, ROM, flexibility
- Active/Active assist, passive
- progressive resistive exercises
- stretches
7
Q
CPT Category: Neuromuscular retraining
A
- Movement, balance, coordination, kinesthetic sense, posture, proprioception
- PNF, dynamic balance activity to establish proprioception
8
Q
CPT Category: Gait training
A
- retraining locomotion after a significant change in function
- Stair training
9
Q
CPT Category: Manual Therapy
A
- connective tissue message, joint mobilizations, manipulation, manual traction, PROM with manual, soft tissue mobilizations, therapeutic massage
- Administered with the hands
10
Q
CPT Category: Therapeutic Activities
A
- Use of dynamic activities to improve functional performance for specific body part of whole body directed at a loss of restriction of mobility, strength, balance, coordination and specific functional outcome
- Lifting , carrying, pulling, pinching, grasping, crawling, climbing, throwing’s, catching, jumping, car transfers, sport specific, work specific
11
Q
CPT Category: Self care training
A
- Training ADL’s, compensatory training, meal preparation, safety procedures, instruction of adaptive equipment
- Bathing, grooming, dressing, personal hygiene, household cleaning, chores, energy conservation, adaptive equipment
12
Q
Joint Mobs: Glenohumeral Joint
Abduction
Extension
ER
IR
Flexion
A
- Abduction= inferior glide
- Extension = anterior glide
- ER= anterior glide
- IR= posterior glide
- Flexion = posterior glide
13
Q
Joint Mobs: Scapulothoracic
Elevation
Depression
Flexion
Adduction
Abduction
A
Elevation= Superior glide
Depression= Inferior glide
Flexion= Upward rotation
Adduction= medial glide
Abduction= Lateral glide
14
Q
Joint Mobs: Sternoclavicular
Elevation
Depression
Protraction
A
Elevation= inferior glide
Depression= superior glide
Protraction/Retraction= posterior glide
15
Q
Joint Mobs: ACJ joint
UR/Elevation
DR/Depression
Protraction/IR
Retraction/ER
A
UR/Elevation= Inferior glide
DR/Depression= superior glide
Protraction/IR= Anterior glide
Retraction/ER= Posterior glide
16
Q
Joint Mobs: Humeroulnar
A
Distraction/Compression
17
Q
Joint Mobs: Humeroradialulnar
A
Medial/lateral gapping
18
Q
Joint Mobs: PRUJ
Pronation
Supination
A
Pronation= posterior glide (PPP= proximal pronation posterior)
Supination= anterior glide
19
Q
Joint Mobs: DRUJ
Flexion
Extension
Pronation
Supination
A
Flexion= anterior glide
Extension= posterior glide
Pronation= anterior glide
Supination = posterior glide
20
Q
Joint Mobs: Radiocarpal
Flexion
Extension
RD
UD
A
Flexion= posterior glide/pronation
Extension = anterior glide/supination
RD= Medial glide
UD = lateral glide
21
Q
Joint Mobs: Midcarpal
Flexion
Extension
RD
UD
A
Flexion= posterior glide/pronation
Extension = anterior glide/supination
RD= Medial glide
UD = lateral glide
22
Q
Joint Mobs: Coxafemoral
Flexion
Extension
Abduction
IR
ER
A
Flexion = posterior glide
Extension= anterior glide
Abduction= inferior glide
IR = posterior glide
ER = anterior glide
23
Q
Joint Mobs: Tibiofemoral
Flexion
Extension
A
Flexion= posterior glide
Extension= Anterior glide
24
Q
Joint Mobs: Patellarfemoral
Flexion
Extension
A
Flexion= inferior glide
Extension = superior glide
25
Joint Mobs: Tibiofibular
Flexion
Extension
Flexion= Anterior glide
Extension= Posterior glide
26
Joint Mobs: Distal Tibiofibular
DF
PF
DF= Posterior glide
PF= anterior glide
27
Joint Mobs: Talocrural
DF
PF
DF= posterior glide
PF= anterior glide
28
Joint Mobs: Subtalar
Inversion
Eversion
Inversion= medial glide
Eversion= lateral glide
29
Hierarchy of Interventions
Pain
Mobility
Stability
Movement
Work
Strength
Power
Speed
30
Hemostasis Healing Phase
- 0-6/8 hours : can last 1-2 days
- Goal : Stop bleeding
- Cellular and vascular cascade from damage: local vasoconstriction: clot formation: fibroblasts drawn to area by growth factors to repair ECM
- Management by protective phase
support healing
Restore full PROM, prevent atrophy, maintain soft tissue integrity
PRICEMEM
31
Inflammatory Healing Phase
0 hours-2 weeks
Peaks at 2-3 hours
- Clean up wound site- prepare for construction
- Clinical signs: rubor, calor, tumor, dolor, function loss, swelling, redness, heat
- Passive movement pain
- Protective phase= control pain/edema, restore full PROM, prevent atrophy, maintain soft tissue integrity , PRICEMEM
32
Proliferative Phase of Wound Healing
4-22 days peak 2-3 weeks bulk of scar tissue is formed
- Rebuild damaged structures and strengthen wound
- Proliferation of fibroblasts--> drawn in by platelets macrophages--> lay down collagen
- Clinical Sign= decrease in pain, erythema resolved, no active effusion, increase pain free AROM/PROM, pain is felt at point in tissue resistance
- Management= controlled motion phase
tolerance of increased strengthening , create a strong extensible scar
Interventions= education, transition from passive toward progressive stress of tissue
33
Remodeling Phase
Few days to 2 years
- Modify scar tissue into its mature form
- process of collagen turnover/reabsorption and deposition
- Myofibroblasts pull wound edges together to contract wound
- At 3 weeks only 30% scar strength
- At 3 months 80% scar strength
- Progression to pain free function and activity- pain is felt at end range of passive movements after tissue resistance is met
- Return to function phase
Gradual return to full and pain free range then progressive increase in speed and neuromuscular control
Work/Sport related specific movements
34
Healing Potential Low to high
(low) Cartilage--> Meniscus--> ligament--> tendon--> bone--> muscle
35
Protective Phase
PRICEMEM- inflammation phase
Pt education
PROM, AAROM, AROM
36
Controlled Motion Phase
Proliferative phase
AAROM, AROM, Flexibility
Submaximal isometrics--> multiangle submax isometrics--> multiangle max isometrics--> PREs
Simple safe balance proprioception activities
Corrective exercise of associated biomechanical deficiencies
37
Return to Function Phase
Remodeling phase
Endurance and maximizing strength, concentric--> eccentric training
General return to activity- 80% strength of unaffected contralateral
Speed, power, agility
38
Re-Injury Prevention Phase
and COmplications
Education on proper warm up
Holistic conditioning
Maintenance of flexibility/strength
Immobilization/disuse-less force, less tolerance to lengthening
Reinjury
Fibrosis
NSAIDs induce impairment in functional capacity histology when administered at later points
39
Peak Growth For Boys and girls
Boys = 14-15
Girls= 12-13
40
Peds Manual Therapy Considerations
- Literature is not definitive
Physical, psychological, emotional response
Structures: less ridged/more flexible
Joint mobility changes with age and conditions
Communication
Ability to Gauge responses
Parental facilitators
Neuro impairments can be more involved than orthopedic impairments
41
Neuromatrix Theory of pain
1. The brain and spinal cord are what produce the pain not the tissue damage
2. Various parts of the CNS work together to produce pain
Nociception + threat= pain
42
Nociceptive pain
Localized and proportionate to injury
43
Nociplastic/central sensitization
Amplification of neural signaling in the CNS that creates pain hypersensitivity
44
Central Sensitization
Disproportionate pain
Diffuse Pain
>40 on CSI
45
Pain Catastrophizing Scale
1. Rumination= attention
2. Magnification = exaggeration
3. Helplessness= low self-efficacy
46
Stress stages
1. Stimuli from one or more of the 5 senses are sent to the brain
2. The brain deciphers the stimulus as either a threat or non-threat
3. The body stays activated or aroused until the threat is over
4. The body returns to homeostasis once threat is gone
- Cortisol inhibits hypothalamus and pituitary
- Low cortisol levels impair ability to control inflammation
47
What are the cortical changes in response to pain?
- Size changes: body representation grows
- With cortical changes the discrimination usually gets bigger
- Sensation localization + graphesthesia (recognize a symbol)
48
Laterality Recognition
Identify L vs R
49
Top down
Cognitive based intervention
50
Bottom Up
Physical intervention
51
Cognitive behavioral Therapy
Thoughts, emotional responses, physiological and behavioral responses interact and influence eachother
- PT needs to de-educate and then reeducate based on the understanding of pts true beliefs
- USE METAPHORSS , use layman's terms, they aren't alone
52
In what order do these things go into from low to high
A. L/R judgment
b. Observing
C. Imagining Movement
D. Physical movement Activities
E. mirror
Starting at Low: observing --> L/R judgement --> Imagining movements--> mirror--> physical movements/activities : high
53
How is conventional radiographic image created and what are the basic equipment components?
Requires: X-ray source, patient, image receptor
- X-rays have shorter wavelengths, manmade
- Image receptors- film, modem, fluorescent screen
Electrodes from cathode and anode
Primary radiation= patient attenuates the beam
54
Concepts of radiodensity, radiolucency, shading of various tissues/materials on radiograph: including identifying on radiographs
Radiodensity= combo of physical qualities of an object that determine how much radiation it absorbs from the x-ray beam
- Composition and thickness determine density ( thicker has more radiodensity vs thinner)
-
55
Tissues are Five major Compositions
Air
Fat
Water
Bone
Metal
Air= black most radiolucent
Fat= grey/black
Water=grey
Bone= white
Metal= radiopaque- whitest on image
56
1.Radiolucent
2. Radiopaque
3. Radiodense
1.Easily penetrated
2. impenetrable
3. increase radiodensity (calcification)
57
Routine radiography examination, series, patient positions , and projections
Patient positions
- Upright, seated supine, erect, Trendelenburg
- Seated and supine most common
58
Anteriorposterior/ PA x-ray
Supine/ Standing
Good for chest, want heart and lungs closest to receptor
59
Lateral X-ray
Left or right side closer to receptor
60
Oblique X-ray
45 degrees between AP and lateral
- Position named by side of the trunk touching the receptor
- AP and PA oblique
61
What is the Search pattern and What does the "ABCS" mean?
- Search pattern= describes the methodology of looking at an image in an organized fashion, helps ensure that everything possible to see has been accounted for, equivalent to gathering data
A= alignment - anatomy + normal structures/landmarks (bone, organn, BV)
B= Bone Density- fracture, dislocation, deformity
C= cartilage- integrity, thickness, alignment, spacing
S= soft tissue- symmetry, masses, enlarge lymph nodes, cysts
62
A= Alignment
A: Alignment
Alignment analysis includes evaluation of each item in the following three lists.
1. General Skeletal Architecture
Assess gross normal size, appearance, and number of bones.
2. General Contour of Bone
- Smooth continuous cortical outlines
- Abnormalities- cortical, avulsions, impaction fractures, spurs, markings of past surgical sites
3. Alignment of Bones Relative to Adjacent Bones
Assess articulating bones for normal positional relationships.
- Abnormalities= fractures, joint subluxation or dislocation
63
B= Bone Density
General bone density- sufficient contrast, shades of gray soft tissue and bones, enough contrast within each bone, between cortical shelf and cancellous center
- Abnormalities= general loss of bone density- bad contrast, thinning or absence of cortical margins
Textual Abnormalities= appearance of trabeculae altered= may look thin, lacy, delicate, coarsened, smudged, fluffy
Local bone density changes= sclerosis in areas with increased stress, like weight bearing surfaces or ligament/tendon attachments
- Abnormalities= excessive sclerosis, reactive sclerosis that walls off lesions, osteophytes
64
C= Cartilage
C: Cartilage Spaces
Joint space Width- well preserved - means normal cartilage/disc thickness
- Abnormalities= decreased joint space- could imply degenerative or traumatic
Subchondral Bone- smooth surface
-Abnormalities= excessive sclerosis, erosion
Epiphyseal Plates- normal size relative to epiphysis and skeletal age
- Abnormalities= compare contralateral for changes in thickness
65
S= Soft Tissue
Muscle- normal size
-Abnormalities= gross wasting or swelling
Fat pads and fat lines- radiolucent crescent parallel to bone, radiolucent lines parallels to length of muscle
- Abnormalities= displacement of fat pads into soft tissue= joint effusion; elevation or blurring of fat pads means swelling
Joint capsules- normally indistinct
- Abnormalities=observe whether effusion or hemorrhage distends capsule
Periosteum- normally indistinct, solid periosteal reaction is normal in fracture healing
-Abnormalities= look at reactions- solid, laminated, onionskin, spiculated, sunburst
Miscellaneous soft tissue findings- soft tissues are normally water-density shade of gray
- Abnormalities= foreign bodies seen by radiodensity, gas bubbles are radiolucent, calcifications are radiopaque
66
What are the categories of skeletal pathology
1. Congenital (cervical rib)
2. Inflammation (gout)
3. Neoplastic (bone tumor)
4. Metabolic (paget's disease)
5. Traumatic ( fracture)
6. Vascular ( avascular necrosis)
7. miscellaneous (osteoarthritis, infection)
67
Monostotic
1 bone
68
Monoarticular
1 joint
69
Poluostotic
many bones
70
Polyarticular
many joints
71
What are the characteristics seen on film for RA
- Soft tissue changes- fusiform periarticular swelling of small joints
- Articular erosions- radiolucent defects, synovial cysts
- Osteoporosis-periarticular rarefaction 2 degrees increased blood flow to synovium
- Joint deformities- concentric joint space narrowing, subluxations, contractures, swan neck, boutonniere, telescoping, ankylosis
- Changes in cervical spine- erosion and subluxation of facet joints C1/C2 subluxation diagnose with stress films
72
What are the characteristics seen on film for OA
- Joint space narrowing asymmetrical
- Subchondral sclerosis
- Osteophyte formation
- Pseudocysts- false cysts
- Temporary joint effusions from flare ups
- Joint deformities
- Done in weight bearing to see functional positions of knee/hip
73
What are the characteristics seen on film for Osteoporosis
- impossible to distinguish on radiograph- could be osteoporosis, osteomalacia, hyperparathyroidism
- Cortical thinning, osteopenia, rarefaction, trabecular changes, fractures collapse, overuse
74
What are the characteristics seen on film for Infection
- Soft tissue swelling, periarticular rarefaction (demineralize both sides of the joint), joint space narrowing, subchondral bone erosion
75
What are the characteristics seen on film for Tumors
- Benign- narrow zone of transition, well defined margins
- malignant- poorly defined margins
76
What are the characteristics seen on film for Osteomyelitis
- soft tissue swelling, loss of tissue planes
- Lytic lesion
- Sequestra and involucre- dead bone and envelop dead bone
- draining sinus tracts for pus to relieve pressure
77
How is fracture location described in the Peds population?
By region of development
1. Diaphysis is central shaft
2. Metaphyseal= involves expanding end
3. Physeal = involves growth plate
4. Epiphyseal = involves epiphysis
78
What are incomplete fractures in this population?
Greenstick
Torus
Plastic Bowing
79
Closed reduction
Fragments manually guided into place via manipulation or traction
80
Open reduction
Surgically expose site when closed reduction fails, know to be ineffective or associated injuries exist
81
External Fixation
Plaster cast immobilizations or splints, used to maintain closed reductions
82
Internal Fixations
For open reductions, uses orthopedic appliances like pins, wires, plates, screws, rods
83
What is an Eponym?
Convenient type of orthopedic shorthand like "housemaids knee" or " mallet finger"
84
What are the principles of CT imaging? How is it similar to radiograph? How is it different?
- Based on same imaging principles as conventional X-ray
- Employs X-rays that are attenuated by body tissues represented in the image of 4 shades of gray
- Different= CT creates an image based on axial (cross sectional) slices, creating up to 1000 projects from different angles
85
What is a CT myelogram?
Invasive nature, inject contrast material into subarachnoid space
- good for postop spinal stenosis
86
Window Levels = Bone or soft tissue window
Windowing is the range of radiodensities displayed in an image
Soft Tissue Window= can see gray and white matter
Bone Window= can see cortical and cancellous bone
87
1. what are some clinical uses of CT ?
2. Indications
3. Advantages
4. Disadvantages
5. Limitations
1. Clinical uses in identifying subtle fractures or complex, degenerative changes, osseous alignment, loose bodies in joint, serious trauma
2. Indications: evaluation of spinal stenosis, helpful when combined with diskogram- condition of intervertebral disc
3.Advantages: less expensive than MRI, less claustrophobic, less expensive than MRI, can image soft tissue and osseous structures in one series
4. Disadvantages: volume averaging of radiodensities within a voxel if pathological only gives one shade of gray, high radiation exposure
5. Limitations: Determining histological makeup of imaged tissues, tissues with similar radiodensities may be given the same shade of gray
88
Principles of MR
Based on measurements of energy emitted from hydrogen nuclei after their stimulation by radiofrequency signals, energy emitted varies according from which tissues it comes from
- Use magnetic field
89
T1 Weight MRI
- T1 weighted images show great anatomical detail and tend to highlight structures rich in fat
- Short time to repetition and time to echo times, signals caught early
- Tissues with high free water content appear darker
90
T2 Weight MRI
- T2 images are grainer and emphasize structure with high free water content and inflammation
- Makes fluid brighter
- long time to repetition and time to echo
- very helpful in detecting inflammation
91
T1 vs T2 weighted MRI
92
What are the clinical uses of MRI? Indications? Limitations? Contraindications
1. Clinical indications: soft tissue injuries, bone tumors, stress fractures, osteomyelitis, avascular necrosis, intervertebral disc pathology, detecting changes in bone marrow, arthroscopy for meniscal tears
- Best modality for evaluating disc herniations and other nerve root impingements
2. Limitations: not good at imaging cortical bone, time needed to produce image, claustrophobia, and need for sedation, orthopedic hardware is not ferromagnetic so could distort image, high cost
3. Contraindications: magnetic field can lift heavy metal objects in close proximity, surgical clips, brain aneurysm clips, can displace clips, pacemakers may malfunction
93
MRI advantages
Greater contrast resolution for soft tissue, image organs surrounded by dense bone, no ionizing radiation, less risk missing disease processes because of all the sequences used
94
CT Advantages
Less expensive, greater availability, faster imaging times, less operator time involved in selecting imaging parameters, thinner slices, less loss of image quality due to motion, greater power resolution when imaging cortical bone, easier imaging of individuals with metal implants
95
How does an Ultrasound work
waves reflected from the body tissues cause transducer crystal to deform- electrical charges on opposing surfaces of crystal- negative or positive- creation of electricity- piezolectric effect
96
What are the clinical uses of US
Indications
Advantages
limitations
disadvantages
Indications: tendons can stress test ligaments during inflammation of nerves, pediatric joint, developmental dysplasia can predict fracture risk of strength of bone
Advantages: high resolution, low cost, safety of use to modify the examination, joint may be place in different positions, can be a dynamic test performed in real time, able to stress ligaments, can apply traction, resisted muscle contractions or passive stretch during
Limitations: operator dependent, does not penetrate bone so structures deep to bone are not seen
97
Winter 2024 MSK 1
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