Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
The objective assessment is the method by which you discover the clinical signs of the pathology rather than just the symptoms. It is good practice to obtain ...
Typology: Lecture notes
1 / 16
This page cannot be seen from the preview
Don't miss anything!
Nick Southorn
Studying physiotherapy
The Student’s Companion to Physiotherapy
Musculoskeletal physiotherapy (MSK) is probably the largest area of physiotherapy in terms of practitioner and patient numbers. It is also the area that is common to physiotherapy around the world. MSK in this sense means orthopedic medicine, manual therapy, the alternative therapies such as osteopathy, sports medicine, Maitland, etc. Basically, MSK encompasses all the “hands on” manual techniques and exercise prescription for the relief or prevention of disorders of the musculoskeletal system. It is a culmination of detailed anatomic, physiologic, pathologic knowledge. What appears to catch most students out is the necessity of a detailed and concise assessment. As with all areas of physiotherapy, the assessment is the single most important part. The big difference here is that you are the main diagnostician in the treatment of your patient. This may mean looking at results of diagnostic imaging, blood biochemistry, nerve conduction studies, biopsies, etc, to help you develop a true clinical picture and a diagnosis.
Fig. 4.1 A goniometer for precise measurements of joints is very important.
A glossary of terms may be useful to begin with: For a more comprehensive list of physiotherapy terms, The dictionary of physiotherapy (Porter 2005) is necessary. ● (^) Abduction : movement away from the midline of the body. ● (^) Accessory movement : a movement that can be done by the therapist, which makes up part of a gross overall movement. However, the patient cannot isolate and carry out this movement. For example, in shoulder abduction, the humeral head glides inferiorly in the articular surface of the glenoid cavity. A therapist can perform a passive accessory caudad glide to help improve the whole movement of abduction. The opposite is physiologic movement. ● (^) Active movement : movement performed without facilitation. ● (^) Adduction : movement towards the midline of the body. ● (^) Caudad : movement towards the tail (literally) or towards the feet (practically).
The Student’s Companion to Physiotherapy
● (^) asthma ● (^) rheumatoid or osteo-arthritis (be prepared to explain the difference between them) ● (^) steroid usage ● (^) anticoagulant therapy ● (^) allergies ● (^) any recent significant weight loss that can’t be explained by dieting or increase in activity ● (^) cancer. Some questions may be guided by the type of condition, such as the cauda equina check for low back pain. ● (^) Bladder retention/incontinence, bowel incontinence ● (^) Saddle anesthesia ● (^) Bilateral leg pain/weakness Headings that may help gather a database of your patient are listed below. Something that may be of use to you is to work towards a SIN factor, which is the Severity, Irritability and Nature of the condition. While you read through these, have a think about some answers and which heading – severity, irritability or nature – they may contribute to.
● (^) What is your main problem with your condition?
● (^) Was there a major event that led to these symptoms (like a vehicle incident) or is it a result of microtrauma (such as repetitive strain injuries)? Perhaps it just came on (insidious onset).
Musculoskeletal physiotherapy
Since you have asked about the main problem in question 1, they should have explained the whole story of that so now is a good time to ask what other symptoms/problems they can think of.
● (^) Do they have any?
● (^) Is it constant or intermittent? Explain that constant means all the time, 24 hours of the day. ● (^) Ask them to describe the pain – throbbing, sharp, dull, “toothache like,”
shooting, etc. ● (^) Can they rate it out of 10? The Numerical Rating Scale (NRS) is a 0– scale which is very useful as an objective measure. Ask for a number between 0 and 10 to describe when the pain is at its worst, least and right now. ● (^) Is it the same intensity or variable?
● (^) Aggravating/easing factors – remind them that rubbing, heat and rest are valid answers here. Also explore the length of time it takes for the pain to disappear. ● (^) Is the pain so bad sometimes that they have to miss something (like work,
hobbies)? ● (^) Diurnal pattern.
Simply a list of conditions and operations that the patient has had in the recent past. Some things may appear insignificant to the pathology you face, such as the patient with adhesive capsulitis who tells you that they also have hypothyroidism or diabetes mellitus – the two have been likened to adhesive capsulitis (Siegel et al 1999).
Just a list of medication they take plus any other drugs they may wish to inform you of. Remind the patient that it is not only prescribed medications you need to be aware of – many people will buy their own from a pharmacy or herbalist.
● (^) What do they do for a living?
Musculoskeletal physiotherapy
● (^) Artefacts.
● (^) Standing and sitting posture.
● (^) What are the feet doing?
● (^) Measure the joints above and below the pathologic one.
● (^) Use of the goniometer is essential for accuracy. Remember – left and right!
The Student’s Companion to Physiotherapy
● (^) Functional or gross movement.
Clinical semaphore
Any healthcare practitioner needs to know the signs and symptoms that should ring alarm bells. Currently, a common system is the red and yellow flags. Red flags are physical risk factors that require co-ordinated care from the patient’s general practitioner or, in some cases, immediate referral to the emergency department. Red flags include (nonexhaustive list): considerable unexplained weight loss, unremitting night pain, cauda equina symptoms (bladder and bowel incontinence or retention, saddle anesthesia), pulsatile mass in the abdomen, progressive motor/sensory loss in lower limbs, etc. Yellow flags are psychologic risk factors that may hinder the treatment and hence recovery and can include (nonexhaustive list): inappropriate thoughts regarding condition, i.e. pain harm, catastrophizing, a substantial amount of time off work, excessive visits to health professionals recently, depression, and so on. A whole system of flags is in use, including black (work conditions that may inhibit rehab), blue (perception of work) and orange (significant psychologic issues, including drug abuse). Not all clinicians subscribe to this method so even if you become the oracle of flags you should check local policy for abbreviations in clinical notes before you use them.
Treatments
The treatments in musculoskeletal therapy vary, as previously mentioned. Rather than explain the individual treatment techniques, I have given a brief
Fig. 4.2 This reverse scapulohumeral rhythm is obvious but not all conditions of movement are as easy to spot. (Reproduced from Magee 2008, with kind permission from Elsevier.).
The Student’s Companion to Physiotherapy
Further information relating to Cyriax and orthopedic medicine can be found on the website of the Society of Orthopedic Medicine (SOM): www.somed.org. James Cyriax was a physician who noticed that there were, at the time, many undiagnosed and poorly treated conditions affecting the musculoskeletal system. He set about developing a system of assessment and diagnosis for these as well as nonsurgical treatments for soft tissue lesions (SOM 2004). The principles of Dr Cyriax and therefore orthopedic medicine were: ● (^) all pain has a source ● (^) all treatment must reach the source ● (^) all treatment must benefit the lesion. We now know that pain is much more complex than this (see Professor Paul Watson’s contribution, Chapter 9) and thus orthopedic medicine has undergone constant development and reappraisal in light of evidence. Examination by tissue tension is a pillar of the Cyriax concept too. The idea is simple – if a tissue is damaged, it will be painful to pull. Dr Cyriax devised three principles to back this. ● (^) Isometric contractions test the function of the contractile tissues. ● (^) Passive movements test the function of the inert structures. ● (^) The capsular pattern differentiates between joint conditions and other structural lesions. It is for these reasons that physiotherapists trained in orthopedic medicine are hot on their functional anatomy as the concept deals with identifying the slightest imbalance or irregularity and the structure involved. The treatments involve mobilizations and soft tissue massage together with electrotherapeutic agents.
Robin McKenzie is not only a lucky chap but also a very astute physiotherapist from New Zealand. Legend has it that, while treating a back patient with little success, Robin told him to lie down on the plinth while he got ready. Robin walked in to find his patient lying prone (on his front) but with the head break in the bed so that the patient was in extreme back extension. The patient explained that this was the most comfortable position for him as it reduced the pain in his back. A lesser physiotherapist may have dismissed such a comment (well, they would have done in the mid 1950s, which is when this story is said to have happened). However, Robin formed a spinal treatment from it that is widely used by physiotherapists and orthopedic surgeons today. The idea is to “centralize the pain” by exercises. It is postulated that in a posterior disk hernia, an extension will express pressure over the posterior aspect of the disk, forcing the gelatinous nucleus pulposus back into a central position. This will provide pain relief, allowing more effective exercise to be carried out. A true McKenzie practitioner will not use other modalities in practice such as acupuncture or heat.
Acupuncture is administered by trained physiotherapists for the relief of pain and relaxation. It has been in use for over 3000 years in the Far East,
Musculoskeletal physiotherapy
a method that has really stood the test of time. Two theories are used: the Traditional Chinese Medicine (TCM) approach and the Western medicine approach. As medical practitioners, it is important to ensure that the aspects of acupuncture with a sturdier scientific base are delivered, and the use of other aspects is not justifiable until they have similar backing. As it stands, pain management is the only indication for acupuncture in the UK. The ancient Chinese believed that the body’s health is dependent on the smooth and balanced movement of qi (energy) through meridians (channels). A number of factors can affect the flow, including the weather, stress, fear, infection, etc. The insertion of needles in the right places can free the flow, stimulating the body’s own healing power. The Western approach has the benefit of modern investigations such as functional magnetic resonance imaging (fMRI). However, there are many questions that remain unanswered by Western science and many theories that are yet to be proven. Without wanting to get carried away, here is just one development in the search for an answer to a 3000-year-old question. A recent study (Dhond et al 2008) showed increased connectivity in many parts of the brain during and after acupuncture, in particular the anterior cingulate cortex (ACC), which is known to be involved in the downregulation of pain (the way pain perception is controlled by the brain). However, although evidence would appear to support the use of acupuncture for pain, we don’t know the exact consequences of the increased activity in the ACC. It is therefore hard to make a solid link between the reduction of perceived pain and the increased activity in the ACC during acupuncture. The pain gate theory is also used for acupuncture, stimulation of mechanoreceptors “closing the gate.” Simple relaxation is another theory; we know that when you are more relaxed, the pain you feel is reduced. I will not go any further but I advise you to speak to a practicing physio- therapist who uses acupuncture. I am sure that they would love to discuss the theories and science behind it all.
Muscle energy techniques (MET)
This technique is commonly used by osteopaths and physiotherapists and is based on the fact that to increase a joint range, it is necessary to overcome the neuromuscular barrier (i.e. the reflex contraction following stimulation of the Golgi body). The principle is that this reflex arc will fatigue with excessive use and can therefore be overcome. There are a few techniques to learn. Reciprocal inhibition is simply the fact that contraction of an agonist will exert an inhibitory effect upon the contraction of its antagonist. Let’s think about the elbow – during biceps contraction (the agonist), the triceps (its antagonist) will relax and allow additional force to be expressed over it (i.e. a stretch). Postisometric relaxation works by the principle that maximal contraction is followed by maximal relaxation. The reflex arc will enter a phase of refraction and thus will tolerate a stretch being applied without activation of the muscle. Sustained stretch is arguably a MET but is simply the sustained stretch over a muscle that will eventually fatigue the reflex arc and allow greater range to be achieved.
Exercise therapy Musculoskeletal physiotherapy
Therapeutic exercise is defined as the systematic and planned performance of bodily movements, postures or physical activity to remediate or prevent injury, restore or improve physical function, reduce health-related risk factors, and optimize overall health (Kinser & Colby 2002). Exercise is one of the earliest forms of physiotherapy treatment. Physiotherapists are renowned for their knowledge of therapeutic exercise and it remains one of the most common treatments used. One of the reasons is similar to that for Pilates treatments – the patient achieves a sense of ownership over their rehabilitation. This is a double-edged idea, however: if your patient lacks motivation, do you think they will do the home exercises? The answer, alas, is no! For this reason, part of the skill of prescribing home exercise is placing the emphasis on them that is appropriate for the patient. If the patient is ultra motivated and willing then a large portion of the therapy can be home exercise. If not, then you give some home exercises and make more effort in the clinic. Learning about exercise isn’t just a matter of thinking “Well, he has weak biceps, I’ll give him some biceps curls.” There are many things to consider. ● (^) Am I trying to achieve increased strength or stamina? How does that
influence the prescription? ● (^) Can the patient achieve contraction against gravity? What do you do if they cannot? ● (^) How many repetitions (number of times they lift the weight) and sets
(number of times they are to perform all the repetitions)? ● (^) How much weight do I use?
● (^) How long should a stretch be applied for?
Sometimes you will be inclined to give general exercise advice for someone who is looking to improve general fitness and maybe lose weight. This is within the scope of the physiotherapist and something that you should relish the opportunity to do. As with all types of exercise prescription, you should consider the following. ● (^) Warm-up – this is vital. Do not forget to give appropriate advice relating to an effective but not exhausting warm-up. ● (^) Environment – this has to be nondistracting and conducive to exercise but
above all SAFE. ● (^) Amount to do – this is easily worked out. You must always ask the patient to carry out the exercises you are giving them and, in some cases, show them. Time how long it takes for them to carry out these tasks and decide whether or not you have given too much. You may think that you are doing them a service by giving them 2 hours’ worth of workout but realistically, who is going to stick to that?
● (^) Pain – another reason why you get them to demonstrate the exercises. If it is painful, you will have to redesign the workout. ● (^) Times of the day – when do you suggest they do this? Largely, it is
considered counterproductive to get someone doing hard physical activity 2 hours before going to bed as they may be aching and lose sleep.
The Student’s Companion to Physiotherapy
● (^) Are they compensating? Again, watch the patient as they give you a demonstration! Even in good health, you will see people cheating at exercise. I do it all the time and I am quite sure most of you do at some point too! Next time you go to the gym, watch the big macho man doing biceps curls: how much of that action is elbow flexion and how much is back extension followed by additional flexion once he has overcome the gravity line? Also, how fast do some people do leg presses? That is simply using momentum to your advantage, i.e. cheating! Patients are amazing at compensating – you will never tire of spotting their very subtle ways to overcome gravity or recruit other muscles to take over. All in all, therapeutic exercise is something that you should spend a great deal of time studying regardless of the clinical area you head towards. Two excellent books for understanding exercise are Therapeutic exercise: foundations and techniques (Kisner & Colby 2002) and Therapeutic exercise for lumbopelvic stabilization (Richardson et al 2004).
Massage is something that is often confused in physiotherapy; there is a difference between the massage you get with a masseur and the therapeutic massage you will provide as a physiotherapist. I don’t envy the female physiotherapists who have to put up with the moronic sleaze bag claiming “I have a groin strain injury – can I have a massage?” If they knew that you are far more likely to get hands on with some serious deep transverse friction massage than a nice soothing rub down, perhaps they would forget it. Having said that, with your anatomic knowledge and understanding of the physiologic effects of massage, there is no reason why you can’t use “normal” massage for therapeutic relaxation. A good definition of massage is provided by Holey & Cook (1997): Massage is the manipulation of the soft tissues of the body by a trained therapist as a component of a holistic therapeutic intervention. (p3) A well-conducted therapeutic massage can: ● (^) promote flow of bodily fluids (lymphatic, edematous, blood, etc.) ● (^) reduce muscle soreness and spasm ● (^) reduce pain in general ● (^) mobilize connective tissue ● (^) promote normal remodeling of tissues ● (^) promote the release of endorphins. The deep transverse friction massage mentioned earlier is a deep manipulation of specific tissues and can relieve pain, improve function and increase blood flow to the area, kick starting the inflammatory processes. This is a skilled massage and involves a detailed anatomic knowledge as getting it wrong will be hellishly uncomfortable for the patient.
In the clinic
As you can see, there is an awful lot that falls under the heading of musculoskeletal physiotherapy. During your placement, however, you will find
