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338 Cards in this Set
- Front
- Back
Typical mechanism of injury of AC joint.
|
Fall on adducted shoulder
|
|
Classification of AC joint injuries
|
* Rockwood classification
- Type I: tenderness without anatomic deformity - Type II: AC lig tear, CC lig sprain with preserved CC space. - Type III and IV: AC lig tear, CC lig tear and displaced CC space. |
|
General treatment of AC joint injuries
|
- Rockwood type I and II: rest, ice, sling, progressive ROM, return to play when non-tender and deltoid normal
- Unstable type 2 may require sling for 2-4 weeks - Type III and IV: can attempt conservative management but often need ORIF |
|
2 basic risk factors for shoulder impingement
|
- repeated overhead activity
- acromion shape |
|
What time of day is shoulder impingement pain often the worst?
|
At night; often bad with pressure on that shoulder
|
|
What is the typical degrees for painful arch in shoulder impingement?
|
70-110 degrees of shoulder abduction
|
|
Which direction does the shoulder most common dislocate in?
|
Anterior
|
|
List 3 more common complications of shoulder dislocation
|
- axillary nerve injury
- recurrent dislocations - rotator cuff tears. |
|
What is a Bankart lesion?
|
avulsion of the anterioinferior glenoid labrum and capsule from the glenoid rim
|
|
What is thought to be the major factor in recurrent shoulder dislocations?
|
Bankart lesions
|
|
What is a Hill-Sachs lesion?
|
A compression fracture of the humeral head (when posterolateral aspect of the humeral head compresses against the anterior glenoid rim).
|
|
Rates of recurrent shoulder dislocation based on age:
|
Younger: up to 90%
> 40yo: 10-15% |
|
What is the Stimson technique?
|
Method for reducing a shoulder dislocation where you lie prone and use a 5-10 wrist weight for distraction and reduce over 15-20 minutes.
|
|
General approach to rehab after shoulder dislocation
|
Sling for 1-3 weeks for capsular healing; maintain other UE ROM, isometric exercises (initially avoid greater than 45 degrees of abduction and any external rotation).
|
|
Define adhesive capsulitis
|
A syndrome characterized by a progressive painful loss of passive and active glenohumeral ROM.
|
|
What is motions are most and least effected in adhesive capsulitis?
|
- most: external rotation, abduction
- least: internal rotation |
|
Typical recovery time for adhesive capsulitis.
|
Months to years
|
|
General risk factors for bicipital tendinitis
|
- overhead activities
- sports - shoulder impingement |
|
Named-test for biceps tendinitis
|
Speed's test: resisted arm elevation against resistance; + is pain in bicepital groove
|
|
Medial scapular winging indicates weakness in the ____ mm., innervated by the _____ nerve.
|
- Serratus anterior
- Long thoracic nerve |
|
Lateral scapular winging is typically causes by weakness in the ____ mm., innervated by the ____ nerve.
|
- trapzeius
- CN XI |
|
Lateral scapular winging can be elicited by
|
shoulder abduction
|
|
Golfer's elbow =
|
Medial epicondylitis
|
|
Tennis elbow =
|
Lateral epidondylitis
|
|
What structures are usually involved in Golfer's elbow?
|
- tendinous origin of flexor-pronator mass
- MCL of the elbow |
|
General approach to rehab in medial epicondylitis
|
- stretch elbow during painful period
- when pain free start strengthening of all elbow/forearm muscles - consider elbow strap |
|
Structures typically involved in tennis elbow
|
Wrist extensor tendons, especially the ECRB.
|
|
Where do you wear an elbow strap?
|
Should be circumferential just distal to the elbow joint
|
|
Modificatons to a tennis racket that can help with tennis elbow
|
- larger racquet grip
- larger racquet head - less string tension |
|
Typical surgical interventions for tennis elbow that has failed conservative therapy.
|
- fasciotomy
- conjoined tendon fixation |
|
What is DeQuervain's disease?
|
Tenosynovitis of the 1st dorsal compartment of the hand
|
|
Major tendons involved in DeQuervain's disease?
|
- Abductor pollicus longus
- Extensor pollicus brevis |
|
What named test is perormed for DeQuervain's disease?
|
Finkelstein's test
|
|
What type of splint is helpful in DeQuervain's?
|
A thumb spica with the 1st MCP immobilized and the IP joint free.
|
|
Which carpal bone is most commonly fractured?
|
Scaphoid
|
|
Where do you have pain with a scaphoid fracture?
|
The snuffbox
|
|
Treatment of scaphoid fracture with negative films and reasonable clinical suspicion
|
Immobilization in short arm cast or thumb spica and repeat films in 2 weeks; if repeat films negative can consider CT/MRI.
|
|
Where does the blood supply enter the scaphoid bone?
|
The distal pole
|
|
What type of scaphoid fractures put you at high risk for non-union/AVN?
|
at the waist and proximal pole
|
|
Treatment of displaced scaphoid fractures
|
surgical
|
|
Trigger finger aka
|
digital stenosing tenosynovitis
|
|
2 major disease that are risk factors for trigger finger
|
- RA
- DM |
|
Treatment of trigger finger
|
- NSAIDs/ steroid injection
- Volar static hand splint with MCP immobilization for allows IP flexion (rests flexor tendons) - possible surgery if locked in flexion |
|
What should you certainly stretch with trochanteric bursitis?
|
ITB
|
|
Typical triggers for IT band syndrome
|
- overtraining
- running on uneven surfaces |
|
Typical source of pain from IT band syndrome
|
Pain at the knee when the ITB slides over the lateral femoral condyle; most at risk at 20-30 degrees of flexion.
|
|
People with ITB syndrome are usually tender over
|
Gerdy's tubercle
|
|
Named test of IT band length
|
Ober's
|
|
General rehabilitation for ITB syndrome
|
- stretch ITB, hip flexors and gluteus max
- strengthen hip abductors - correct foot pronation |
|
Typical time course for ITB syndrome to improve
|
2-6 months
|
|
What muscles make up the pes anserine?
|
- Sartorius
- Gracilis - Semitendinosis |
|
What's the mneumonic for pes anserine?
|
Say Grace before Tea
|
|
Where does the pes anserine insert?
|
MEDIAL proximal tibia
|
|
General rehabilitation for pes anserine bursitis
|
- stretching of medial hamstrings
- where knee pads (athletes) - steroid injections |
|
Attachments of the ACL
|
anterior medial tibial --> medial lateral femoral condyle
|
|
ACL prevents/restricts which movements
|
- anterior translation of the tibia
- ER of tibia on femur - knee hyperextension |
|
Primary function of ACL in athlete
|
maintain joint stability during deceleration
|
|
Typical mechanisms of injury for the ACL
|
- lateral trauma to the knee
- pivoting / cutting - hyperextension - hyperflexion |
|
What is the Lachman test used for?
|
Tests posterior fibers of ACL (knee flexed 20 degrees, better than anterior drawer test)
|
|
Imaging test of choice for ACL injury
|
MRI
|
|
What secondary injury is common after ACL tears?
|
Patellar pain with quad weakness
|
|
2 major strengthening exercises to focus on after ACL tears.
|
- hamstrings to hold tibia in place
- terminal range squats for quad strength to prevent knee pain |
|
Bracing in ACL injuries should limit
|
- terminal extension
- rotation |
|
Post-op rehab for ACLs typically lasts
|
6-9 months
|
|
Typical precautions right after ACL surgery
|
WBAT in an extension knee brace
|
|
General course of conservative strengthening in ACL rehabilitation
|
ROM with CPM, include patella up to 6 weeks, advance as tolerated 6-10 weeks, shift to focus on strengthening at 10 weeks
|
|
Attachments of the PCL
|
- posterior tibia
- medial femoral condyle |
|
PCL prevents/limits which movements?
|
- internal rotation
- posterior translation of the tibia - aid in knee flexion |
|
3 classic mechanisms of injury for PCL
|
- MVC when knee hits dashboard
- High valgus stress - Falling on flexed knee |
|
Is swelling common with PCL injuries?
|
no
|
|
2 tests for PCL integrity
|
- posterior drawer test
- sag test (posterior displaced tuberosity with the quad relaxed) |
|
Treatment of mild PCL sprain
|
Quad strengthening
|
|
Treatment of sever PCL injury
|
Arthoscopic repair
|
|
Which meniscus in the knee is more often injured?
|
medial
|
|
Typical mechanism of injury for knee meniscus
|
excess rotational stress, usually twisting on a flexed knee
|
|
Gold standard for diagnosis of a tear of the meniscus?
|
arthroscopy
|
|
When should you refer meniscus tears to surgery?
|
Mechanical symptoms
|
|
Which portions of the meniscus have vascular supply and which do not?
|
- Outer 1/3: vascular, can repair
- Inner 2/3: non-vascular |
|
When can patients fully weight bear after meniscal repair?
|
When pain free (often takes 6 weeks)
|
|
What position/activity is discouraged after meniscal injury/repair?
|
deep squatting
|
|
General risk factors for patellofemoral syndrome
|
- overuse
- muscle imbalance - biomechanical factors (pronation, increased q angle) |
|
Classic history of patellofemoral syndrome
|
anterior knee pain worse with activity, prolonged sitting and descending stairs
|
|
Classic rehab approach for patellofemoral syndrome
|
- avoid prolonged sitting
- quad strengthening (short arch closed kinetic chain in 0-45 deg to strengthen all quads); avoid full ROM and open chain - stretching quads, hamstrings, ITB and PF |
|
What's the McConnell technique?
|
Type of taping technique suing super-rigid, cotton mesh highly adhesive tape to change biomechanics and neuromuscular re-education. Especially used for patella and shoulder.
|
|
2 major causes of exercise induced leg pain?
|
- medial tibial stress syndrome
- chronic compartment syndrome |
|
"Shin splints" is better defined as
|
exercise induced tibial pain without evidence of fracture on x-ray
|
|
Sports especially at risk for medial tibial stress syndrome
|
- running
- gymnasts - dnacers |
|
Risks factors for medial tibial stress syndrome
|
- sport type
- increase in exercise intensity - poor footwear - hard training surface - poor biomechanics |
|
Where is the pain location and typical pattern for medial tibial stress syndrome?
|
- localized pain in distal 1/3 tibia
- quickly relieved by rest, not aggravated by passive stretch |
|
Why do we care if tibial stress fractures are medial vs. anterior?
|
Anterior often take several months of rest and/or bone graft to heal.
|
|
What x-ray view is needed to see anterior tibial stress fractures?
|
oblique x-ray
|
|
Typical pain characteristics for chronic compartment syndrome of the leg
|
- pain with a certain amount/duration of exercise
- parasthesia, numbness, weakness in the distribution associated with the compartment |
|
Edx studies in chronic compartment syndrome usually show
|
normal findings
|
|
What pressure measurements are consistant with chronic compartment syndrome as a source of leg pain?
|
>30mmHg at rest
>60mmHg 15 sec post exercise >20mmHg 2 min post exercise |
|
Initial treatment of chronic compartment syndrome of the leg
|
- NSAIDs
- footwear - correct training errors - refer for possible surgery if no better in 1-2 months of retraining |
|
Risk factors for achilles tendinitis
|
- overuse
- overpronation - heel varus deformity - poor flexibility of PF and hamstrings |
|
Classic sports for achilles tendinitis
|
- Basketball (jumping)
- Runners who increase mileage or start hills |
|
Severe cases of achilles tendinitis may take ___ months for recovery
|
24 months
|
|
Most common mechanism of injury for ankle sprain
|
Lateral ankle sprain from a inversion injury on a PF foot
|
|
Order of involvement of ligaments in ankles sprain
|
ATFL --> CFL --> PTFL
ATFL = anterior talofibular lig. CFL = calcaneofibular lig. PTFL = posterior talofibular lig |
|
When is an anterior draw test for the ankle considered positive?
|
>5mm displacement
|
|
What is the talar tilt test and what does it test?
|
- Inversion stress to talus
- positive if 10+ degrees greater motion than unaffected side - checks integrity of the CFL |
|
Medial ankles injuries involving the deltoid ligament often have an associated
|
proximal fibula fracture (Maisonneuve fracture)
|
|
What are the 3 phases of ankle sprain rehabilitation?
|
- Phase I (days 1-3): RICE
- Phase II (weeks): restore ROM, strengthen ankle stabilizers, stretch PF - Phase III (weeks-mo): when motion is near normal, add proprioceptive and endurance exercises |
|
What should you avoid in the first 24 hours after an ankle sprain?
|
- hot showers
- EtOH - methylsalicylate compounds (BenGay) - anything else that increases swelling |
|
Give one example of return to play guidelines after ankle sprain
|
- Grade I (no laxity): 0-5 days
- Grade II (mild laxity): 7-14 days - Grade III (can't bear weight): 21-35 days - Syndesmosis injury: 21-57 days |
|
Classic history for plantar fasciitis
|
pain with first few steps in the morning or pain worse at beginning of activity
|
|
Treatment of plantar fasciitis
|
- relative rest
- daily stretching - fell cushioned shoes - soft medial arch supports - night splints |
|
Typical symptom resolution for plantar fasciitis occurs within
|
6-12 weeks
|
|
Complication of corticosteroid injection for plantar fasciitis
|
necrosis of the heel fat pad; cannot be easily treated/reversed
|
|
What surgery is done for plantar fasciitis
|
release of the fascia where it attaches at the calcaneus
|
|
Most common cause of sudden cardiac death in young male athletes
|
hypertrophic cardiomyopathy
|
|
Exercise stress testing is recommended for which group of asymptomatic individuals prior to starting vigorous exercise?
|
- men greater than 45
- women greater than 55 |
|
What constitutes a "vigorous" exercise program
|
reach greater than 60% of VO2 max
|
|
What level of visual impairment is concerning for sports participation?
|
Uncorrected greater than 20/40
|
|
What are the classic PE findings for hypertrophic cardiomyopathy?
|
- displaced point of maximal impulse
- systolic murmur that increases with upright posture/valsalva and decreased with squatting |
|
Contraindications to sports participation
|
- myo/pericarditis
- hypertrophic cardiomyopathy - uncontrolled severe HTN - suspected CAD - long QT - recent TBI (contact) - poorly controlled seizures - unexplained UE radic symptoms/stingers - mono with splenomegaly - sickle cell disease (relative) - untreated eating disorder |
|
What are the general activity restrictions in sickle cell disease?
|
no high exertion, contact or collision sports
|
|
Normal q angle in men
|
13 degrees
|
|
Normal q angle in women
|
18 degrees
|
|
Lifetime risk of hip fracture in industrialized nations
|
- women 18%
- men 6% |
|
1 year mortality after hip fracture
|
20%
|
|
Percentage of people non-ambulatory after a hip fracture
|
20%
|
|
Advantages and disadvantages for non-cemented hip arthroplasty
|
- more durable surface
- longer period of non-weight bearing/protected weight bearing |
|
General hip precautions after hip arthroplasty
|
Usually last 6-12 weeks
- Hip flexion to 90 - No adduction past midline - No ER - No IR when hip flexed (further restrictions based on if gluteus medius preserved or not) |
|
Groups with poorer results after hip arthroplasty
|
- younger
- male - obese - highly active |
|
Presumed key factor in total knee arthroplasty prosthetic failure
|
wear of the polyethylene liner (micro debris can trigger an inflammatory reaction which may lead to component loosening)
|
|
Define pain
|
an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP definition)
|
|
Define dysesthesia
|
An unpleasant abnormal sensation whether spontaneous or evoked
|
|
Define paresthesia
|
an abnormal sensation, whether spontaneous or provoked
|
|
Define hyperalgesia
|
an increased response to a stimulus which is normally painful
|
|
Define allodynia
|
pain due to a stimulus that does not normally provoke pain
|
|
Define chronic pain
|
Pain that exceeds the actual course of an injury or disease; often considered pain for more than 6 months
|
|
Define chronic pain syndrome
|
patients behave in a learned patterns in order to maintain secondary gains
|
|
How have pain drawings been validated to help assess psychological components of pain?
|
Diagrams with unusual distributions correlate with symptom magnification and psychological significance.
|
|
High scores in the affective section of the McGill Pain Questionnaire correlate with...
|
greater anxiety and sickness impact regardless of pain intensity
|
|
2 primary factors that directly trigger pain in afferent neurons
|
- leukotrienes
- prostaglandins |
|
Where do A-delta fibers primarily synapse in the spinal cord?
|
Rexed laminae I and V
|
|
Where do C fibers primarily synapse in the spinal cord?
|
Rexed laminae II
|
|
What pain information travels in the neospinothalamic tract and where does it go?
|
- rapid precise pain localization
- posterior ventral thalamus --> postcentral sensory cortex |
|
What pain information travels in the paleospinothalamic and spinoretibular tracts and where does it go?
|
- poorly localized, dull, aching, and burning sensations
- hypothalamus and intralaminar thalamic nuclei --> limbic system |
|
Who and when proposed the gate control theory of pain?
|
Melzack and Wall in 1965
|
|
Describe the gate control theory of pain
|
activation of large diameter sensory afferents can inhibit the transmission of pain signals from small-diameter pain fibers through interactions in the substantia gelatinosa of the dorsal horn
|
|
Describe the 7 general steps in pain between activation of the peripheral nociceptor to overall reaction
|
1. transduction in peripheral nociceptor
2. transmission in peripheral neuron 3. central facilitation 4. modulation 5. spinal reaction 6. Neocortical and paleocortical perception 7. Supraspinal reaction |
|
What's the difference between Complex Regional Pain Syndrome for types I and II
|
- CPRS type I: not associated with a known nerve injury
- CPRS type II: associated with a nerve injury |
|
Typical presenting history of CPRS
|
Traumatic or neurological event followed by immobility
|
|
What are the general stages of CPRS?
|
- Acute (hyperemic) stage
- Dystrophic (ischemic) stage - Atrophic stage |
|
Describe the acute stage of CPRS
|
- aka hyperemic stage
- constant burning pain, hyperpathia/allodynia, local edema/warmth, skin smooth and taut. - lasts several weeks to 6 months |
|
Describe the dystrophic stage of CPRS
|
- cold, atrophic extremity with increase edema, increased pain, muscular wasting, patchy osteoporosis and decreased function
|
|
Describe the atrophic stage of CPRS
|
- marked trophic changes with weakness and loss of ROM; pain may be reduced
|
|
Generally favored most effective treatment for CPRS
|
sympathetic blocks in the acute phase
|
|
Define myofascial pain syndrome
|
exquisitely painful trigger points with characteristic patterns of referred pain.
|
|
What is the female to male ratio in myofascial pain syndrome?
|
3:1
|
|
What is the female to male ratio in fibromyalgia?
|
10:1
|
|
What is typically injected for trigger point injections when using local anesthetic?
|
0.5cc of 1% lidocaine
|
|
Common associated findings with whiplash
|
-headaches
- dizziness - visual disturbances - ulnar sensory changes |
|
Whiplash generally improves within what time frame?
|
2 weeks
|
|
If neck or headache symptoms after whiplash injury continue at 4 weeks, consider
|
- head CT for HA
- cervical spine MRI for neck pain |
|
Point and lifetime prevalence of low back pain
|
- point: 15-30%
- lifetime: 60-70% |
|
Percentage of patients with low back pain at 4 weeks that have a definable lesion
|
~15%
|
|
Most helpful ROS/history questions for low back pain
|
- general pain history
- age - cancer history - weight loss - response to previous therapy - IV drug use - UTI - Psych history |
|
Decreased lumbar lordosis with back pain may indicate
|
- disc problem
- vertebral collapse |
|
Increased lumbar lordosis with back pain may indicate
|
- obesity
- high grade spondylolisthesis |
|
During what part of the straight leg raise is the sciatic nerve stretched the most?
|
between 35 and 70 degrees
|
|
+ SLR at more than 70 degrees tends to reflect what pathology
|
pain secondary to the joint
|
|
How were Waddell's signs meant to be used
|
- in low back pain considering pain behaviors; if more than 3 or the 5 Waddell signs are positive then a non-organic basis for the physical complaints is likely and the physical exam is likely invalid
|
|
What are the Waddell's signs?
|
1. Regionalization
2. Overreaction (to non-painful stimuli) 3. Simulation (pain with axial loading) 4. Distraction (inconsistent results with distraction) 5. Tenderness (non-anatomic or superficial) |
|
DISH stands for
|
Diffuse idiopathic skeletal hyerostosis
|
|
What is the evidence for use of NSAIDs in acute low back pain
|
- Different NSAIDs without different benefits
- good for pain - do not change return to work, natural history or chronic pain |
|
Why is bed rest not recommended for back pain
|
- it has not shown to work
- there are complications with immobilization including loss of bone mineralization and weakness |
|
Risk factors for internal disc disruption?
|
- repetitive twisting
- prolonged sitting |
|
Typical history of internal disc disruption
|
Insidious pain with exacerbation by lifting, coughing, sitting, standing or transitional movements.
|
|
Best PE test for lumbar radiculopathy
|
+ crossed-straight leg raise
|
|
Useful signs and symptoms in lumbar radiculopathy
|
- pos crossed SLR
- pain at night - severe radicular pain - unilateral leg pain worse than back pain - loss of lordosis |
|
2 most common levels of lumbar disc herniations causing radiculopathy
|
- L4-5 (L5 radic)
- L5-S1 (S1 radic) |
|
Typical definition of clinically significant lumbar spinal stenosis on MRI
|
AP diameter less than 7-10 mm
|
|
Typical pain features for lumbar spinal stenosis
|
- pain with standing or walking, insidious
- worse with walking downhill, with lumbar extension, relieved with lumbar flexion |
|
Does lumbar z-joint pain radiate below the knee?
|
no
|
|
2 most common levels involved in spondylolysis
|
* L5
L4 |
|
Where is spondylolisthesis most commonly seen
|
at lumbosacral junction
|
|
Causes of spondylolisthesis
|
- spondylolysis
- degeneragtive changes - Paget's disease - Bony dysplasia |
|
General rehabilitation approach to less than grade 2 spondylolisthesis
|
- heat
- massage - stretching of hip flexors, hamstrings and PF - lumbar flexion/isometric exercises (avoid extension) |
|
when should you send a spondylolisthesis for surgical evaluation
|
grade 3 or 4 or any neuro symptoms
|
|
What are the 10 essential points of a modalities prescription?
|
1. Diagnosis
2. Impairments/disability 3. Precautions 4. Modality 5. Area to be treated 6. Intensity/settings/temp range 7. Frequency of treatment 8. Duration of treatment 9. Goals/objective of treatment 10. Date of re-evaluation |
|
What is the therapeutic heat range?
|
40-45 C
|
|
How long should therapeutic heat be maintained?
|
5-30 minutes
|
|
Define superficial heat
|
1-2 cm
|
|
Define deep heat
|
3.5-8cm
|
|
Give examples of modalities that use conduction
|
(direct transfer of heat by contact)
- paraffin, heat packs |
|
What's the heat usually set at for paraffin and why can we tolerate it so hot?
|
52-54C; poor heat conductivity allows tolerance.
|
|
Give examples of modalities that use convection
|
(flow of heat)
- fluidotherapy, whirlpool, moist air |
|
Give examples of modalities that use conversion
|
(non-thermal energy into heat)
- infrared - ultrasound - shortwave diathermy - microwave diathermy |
|
Depth of penetration of infrared
|
2cm
|
|
Depth of penetration of US
|
3.5-8cm
|
|
Where is the greatest heating for US located?
|
At the bone-tissue interface
|
|
What are the frequency parameters for US?
|
0.8-1-1 MHz
|
|
What are the intensity parameters for US?
|
0.5-4 W/cm2
|
|
What are the treatment area parameters for US?
|
100cm2
|
|
What are the duration parameters for US?
|
5-8 min
|
|
In short wave diathermy, which is heat more fat or muscle?
|
fat
|
|
What is the penetration of short wave diathermy
|
4-5cm
|
|
What is the most commonly used frequency for short wave diathermy
|
27.12MHz
|
|
What are the general contraindications to heat therapy?
|
- acute hemorrhage
- bleeding dyscrasia - inflammation - malignancy - insensate skin - inability to respond to pain - atrophic skin - ischemia |
|
Specific contraindications for US?
|
- treatment over fluid filled cavities (eye, uterus)
- no treatment near pacemaker - not near laminectomy site or joint prosthesis |
|
Specific contraindications of short wave diathermy
|
- childrens (immature epiphyses)
- metallic implants - contact lenses - menstruating/pregnant |
|
Specific contraindications of micro wave diathermy
|
eyes (develop cataracts)
|
|
Which penetrates deeper for micro wave diathermy - 915 MHz or 2450 MHz
|
915
|
|
How can cold decreased spasticity?
|
Group Ia firing rates are decreased which reduces the muscle stretch reflex
|
|
Physiologic effects of superficial cold
|
- hemodynamic vasoconstriction
- slowing of nerve conduction velocity |
|
Contraindications for cold therapy
|
- ischemia
- insensate skin - severe HTN - cold sensitivity syndromes (Raynaud's, cryoglobinemia, cold allergey) |
|
General guidelines for cervical traction
|
25-30 pounds at 30 degrees of flexion
|
|
In what position is the cervical intervertebral space the greatest?
|
at 30 degrees of flexion
|
|
General weight guidelines for lumbar traction
|
26% of body weight needed for friction (supine with hips and knee flexes), another 25% of body weight needed for vertebral separation
|
|
General contraindications to spinal traction
|
- ligamentous instability
- osteomyelitis - discitis - bone malignancy - spinal core tumor - severe osteoporosis - untreated HTN |
|
Additional cervical spine traction contraindications
|
- vertebrobasilar artery insufficiency
- RA - midline herniated disk - acute torticollis |
|
Additional lumbar spine traction contraindications
|
- restrictive lung disease
- pregnancy - active peptic ulcers - aortic aneurysm - gross hemorrhoids - cauda equina syndrome |
|
Contraindications to TENS
|
- near pacemakers
- pregnant - not to be done over carotid sinus |
|
2 hypotheses about why TENS works
|
- gate theory of pain where the stimulation of A-beta and A-gamma fibers stimulate interneruons in substantia gelatinosa which inhibit lamina V where the pain neurons synapse
- may release B-endorphins |
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What are the 2 general approaches to settings in TENS?
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- "Conventional" is high frequency (50-100Hz), low amplitude, short duration is barely perceptible and requires adjustment as people accommodate
- "Accupuncture-lie" uses larger amplitude, low frequency (1-4Hz) that may be uncomfortable. |
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What are the 3 classic western techniques in massage?
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- effleurage (stroking)
- petrissage (kneading) - tapotment (percussion) |
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What does the swedish approach to massage combine?
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tapotment + petrissage + deep tissue massage
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What is deep friction massage used for?
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Breaking up adhesions in chronic muscle injuries
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What is the goal of myofascial release/how is it done?
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release soft tissue entrapped in tight fascia through the prolonged application of light pressure in specific directions
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What are the absolute contraindications to massage?
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- malignancy
- DVT - atherosclerotic plaques - infection |
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What are the relative contraindications to massage?
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- incompletely healed scar tissue
- anticoagulation - calcified soft tissues - skin grafts |
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Define phonophoresis
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topical medicals are mixed with an acoustic coupling medium and are driving into the tissue by ultrasound
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2 common medications involved in phonophoresis
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- steroids
- analgesics |
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List 8 common uses for phonophoresis
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- OA
- bursitis - capsulitis - tendonitis - strains - contractures - scar tissues - neuromas |
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Define iontophoresis
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electrical currents are used to drive medications across biological membranes (try to avoid systemic effects)
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Who put forth the 6 determinants of gait...and when?
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Sanders, Inman and Eberhart in 1953
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List the 6 determinants of gait
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1. Pelvic rotation int he horizontal plane
2. Pelvic tilt in the frontal plane 3. Knee flexion 4. Knee motion 5. Ankle motion 6. Lateral pelvic displacement |
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What are the determinants of gait (generally)
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Describes 6 ways that normal gait is more efficient by minimizing vertical and lateral excursions of the body's center of mass.
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Describe pelvic rotation in the horizontal plane as a determinant of gait
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- pelvis rotates 4 deg each side
- maximal during double support - elevates the nadir of center of mass about 3/8" |
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Describe pelvic tilt in the frontal plane as a determinant of gait
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- pelvis drops 5 degrees on the side of swinging leg
- decreases the apex of center of mass about 3/16" |
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Describe knee flexion as a determinant of gait
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- knee flexion during midstance lower center of mass 7/16"
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Describe knee and ankle motion as determinants of gait
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smooths out the pathway to make the curve more sinusoidal
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Describe lateral pelvic displacement as a determinant of gait
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- normal valgus at the knee decreases lateral sway
- reduces total horizontal excursion from 6" to less than 2" |
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During what phases of the gait cycle do the ankles dorsiflexors concentrically and eccentrically contract?
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- concentric: swing phase
- eccentric: heel strike to foot flat |
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During what phases of the gait cycle do the ankle plantarflexors concentrically and eccentrically contract?
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- concentric: push off
- eccentric: midstance |
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During what phases of the gait cycle do the hip abductors concentrically and eccentrically contract?
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- concentric: none
- eccentric: stance (limit pelvic tile of swing phase leg) |
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During what phases of the gait cycle do the hip flexors concentrically and eccentrically contract?
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- concentric: swing phase to clear leg
- eccentric: after mid-stance to slow trunk |
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During what phases of the gait cycle do the hip extensors concentrically and eccentrically contract?
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- concentric: none
- eccentric: before heel strike to foot flat |
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During what phases of the gait cycle do the knee extensors concentrically and eccentrically contract?
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- concentric: toe off
- eccentric: stabilize in heel strike |
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Classic location of center of mass at rest
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2" anterior to S2
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Where is the GFR vector in relation to the hip, knee and ankle at initial contact?
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- hip: anterior
- knee: through - ankle: posterior |
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Where is the GFR vector in relation to the hip, knee and ankle at loading response?
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- hip: anterior
- knee: posterior - ankle: posterior |
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Where is the GFR vector in relation to the hip, knee and ankle at midstance?
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- hip: posterior
- knee: posterior - ankle: anterior |
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Where is the GFR vector in relation to the hip, knee and ankle at terminal stance?
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- hip: posterior
- knee:anterior - ankle: anterior |
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Where is the GFR vector in relation to the hip, knee and ankle at pre-swing?
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- hip: anterior
- knee: posterior - ankle: anterior |
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The only muscle active in normal quiet standing?
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Triceps surae, mostly just the soleus
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Typical gait deviations noted in an antalgic gait?
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- decreased stance phase
- reduced step length on unaffected side - increased time in double support |
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Characteristic observation with weak plantarflexors
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Shortened step-length on contralateral side
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Treatment of gait problems from weak plantarflexors
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AFO with long sole shank to simulate PF during terminal stance
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Which side drops in a Trendelenburg gait?
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The contralateral pelvis
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How do you compensate for a Trrrendelenburg gait?
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Ipsilateral trunk lean
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What is classically observed in the gait of someone with hip extension weakness?
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posterior trunk / extensor lurch
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Treatment of bilateral extensor lurch gait?
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2 crutches or canes for a 3 point gait
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Why is gait speed slowed in the hemiplegic patient
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to maintain optimal energy expenditure
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The classic triad of Parkinson's disease...
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tremor, bradykinesia, instability with at least 2 affecting gait
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Festination gait is classically associated with
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parkinsons
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Turns in a Parkinson gait are made
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en bloc
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treatment of Parkinson gait
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- heel lifts and assistive devices to decrease falls backwards
- weighted assistive devices - PT for postural issues |
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When do patients typically use foot slap vs. steppage gait in TA weakness?
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>3/5 = foot slap
<3/5 = steppage gait |
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A standard AFO with plantar flexion stop may destabilize
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the knee
|
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What AFO option will assist dorsiflexion but still allow for plantarflexion and knee stability?
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Posterior spring AFO
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How should you ascend stairs with a cane?
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Strong limb --> weak limb and cane
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How do you measure appropriate can length?
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from the bottom of the shoe's heel to the top of the greater trochanter
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What position should the elbow be in when using a cane that is correctly sized?
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20 degrees of flexion to allow for assistance during push-off
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Maximum percentage of body weight that a cane can unload
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20%
|
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Why are crutches more stable than canes?
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They have 2 points of contact with the body
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What muscles are important in ambulating with crutches?
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Should depressors (latissimus dorsi and pectoralis major), triceps, biceps, quads, hip ext, hip abd
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How do you measure correct axillary crutch length?
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Measure the distance from the anterior axillary fold to the ground 6 inches lateral to the bottom of the heel while standing and add 1-2"
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What is the correct UE position when using a crutch?
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elbow flexed 30 deg, wrist in extension, fingers forming a fist
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|
Forearm crutches aka
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Lofstrand crutches
|
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What is the major indication for forearm crutches?
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When pressure to the trunk is contraindicated
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Should you pad the top of an axillary crutch?
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No, this encourages weight on the brachial plexus
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A single forearm crutch can unload what % on body weight?
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40-50%
|
|
2 point crutch gait aka
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"hop-to"
|
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What is the general 3 point crutch gait?
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Crutches advanced together, then LEs advanced individually
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Walkers can unload what percentage of LE weight?
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up to 100%
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Why are walkers more stable that crutches/canes?
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Wider base of support
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How do you properly fit a walker?
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With the walker 10-12" in front of the patient they should be standing straight with relaxed level shoulders and elbows flexed to 20 degrees
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When are rolling walkers indicated
|
- after joint replacement (allow for smoother gait)
- when pts lack the UE strength/coordination to lift a regular walker |
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Why can a hemiwalker be better than a quad cane?
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More lateral support
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Platform walkers bear weight through
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the elbows (bypass the hand)
|
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Examples of indications for platform walkers
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- UE joint deformities, grip weakness, flexion contracture of the elbow, multiple fractures
|
|
Mneumonic for foot amputations
|
Chopart is shorter, Lisfranc is longer
|
|
Incidence of major amputations per year in US
|
70,000
|
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% of amputation in US due to peripheral vascular disease
|
65%
|
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% of amputation in US due to trauma
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25%
|
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% of amputation in US that are congenital
|
5%
|
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% of LE amputees from diabetes who will have the other leg amputated within 5 years
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about 50%
|
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% of amputation in US due to malignancy
|
5%
|
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Typical age range for amputation from malignancy
|
10-20 years
|
|
What is the preferred mature residual limb length and shape in transhumeral amputations
|
cylindrical appendage with retention of the deltoid tuberocity with goal up to 90% of length
|
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What is the preferred mature residual limb length and shape in transradial amputations
|
shape of natural limb, longer is better for heavy labor, try to preserve brachioradialis to improve EF; medium length is better for externally powered prostheses
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What is the preferred mature residual limb length and shape in transfemoral amputations
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conical shape with longer length
|
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What is the preferred mature residual limb character in a short transfemoral amputation?
|
preserving the greator trochanter and the hip abductors
|
|
What is the preferred mature residual limb length and shape in transtibial amputations
|
cylindrical 1/3 of original tibial length with retention of patellar tendon; fibula should be shorter than the tibia.
|
|
When can elastic shrinker socks be worn after amputation
|
When the incision has healed they should be worn at all times when the person is not wearing a prosthesis
|
|
List mechanisms for residual limb shaping after amputation
|
- figure of 8 elastic bandage qid
- elastic shrinker - immediate post-operative fitting prosthesis (IOPO) - rigid removable dressing |
|
Common contractures after LE amputation
|
HF, H abd, KF
|
|
Classic strategies for prevention of contractures after LE amputation
|
- prone 15 min tid
- firm mattress - knee extension while resting |
|
Good test for CV demand for walking with a prosthesis
|
Ability to walk with a walker without prosthesis
|
|
When do most patients get their definitive prosthesis?
|
3-6 months
|
|
What is the purpose of the socket in a prosthetic limb?
|
Connect the residual limb with the rest of the prosthesis and (in LEs) helps transfer body weight to the ground.
|
|
The patellar tendon bearing socket is also known as the
|
Total contact socket
|
|
What are the "pressure tolerant" areas where the prosthesis generally bears weight in a transtibial amputation?
|
- patellar tendon
- pre-tibial muscles - lateral fibular surface - popliteal fossa - gastroc-soleus |
|
What are the classic "pressure sensitive" areas that should be avoided in designing a transtibial socket?
|
- fibular head
- tibial condyles - distal fibula - tibial tubercle, crest and distal tibia - hamstring tendons |
|
"Stump chocking" often shows up as what skin change
|
verrucous hyperplasia
|
|
Give 3 categories of types of suspension options for transtibial prosthesis.
|
differential pressure, anatomic, sleeve
|
|
SACH foot stands for...
|
Solid Ankle Cushioned Heel
|
|
Give 4 categories of feet for prosthetic limbs
|
- SACH
- Single axis foot - Multi axis foot - Dynamic elastic response foot |
|
What is the typical angle of fit for a transfemoral socket and why?
|
5 degrees of flexion and adduction to given the hip extensors and abductors a mechanical advantage
|
|
What are the 2 major types of sockets for transfemoral amputees?
|
Quadrilateral design
Ischial containment design |
|
Which transfemoral design is narrow AP?
|
quadrilateral
|
|
Which transfemoral design is narrow M-L?
|
Ischial containment
|
|
What are the general advantages and disadvantages of a quadrilateral design socket?
|
- easy to make
- less stable for shorter limbs - less comfortable |
|
What are the general advantages and disadvantages of a ischial containment socket?
|
- better stability especially for shorter limbs
- more efficient energy with narrow ML |
|
What is included in the "bony lock" of the ischial containment socket?
|
- ischial tuberosity
- pubic ramus - greater trochanter |
|
Give 4 examples of suspension options for transfemoral sockets
|
-suction
-silesian belt/bandage -total elastic suspension (belt; TES) - pelvic band and belt |
|
What are the main advantages and disadvantages of the single axis or constant friction knee?
|
Advantages: durable, inexpensive
Disadvantages: fixed cadence, poor stability, only indicated for level surfaces |
|
What are the main advantages and disadvantages of the stance control or safety knee?
|
Advantages: cannot be flexed during weight bearing so more stance phase stability, good in poor hip control, allows for more ambulation on uneven terrain
Disadvantages: delays swing phase because full unloading is needed to bend the knee |
|
What are the main advantages and disadvantages of the polycentric knee?
|
Advantages: knee remains behind the GFR for more stability, closer to anatomic knee location, good cosmesis especially with sitting
Disadvantages: heavy, expensive (especially used in knee disarticulations) |
|
What are the main advantages and disadvantages of the fluid controlled knee?
|
Advantages: automatic swing phase control at variable cadences, smooth natural gait
Disadvantages: heavy, costly |
|
What are the main advantages and disadvantages of the manual locking or fixed lock knee?
|
Ultimate in stability but awkward and energy consuming
|
|
When can phantom pain develop after amputation?
|
Any time
|
|
What percentage of patients experience phantom sensations and pain 6 months after amputation?
|
sensations 79%
pain 72% |
|
Risk factors for phantom pain?
|
Chronic pain, pain immediately prior to amputation
|
|
Why does choke syndrome develop in amputations?
|
Proximal limb pressure without full distal contact, often with an underlying vascular disorder.
|
|
What is the typical energy expenditure for able bodied adults at self selected walking speed?
|
4.3Kcal/min
|
|
What is the % energy expenditure increase at self selected walking speed for transtibial amputees?
|
23%
|
|
What is the % energy expenditure increase at self selected walking speed for tranfemoral amputees?
|
99%
|
|
What is the % energy expenditure increase at self selected walking speed for bilateral transtibial amputees?
|
41%
|
|
What is the % energy expenditure increase at self selected walking speed for bilateral transfemoral amputees?
|
186%
|
|
What is the % energy expenditure increase for amputees using a wheelchair?
|
9%
|
|
What is the % decrease in self selected walking speed pace for transtibial amputees?
|
20%
|
|
What is the % decrease in self selected walking speed pace for transfemoral amputees?
|
51%
|