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Symptom

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patient complaint (pain, stiffness, weakness)

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Sign

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objective finding- any finding in exam

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Joint Sign

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objective finding that is abnormal- may or may not be the comparable sign

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comparable sign

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combo of pain, stiffness, abnormal movement or spasm found by therapist in exam that is considered to be compared to the patient's complaint.

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Asterisk Sign

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outstanding signs used for quick re assessment of patient progress in both S.E. and P.E.

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Active movements

answer

movement performed by patient (watch patient squat to the floor)

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passive physiological

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passive performed by therapist; useful to locate R1, R2, P1, P2 (see and feel) (ex. Passive shoulder flexion)

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Passive Accessory

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movements available in a joint which are performed passively by therapist; to determine Rs, Ps, Ls, Bs (ex. shoulder AP glide) (feel the joint). In the spine these are called PAIVMS

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Maitland Thrust Manipulation

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High velocity, small amplitude thrust within or at end of available ROM and is performed such that a patient is unable to voluntarily prevent movement, Grade V

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Pluses and Minuses

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are used to further refine of previous grades (25% increments)

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Lateral thinking

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thinking outside the box "what else could it be?" "am I missing anything?" better than vertical thinking; not sequential and not predictable; involves restructuring and escaping old patterns; new ideas

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Vertical thinking

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using a protocol for treatment; logical, sequential, predictable, conventional thinking. Stays within the problem space. Hindered by the necessity to be right at each stage of the thought process and the attempt to rigidly define everything.

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Maitland's Key Principles

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1. Clinical assessment, 2. Mode of thinking, 3. Irritability and Nature, 4. Pathology, 5. Role of diagnosis, 6. Role of Theories, 7. Treatment of pain and stiffness

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Black Box

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Pathology often in a box; manual therapist approach of treatment of LBP by observing outputs of the box (signs and symptoms) and then applying their skills (inputs) to bring a favorable outcome. Hypothesis of box only becomes favorable when a true pathology exists

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Brick Wall (Two compartment mode of thinking)

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you have what you learned in school (biomedical knowledge/theoretical) that includes what is known and believed (anatomy, physiology) and then you have a clinical presentation what you see and hear and feel. The wall between is permeable when there may be differential dx going on. Need to be able to have biomedical understanding.

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Irritability "super pain patient" is determined by 3 factors:

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1. How much activity to irritate, 2. How much symptom provocation does it cause, 3. How long does it take to settle the symptoms down?

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Treatment for Irritable patient

answer

Grade I/II, brief bouts, short of barriers, treatment in neutral or early to mid-range, slow oscillations (1-2 seconds)

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Bony Block

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abrupt halt to movement; when hard surfaces meet ex. elbow extension

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Capsular end feel

answer

hardish arrest with some give ex. shoulder ER/ stretching leather

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Springy Block

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Intra-articular displacement at end of range ex. knee extension with meniscus tear

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Tissue Approximation

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normal sensation as soft tissue prevents further movement ex. rubber in a metal hinge/knee flexion or elbow flexion

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Empty End Feel

answer

prior to end of range, P2 limits further movement thus no end feel is felt ex. P2 prior to R2 "too painful"

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Spasm

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spasm limits further exploration of ROM S1-S2 is a steel line

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Grade I

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small amplitude of movement at the beginning of range- no resistance

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Grade II

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large amplitude movement within the resistance free range

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Grade III

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large amplitude movement into approximately 50% of resistance.

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Grade IV

answer

small amplitude movement into approximately 50% of the resistance

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Quick Tests

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Active physiological test movements; active ROM to quickly assess a joint.

question

Which Maitland concept is the most important

answer

Assessment (one of the seven maitland concepts)

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Biomedical Principles

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Treatment selection is based on this

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Which thought process used frequently by novices, most likely involves the least amount of reasoning

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Protocol prescription

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Maitland concept is defined as:

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based upon the assessment and treatment of signs and symptoms, respecting the diagnosis including an understanding of the pathology.

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Robert Elvey

answer

developed upper limb tension tests

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David Butler

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refined the concept of neurodynamics

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Jenny McConnell

answer

devised assessments and treatments for the knee and for the shoulder.

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Mark Jones

answer

applied the principles of clinical reasoning to physical therapy

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Gwendolen Jull

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presented high quality clinical and theoretical research on manual physical therapy and stability.

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Three types of assessment include:

answer

analytical, clinical and differential

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What are pitfalls during the assessment process which are behavioral faults?

answer

1. biased questioning 2. obtaining "fringe" info at the first visit, 3. ignoring findings which do not support a favored hypothesis, 4. incomplete SE and PE.

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Which modes of thinking fit into a valid analytical assessment within the clinical decision?

answer

vertical, lateral, inductive and deductive

question

When treating pain or stiffness, what factor is least important in making this clinical decision?

answer

The diagnosis (things like: intensity, duration, and location of pt's pain, amounts taken and the effects of OTC medicine, behavior of patients pain during sleep and throughout the day are important)

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Grade III techniques of exam and treatment are most commonly used for treating:

answer

in range pain

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To learn new techniques and then apply them to patients without accurate assessment is completely the wrong idea. If the patient gets better, the improvement is simply the result of:

answer

random, dumb luck

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What is the key to the therapist self improvement and better patient outcomes:

answer

accurate assessment in all phases of treatment

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For the exam and treatment of a stiff- dom shoulder the grade of the exam and treatment techniques will most likely be:

answer

into both R1 and P1

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For the examination and treatment of a pain dom shoulder the grade of the exam and treatment techniques will most likely be:

answer

short of any barriers (I-II)

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Which types of questions are considered effective types of questions for assessment purposes?

answer

comparative questions

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PPIVMs

answer

Passive Physiological Intervertebral movements: similar to passive physiological movements, theses are techniques used to assess movements at individual spinal levels for example assessing lumbar rotation or flexion/extension. Also used when localizing forces at a spinal level prior to an end range technique of manipulation.

question

What are signs of "iron hands"

answer

1. white knuckles, 2. blanched fingernails, 3. tense muscles. (mobilizing force generated from the therapist's trunk is not one)

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What are ways to progress treatments:

answer

1. increase grade, 2. increase the time of each bout, 3. add more bouts, 4. do the techniques nearer end range

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For a stiffness dom patient what is a desirable outcome

answer

produce and increase the pain of the disorder for 45 minutes and the range of motion increases.

question

therapist do not predetermine or pre set grades, but rather pre set:

answer

desirable outcomes

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For treatment of a stiffness dom patient with accessory techniques the joint to be treated is place in:

answer

near it's pathological limit

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For treatment of a pain dom patient with accessory treatment and exam techniques are placed in:

answer

short of pain (P1)

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Hard

answer

On a movement diagram, an R1 and R2 line which is steep, suggests that the end feel of joint is:

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How do you determine the proper level of treatment

answer

assess the behavior of the tissues at the suspicious level, then get the patient's input

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opening in the cervical spine

answer

contralateral rotation, flexion, and traction

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opening in lumbar spine

answer

ipsilateral rotation, flexion, contralateral sidebending and traction

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Capabilities and restrictions

answer

What a patient can do and what a patient cannot do. It replaces disability and handicap. Ex. Patient is able to walk 5 minutes, or Able to sit for prolonged periods of time/unable to sit for x amount of time.HYPOTHESIS CATEGORY

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Patient's Perspectives

answer

"psychosocial" or "mental status" and "cognitive and affective status"; patient's understanding, beliefs, and feelings. Understanding the whole patient thus includes understanding of the potential effect of the past and present negative personal experiences such as : conflicting dx or prior medical management. HYPOTHESIS CATEGORY

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Mechanisms of the symptom production

answer

Symptoms are either 1. peripheral, 2. central, 3. autonomic or 4. effective in nature and/or maintained. HYPOTHESIS CATEGORY

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Sources of symptoms

answer

Identify the source from which the symptoms are produced. In attempt to determine the source of symptom, the therapist formulates a hypothesis and then this tentative hypothesis is either accepted, rejected, or modified during subjective exam, PE or during tx phase. HYPOTHESIS CATEGORY

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Contributing or predisposing factors

answer

Things that contribute to the onset of the disorder are considered. They may have to be addressed during the course of the treatment and included as part of the preventative program to avoid recurrences of the disorder. HYPOTHESIS CATEGORY

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Precautions and contraindications to PT

answer

Attention to the findings in the SE will help determine the extent and vigor of the PE. Be on the lookout for items int eh special question section regarding general health, medications, and other health problems. HYPOTHESIS CATEGORY

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Management

answer

Is physical therapy indicated? The answer is influenced by an analysis of the patient's main complaint, site of symptoms, behavior of symptoms, precautionary questions, onset and progression, mechanisms of injury, past history, personality, outcomes and response to present tx. HYPOTHESIS CATEGORY

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Prognosis

answer

an estimate of how the patient's disorder appears amenable to PT and the estimated time frame. HYPOTHESIS CATEGORY

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Inductive Reasoning

answer

Forward, sometimes rapid process used by experts. Thoughts go from scripts and patterns to conclusions and actions. Involves the collection of smaller amounts of data most of which is relevant. Often referred to as forward reasoning.

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Deductive Reasoning

answer

Backward, slow process often used by novices. Thought processes go from general to specific. from hypotheses to conclusions and actions; from known to the unknown. Involves the collection of large amounts of data, some of which may be redundant. The reasoning process is often used in the diagnostic approach and often referred to as Backward reasoning.

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