#SPECIALTESTFRIDAY Fri Dial test Fri Patella apprehension test. Summary of part 1 with Kurt Lisle

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Debra Henderson
5 years ago
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#PODCASTTUESDAY W/C 6.10.14 AM Problem Solving Kurt Lisle Acute Knee Injuries Part 2 http://physioedge.com.au/pe-029-acute-knee-injuries-with-kurt-lisle/ W/C 13.10.14 AM Problem Solving Kurt Lisle Acute Knee Injuries Part 3 W/C 20.

Then use scans to confirm or rule out Certain injuries require orthopaedic review: o If knee is mechanically locked and you can t through early treatment unlock it - internal derangement o Avulsion

1 #PODCASTTUESDAY W/C AM Problem Solving Kurt Lisle Acute Knee Injuries Part 2 W/C AM Problem Solving Kurt Lisle Acute Knee Injuries Part 3 W/C AM Problem Solving Review of papers and discussion W/C Am Problem Solving ITB TBA Summary of part 1 with Kurt Lisle Acute ligament injuries: Diagnosis clinically is key. Then use scans to confirm or rule out Certain injuries require orthopaedic review: o If knee is mechanically locked and you can t through early treatment unlock it - internal derangement o Avulsion injuries of ACL in adolescents (Surgically manage within 7 days) o Severe posterior lateral meniscus o Severe ACL, MCL or medial patella-femoral ligament i.e. grade 3 o For young < 20 getting an x-ray can be important to show up avulsion injury Medial Patello-femoral ligament Often from patella dislocation. Consider if patient is describing feeling of dislocation, knee popping out etc. Commonly dislocated laterally. Can also be medially though. Ensure x-ray taken if they do describe that feeling There will always be an effusion- fairly large Rule out other ligament injuries Use apprehension test Glide knee cap laterally and compare Bracing General brace if grade 2 or above and if multiple juries i.e. Including medial compartment, tibial ligament Post-acute injuries To allow for rehab #SPECIALTESTFRIDAY Fri Dial test Fri Patella apprehension test Ege s Test for posterior horn of mensicus Sensitivity Medial 67% Lateral 64% Specificity Medial 81% Lateral 90% Positive likelihood ratio Medial 86% Lateral 58% Negative likelihood ratio Medial 57% Lateral 90% Usefulness: Useful when clinically correlated i.e. with subjective

2 #INTHENEWS Quiz results attached at the end. Having trouble convincing patients, students or physios that loading influences tissue!! Bone is adaptable The BJSM paper mentioned below is a must read for any physio if you haven t already #DRUGOFTHEWEEK- Amitriptyline Used for neuropathic pain pain initiated or caused by a primary lesion or dysfunction in the nervous system (International Association for the Study of Pain). Complex, chronic pain accompanied by neural and non-neural tissue injury. Associated with increased afferent and decreased inhibitory mechanisms, plasticity, sensitisation and hyperexcitability. NSAIDs and paracetamol give poor relief generally, opioid rarely 50% or more relief. Needs careful analgesic selection and titration and often multimodal over high does monotherapy. the close anatomical relationship between areas of brain involved in pain and emotion and the emotional nature of pain.treatment of mood disorders displays a powerful impact on pain by regulating the affective, emotional and sensory dimensions of pain Actions Amitriptyline has multimodal neuropathic pain reducing effects Monoamine reuptake inhibition enhancing pain suppression Blockage of NMDA receptors Blockage of sodium and calcium channels stopping pain getting to spinal cord Has anti-cholinergic (inhibit parasympathetic activity) and sedative properties Possibly normalises acetylcholine which would relax muscle spasm Possibly effects descending pathways inhibitory pathways

Positives Good evidence for chronic pain and neuropathic pain Low dose for pain (10mg-75/100mg) above 50-60 no evidence of further pain relief Well absorbed by gut Highly protein bound Long half

3 Positives Good evidence for chronic pain and neuropathic pain Low dose for pain (10mg-75/100mg) above no evidence of further pain relief Well absorbed by gut Highly protein bound Long half life- 4 days Effect on sleep usually immediate. Usually taken an hour or 2 before bedtime. Should be no later than 8pm. Taken as a tablet or syrup Negatives Many side effects as unselective- anti-histamine effects (sedation), anti-cholinergic effects (dry mouth), constipation, urine retention, postural hypotension, confusion, elevate blood sugar level Recent MI, significant heart disease, known hypersensitivity, pregnancy and breast feeding all contraindicated Can cause arrthymias, tachycardia, hypotension Minimal evidence supporting improved function or quality of life Evidence suggests patients not reaching 3 rd stage sleep cycle- pregabalin gives better REM Can take between 2-6 weeks to have an effect on pain #COURSEOFTHEWEEK- McKenzie A The Lumbar Spine Last week we looked at the 3 syndromes associated with McKenzie theory. I feel it s important to mention a couple of other terms associated. The first being centralisation. Now McKenzie has a different definition for centralisation, centralising and centralised, if you feel knowing this may make you a better physio then by all means look it up, for me that s far too complex and pointless. However centralisation of symptoms is important and the first aim we should have when seeing a patient with associated leg pain. Centralisation is the response to therapeutic loading that pain demonstrates in progressively being abolished in a distal to proximal direction. Back pain is fine for now just get rid of the leg pain. Peripheralisation is the production and / or worsening of distal symptoms Another big thing in McKenzie thoughts is the lateral shift, which when we come on to treatment needs to be the first point of correction. Right Lateral Shift exists when the vertebra above has laterally flexed to the right in relation to the vertebra below, carrying the trunk with it. The upper trunk and shoulders are shifted to the right (not the hip hip will be to left!) Left Lateral Shift exists when the vertebra above has laterally flexed to the left in relation to the vertebra below, carrying the trunk with it. The upper trunk and shoulders are shifted to the left. Picture. Easy stay with the next one as important when we come on to treatment. Contralateral shift exists when the patient s symptoms are in one leg and the shift is in the opposite direction. E.g. right leg pain with upper trunk and shoulders shifted to left. Ipsilateral shift exists when the patient s symptoms are in one leg and the shift is to the same side. E.g. right leg pain with upper trunk and shoulders shifted to the right. Clinical Relevance Upper body is visibly and unmistakenly shifted to one side

Onset of shift occurred with back pain Patient is unable to correct shift voluntarily If patient is able to correct shift they cannot maintain correction Correction affects intensity of symptoms

self-correct, or manual correction has been performed and this is home exercise.

4 Onset of shift occurred with back pain Patient is unable to correct shift voluntarily If patient is able to correct shift they cannot maintain correction Correction affects intensity of symptoms Correction cause centralisation or worsening of peripheral symptoms Generally only present with derangements Correction of lateral shift Self-correction Use if soft lateral shift patient can self-correct, or manual correction has been performed and this is home exercise. Can also be applied to posterolateral derangements that don t have lateral shift deformity but have a lateral aspect to their pain, i.e. extensions not working, but we ll come on to that next edition. 1. Patient against a wall, pain free side next to the wall, bent elbow at the side of patient. Use repeated or sustained pressure depending which works best. 2. Patient in doorway, forearms against doorway and move hips sideways. Close down symptomatic side. 3. Free standing, glide hips laterally whilst keeping shoulders level with floor. Can add OP with hands Manual correction This has 2 components. First the lateral shift is corrected then kyphosis is reduced and extension restored. Monitor symptoms throughout, if symptoms increase / peripherialise then adjust position. If position cannot be adjusted to relieve symptoms then stop. This is used for a patient with a hard lateral shift- unable to correct themselves. Usually for a subgroup 1. Patient in standing, arms at side with elbow on shift side bent to 90 degrees 2. Clinician stands on shifted side and places shoulder against patients arm just above elbow and interlocks fingers over pt s ilium, head behind patient. 3. Press shoulder into arm and pull pelvis towards self, producing a side gliding movement. If no reduction in symptoms may need sustained pressure. 4. To restore extension maintain slight over correction of shift and have patient arch backwards.

5 That s a few more terms and how we deal with a lateral shift. If a patient has a lateral shift then always try to correct that first. I have set up a feed on the clinical forum for McKenzie, be good to get people s experience of how they are using and what is working for people. I have been having some great effects by skipping straight to prone extensions with therapist overpressure and interestingly by applying it to some of my long term niggling necks. Be good to get some views. #EXERCISEOFTHEWEEK Patella Tendon rehab 1. Isometrics a. Sitting knee extension with weight / theraband b. Leg extension machine at the gym, maximum load muscle can tolerate c. Wall sit static position 2. Strength a. OKC quads b. Leg extension machine c. Active knee extension with weight / theraband d. Progress with higher load, lower duration 3. Functional Strength a. Lunge forward b. Lunge sideways c. Walk lunge with rule d. Slow lunge for endurance 4. Speed a. Within above exercises i.e. lunge, but add speed 5. Energy storage / athlete a. Split squats b. Jump and land in squat position c. Skipping d. Stairs e. Plyometric side hops #FROMTHEEDITORS Thanks for reading.enjoy! #AHPSCLINICALWEEKLY COMINGSOON 1. #DRUGOFTHEWEEK- Gabapentin 2. #EXERCISEOFTHEWEEK- a look at options for rehab for the different tendons 3. Summary of Kurt Lisle 4. #ARTICLEOFTHEWEEK- Scott Dye 5. Dial test 6. McKenzie Course Reviewposterior derangement

6 #QUIZOFTHEWEEK 1. A client presents with chronic mid portion Achilles tendinopathy, and asks for platelet rich plasma (PRP) injections. You could tell them that PRP injections, according to current research evidence, may result in: a. A better outcome compared to placebo b. Less morning stiffness c. No difference in outcomes compared to saline injection d. Improvement in their tendon structure 2. After having a platelet rich plasma (PRP) injection for chronic Achilles tendinopathy, the evidence suggests that a person can expect: a. To be more satisfied with treatment at 24 weeks post injection than if they had received a saline injection b. That they will be as likely to return to their desired sport at 24 weeks post injection as they would if they had had a saline injection c. To have improvements on imaging at 24 weeks compared to those who have had a saline injection d. To require another PRP injection at 4 weeks 3. A client presents to you with an Achilles tendinopathy in the reactive stage on the continuum model. The loading intervention most likely to aggravate symptoms is: a. Reducing current levels of sport or activity b. A heavy-load eccentric exercise program c. Completing non weight bearing exercises (e.g. swimming) d. Isometric exercises 4. What loading strategies would be most suitable for a lower limb degenerative tendon? a. Isometric exercises b. Eccentric exercises c. Swimming d. Pilates 5. The following is not a risk factor for tendinopathy: a. Diabetes b. High cholesterol c. Hyperuricaemia d. Vitamin A deficiency 6. Based on current research evidence, which of the following statements is true? a. Adiposity is a risk factor for rotator cuff tendinopathy b. There is no link between tendinopathies and foot ulcers c. There is no increased risk for tendon degeneration in people with familial hypercholesterolaemia d. Individuals with Type 2 Diabetes are not at increased risk of tendon degeneration

7 7. Pain in upper limb tendinopathies is different to lower limb tendinopathies in that: a. Upper limb tendinopathies are generally more painful b. Pain reduces more quickly in lower limb tendinopathies when treated with an eccentric strengthening program c. Upper limb tendinopathies may be more likely to have a central sensitisation component than lower limb tendinopathies d. The upper limb has more nerve fibres to transmit pain to the central nervous system 8. A client presents with chronic patellar tendinopathy with high baseline pain. You prescribe high load isometric exercises. You might see: a. An immediate reduction in pain b. An increase in pain for 2-4 weeks c. An immediate reduction in swelling d. An equal effect on the contralateral limb 9. You see a client who is completing a strength program of heel raises for Achilles tendinopathy. To determine whether the load was appropriate, when would be the best time to monitor the pain response? a. During loading b. Immediately after loading c. 4 hours after loading d. The next morning 10. A client is referred to you with hamstring tendinopathy. Which exercises would you avoid in the reactive stage? a. Swimming as a cross training exercise b. Hamstring curls (seated) c. Isometric hamstring exercises d. Bridging exercise 11. Which of the following statements is true in relation to the imaging of tendons? a. An improvement in tendon structure on ultrasound always correlates with improvements in pain and function b. Imaging of tendons will be able to predict clinical outcomes c. Ultrasound cannot be used to obtain an image of a tendon d. A reduction in pain may not correlate with an improvement in tendon structure 12. Which of the following is true regarding tendon imaging? a. Ultrasound provides more information about tendon structure than MRI b. Imaging techniques cannot visualise changes in tendon structure until 6 weeks post initial tendon injury c. Doppler ultrasound is not used in imaging tendons d. MRI is the gold standard for assessing changes to tendon structure 13. Which of the following is true about exercise therapies for tendinopathies? a. Eccentric exercise is the gold standard in exercise therapies for tendinopathies

8 b. Eccentric exercise may not be beneficial in some tendinopathies c. Heavy slow resistance training is not useful in the management of tendinopathies d. Isometric exercises are appropriate for all stages of tendon management 14. Eccentric exercise has been shown to have no effect or worse outcomes in: a. Mid portion Achilles tendinopathy b. Insertional Achilles tendinopathy when completed off a step c. Lower limb degenerative tendons d. Rotator cuff tendinopathy 15. Tendon pathology may be induced by: a. Overstretching the tendon b. Slowly increasing the tensile load on the tendon c. Inadequate warm up and cool down d. Compressive loads on the tendon 16. A clinical intervention that would reduce compressive load on the insertion of the Achilles tendon is: a. A heel raise in the client s shoe b. Increasing the amount of calf stretching c. Reducing weight bearing exercise d. Using crutches

Week 1 Orthotics- 1. Knee brace locked in full extension at all times except for rehab exercises 2. Elastic bandage as needed to control swelling

Week 1 Orthotics- 1. Knee brace locked in full extension at all times except for rehab exercises 2. Elastic bandage as needed to control swelling General Principles: This protocol was designed to provide the rehabilitation professional with a guideline of postoperative care. It should be stressed that this is only a protocol and should not be a