14 Chapter 05 – Lecture Unit 5: Clinical Practice I

Clinical Practice I:

1. Musculoskeletal System

2. Medical Documentation

Diseases and Conditions

• Musculoskeletal
• Neurological
• Cardiopulmonary
• Integumentary
• Pediatric
• Geriatric

At long last we come arrive at topics in clinical practice: What types of diagnoses you will be treating in the clinic and how you may be treating them.  What follows is just an overview of the topics you will cover in much greater detail next year in your professional practice courses such as Pathophysiology, Rehabilitation, Issues in Clinical Practice and Therapeutic Exercise.   Hopefully this tour of clinical practice topics with inspire you for the work you will soon be doing as a licensed physical therapist assistance.

MUSCULOSKELETAL

Questions regarding your knowledge of the musculoskeletal system comprise the largest component of the national PTA licensure examination. In clinical practice, you will find that regardless of the clinical setting you are in (acute care, long term care, pediatrics) many (sometimes most) of the patients you work with will have musculoskeletal disorders.  Sometimes, that is the reason you are seeing them. Sometimes these disorders will just be part of the PMH (one of their co-morbidities) but will need to be managed properly as you treat their primary condition.

For example, you may be in an in-patient setting working with a patient who has just had a cardiac event.  However, three weeks ago, they may have had knee surgery and their PMH reveals that they have a torn rotator cuff. So while your treatment plan will be focused on interventions to restore the patient’s cardiovascular impairments, you will need to be keenly aware of their knee and shoulder conditions.  Of course, the opposite is also true: You may have a patient who has just had surgery to repair their rotator cuff, but they may also have a history of a neurological impairment. Thus, you will need to manage the impact of that neurological impairment as you treat their rotator cuff repair.

This may seem like a daunting task now. However, by the time you complete your studies in this program, this process of total-patient-awareness will make sense.  Now, however, it is time just to get a lay of the land…let’s begin with just a simple survey of the musculoskeletal system.

MUSCLE CONTRACTION DURING EXERCISE.

STRENGTHENING

As a PTA, you will be providing treatments to either strengthen or lengthen the muscles of your patient.  You will be seeking to return muscle balance to body parts because muscle imbalances (when muscles on one side of a body structure are much stronger or weaker than those muscles on the opposing side) often lead to pain and movement dysfunction. Remember that key phrase: Strengthen or Lengthen as much of your career will focus on this principle.

Strengthen:

We can strengthen a muscle through a variety of exercises based on the degree of muscle weakness and the type of muscle function we are seeking.

1. Isometric exercises: Isometric just means “same length”. This refers to a type of muscle contraction in which there is no movement occurring. For example:
   1. Flex your right elbow to a 90-degree angle with its palm facing upward
   2. Place your left hand on top of your right palm
   3. Push down into your right palm (as if you want to straighten your right arm) AS you SIMULTANEOUSLY flex your right arm with a force equal to that of your left hand.
   4. Your right elbow flexors are contracting isometrically: No motion is occurring, yet those flexors are generating significant force.
   5. When would you choose to do an isometric exercise with a patient?
2. Concentric exercises. Meaning, with movement, this is the type of muscle contraction you are probably most familiar with: The muscle that is contracting, shortens in length.
   1. Repeat the example above, but this time, provide less force with your left hand – allowing your right elbow to flex.
   2. The right elbow flexors are ‘contracting in a concentric manner’ – and consequently, the elbow flexors are ‘shortening’.
3. Eccentric exercises: In lab a few weeks back, you were asked to sit on the mat table “very slowly”. Many of us reported that the slower we lowered ourselves to the mat table, the harder it was for us to do.  Lowering yourself slowly requires muscles to be in a contracted state BUT lengthen at the same time. Huh?  Let’s repeat the above example to illustrate this phenomenon.
   1. In the starting position of elbow flexion, allow the force of the left hand to be slightly greater than that of the right elbow.
   2. What happens is that your right elbow will SLOWLY straighten…and yet, the elbow flexors are still working aren’t they?

   Let’s try another example.  To keep things simple, let’s just focus on one muscle group: The four muscles that make of the muscles that extend the knee: The quadriceps.

   1. Put your hands on your thighs.
   2. Tighten and relax your quads.
   3. Keeping your hands on your quads, stand up. Do you feel them contract?  That was a concentric contraction because they went from being in a lengthened state to a shortened state.
   4. Now, keep your hands on your quads as you SLOWLY sit (really slowly). Can you feel them contract (maybe even “burn” as you sit slowly?).  That is an eccentric activity.  The quads went from a shortened position to a lengthened position while under tension (while still being in a state of contraction).

   We will explore this type of contraction more next semester, but for now, play with these examples a few times to see if this very important type of contraction makes sense.

4. Isokinetic. Isokinetic exercises (“same speed”) are completed with the help of (very) expensive exercise equipment.  For now, just appreciate this term.  More on this in your therapeutic exercise course.

LENTHENING: Flexibility

1. Range of Motion (ROM) will be a term you will soon know well. How far a muscle can move around a joint of body part is referred to as its range of motion.  As a PTA, you will need to be aware of, and become skilled in measuring, three types of ROM.
   1. PROM: Passive range of motion refers to the process of moving a patient’s body part WITHOUT any help or active participation from the patient.  They are “passive” – not helping in any way.
   2. AROM: Active range of motion is the process of allowing the patient to move their body segment as far as they can on their own WITHOUT any of our help or assistance. A way to think of this is that now we are “passive” – not helping them in any way as they actively attempt to move their body part.
   3. AAROM: Active assisted range of motion is just what it sounds like: We assist the patient as the patient is performing their ROM. In a way, no one is passive: Both the therapist and the patient are actively involved in the process of moving the body part.

INJURIES AND CONDITIONS:

• Bursitis: Inflammation of fluid-filled sacs located throughout the body

The bursa provides a cushion between bones and tendons and/or muscles around a joint. When there are unusual or excessive forces being produced at a joint, the bursa that surrounds that joint can become inflamed.  This happens often in cases when the muscle strength and length around a joint is not balanced OR when poor posture or body mechanics are repeated over a period of time.

• Inflammation of the musculotendinous junction is referred to as tendonitis.

The tendon is the part of the muscle that attaches the muscle to the bone.  This part of the muscle is less vascular, but stronger.  Still, it is vulnerable to inflammation for the same reasons the bursa may become inflamed. In fact, if the bursa is inflamed, odds are it will also inflame the tendon.  Tendonitis conditions develop at many joints in the body, are often related to muscle imbalances, poor body mechanics or posture and are slow to heal.  You will be providing both interventions to relieve the inflammation, promote muscle balance as well as improve body mechanics and posture.

• A muscle Strain: A condition is which muscle fibers are torn. If we think of tendonitis and bursitis are conditions of chronic overuse, we might think of muscle strains as acute injuries: One that develops from a one-time event: An athlete who extends their leg farther then they normally would in an effort to beat the first baseman to first base, might tear some fibers of their hamstring muscle.

• A Sprain: This is the term used to describe fiber tears within a ligament. If you remember, ligaments connect bone to bone.  We measure the degree of severity of ligament tears as Grade 1, Grade 2 or Grade 3.

CONDITIONS of the BONE: Fractures and Arthritis

This is a topic that will be covered in great detail over the next semester.  However, it is important that you appreciated the following:

Fractures of bones require immobilization to heal.  If the patient were to bear weight through a fractured body part, that pressure could cause the fracture to worsen.  To help the fracture site stay together, the orthopedic surgeon may:

1. Cast the body part so it can not move AND instruct the patient to bear NO WEIGHT through that body part. Thus, we have the weight bearing restrictions as described in our transfer and gait chapters.
2. Use metal instruments: metal plates, screws or pins to hold the fractured pieces together while the body heals. This is referred to as an Open Reduction Internal Fixation procedure. An ORIF.  Open Reduction just means that the surgeon performed surgery (incised the tissue around the fracture so they could see the bone segments and then…) Internal fixation: The process of using the screws, plates and/or pins to hold the fractured pieces together.
3. Again, the patient is NOT to bear weight on this area during the healing phase.

Arthritis: A condition in which there is inflammation and often degeneration of a joint surface or surfaces.  This condition may be due to an autoimmune response (as in Rheumatoid arthritis) or due to a chronic wearing away of the articular cartilage that covers the joint surfaces (Osteoarthritis).

When the arthritis leads to joint degeneration, pain and a loss of ROM such that the quality of life of the individual is impaired, the orthopedic surgeon may need to perform a joint arthroplasty. You are familiar with this as a “joint replacement” – also known as a “total knee replacement…hip replacement…shoulder replacement” …etc.

TREATMENT: 

Your treatment of the above conditions will be comprehensive in nature; treating the cause of the injury as well as the pain from the injury.  However, you will find yourself often integrating thermal treatments to facilitate healing or pain relief.  Some that you may use include:

Ultrasound: The use of high frequency sound waves to generate increased circulation within muscle, tendon or ligamentous tissue

Diathermy: The use of electromagnetic energy to produce deep therapeutic heating effects.

Cryotherapy: The therapeutic use of cold.

You will also be providing interventions to improve muscle balance through strengthening and lengthening of the muscles that surround the body part. To that end, a thorough knowledge of muscle function will be necessary.  That will be presented to you in PT120 and PT 384.

MEDICAL DOCUMENTATION:

Please use the following link to read chapters 1 – 3 regarding Medical Documentation for the PTA.

Medical Documentation Link

REFLECTION:

Can you think of any reasons why you might utilize one type of ROM over another?

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What do we call the “protractor thing” that we use to measure joint motion?

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When might you choose to use an isometric type of exercise with a patient rather than a concentric exercise?

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Please list YOUR OWN examples of each type of muscle contraction:

1. Isometric____________________________
2. Concentric__________________________
3. Eccentric___________________________

If your patient had a recent ORIF, why might the surgeon direct that they are NWB’g for their gait training?
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What might happen if the patient decided to just do WBAT?

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What might happen if they used their NWB’g LE as the lead leg while scaling steps?
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If the surgeon advances the weight bearing for your patient because they are healing so well and allows “PWB’g”, what types of ADs could you use for gait training?

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What ADs could you not use?

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In what part of the note do you put the patient’s comments?

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