ABG's Normal Values

Interpreting ABG's is an important especially if working in a respiratory setting, but to recognise abnormalities you need to know the normal values of blood gases.

pH - 7.35 - 7.45

pCO2 - 4.7 - 6.0 kPa (35-45 mmHg)

pO2 - 11 - 14 kPa (80-100 mmHg)

HCO3 (bicarbs) - 22 - 26 mmol/l

BE (metabolites) - +2 - -2

Colle's Fracture

Fracture of the distal radius in the forearm with posterior displacement of the wrist

Clincally reffered to as 'dinner fork deformity' due to the resultant shape of the forearm

Usually caused by falling onto outstretched hands (falling on flexed wrists would cause a Smith's fracture)

Common fracture in people with osteoporosis

Enthesopathy

Refers to a disorder which affects the the point at which a ligament or tendon attaches to the bone!

Radiculopathy ?

A radioculopathy is a condition due to a compressed nerve in the spine that can cause: pain, numbness, tingling or weakness along the course of the nerve.

Radiculopathy can occur in any part of the spine but is usually most common in the lumbar and cervical regions.

Occurs due to nerve root compression and results in dermatomal loss of sensation, myotomal loss of motor recruitment and disturbance of spinal reflexes

ULTT2B

For radial nerve (that can also mimic the symptoms of tennis elbow)

You do this one facing the feet!

• Shoulder Depression
• wrist flexion and pronation
• elbow extension
• shoulder medial rotation
• then abduction (LAST!)

Contraindications to ultrasound

DOC-P (2's and 3) MINS-U (1's)

D1 - Deficient sensation (will be unaware if unstable cavitation is occuring resulting in burns)
D2 - DVT in treatment area (could become dislodged and cause pulmonary embelism)
O1 - Over spinal cord after recent spinal surgery (unstable cavitation in CSF)
O2 - Over pelvis or abdomen during menstruation or pregnancy
C1 - Compromised circulation (vessels can't deal with excess demand)
C2 - Cancer (irradiated tumours grow larger and heavier)
P1 - Physio untrained
P2 - Peripheral vascular disease (tissues can't cope with excess metabolic demand)
P3 - Previous deep x-ray therapy (radiotherapy)

M - Metal or plastic implants (cause more standing waves)
I - Infection in treatment area
N - No consent
S - S.E.G Skull, eyes, gonads
U - Unknown diagnosis

ULTT1

ULTT1 - all 3 major upper limb nerves are stretched with a median bias

• Stabilise scapula by depressing shoulder
• Abduct shoulder 1st
• Supinate
• Extend wrist and fingers
• Laterally rotate
• Extend elbow

Apply each one fully and check if the patient's alright before progressing to the next movement.

Be aware of your posture and ELITE

Inform the patient of what you're looking for, for them to not adjust their position as it will effect the results of the test and may produce a false positive and to inform you if they feel any pain or parasthesia

No pillows

Make sure patient is positioned properly on plinth so arm doesn't fall into horizontal extension or not enough room for abduction

Carpal tunnel syndrome

Carpal tunnel syndrome, or median neuropathy at the wrist, is a condition where the median nerve is compressed at the wrist. This leads to paresthesias (pins & needles) and muscle weakness in the hand. Night symptoms and getting woken up is also something that from your subjective assessment would be ringing bells to test for carpel tunnel syndrome. But what are these "tests" you speak of??

The median nerve sits between flexor digitorum profundus and flexor digitorum superficialis

Phalen's Test

This position reduces the size of the carpal tunnel, so if you did

have it, the symptoms would be aggravated temporarily. A +ve

test would reproduce pain, numbness or tingling.

Tinnel's Test

Uses a tapping movements over the line of the median

nerve over the flexor retinaculum area.

You're looking for setting off the sensations of pin's and needles

Peripheral Vascular disease (PVD)

Peripheral vascular disease or PVD is a broad 'umbrella' term used to describe any disease (or pathology) which involves compromised circulation of the large arteries to the arms or legs due to obstruction.

It can result from:
- atherosclerosis
- embolism
- thrombus formation

Causes either acute or chronic ischemia to arms or legs

Beat frequency

"The beat frequency is the resulting low frequency at the cross over point of 2 medium frequency currents"

E.g. If the current at at electrode A is set at 4100 Hz and 4000 Hz at electrode B'

the beat frequency will be 100 Hz and therefore target Abeta fibres (high frequency, low intensity)

Hyperalgesia & Hyperesthesia

Hyperalgesia = An increased sensitivity to pain, may be caused by damage to nociceptors or peripheral nerves. Hyperalgesia also occurs as part of the evolved response to infection and as part of sickness behaviour

Hyperesthesia = a condition that involves an abnormal increase in sensitive stimuli of the senses (hear,touch,taste etc). Increased touch sensitivity is known as 'tactile hyperesthesia' and increased sound sensitivity is known as 'auditory hyperesthesia'.

'RESPIM' a sure fire way to stimulate Abeta fibres ;)

'R' is for

Rub

'E' is for ...

Exercise (high intensity cardiovascular exercise/that stimulates proprioceptors)

'S' is for

Sweeping...synovial sweeping that is

'P' is for Passive movements / accessory

movements

'I' is for

Interferential treatment














'M' is for


Massage

Barkark or Bankart lesion?

An injury of the anterior glenoid labrum due to repeated anterior shoulder dislocation.

It's an indication for surgery and often accompanied by a Hill-Sachs lesion, damage to the posterior humeral head

Tennis elbow

A condition characterized by pain and tenderness on the outside of the elbow and in the back of the forearm. Its medical name is lateral epicondylitis.

Tennis elbow is caused by inflammation of the tendon that attaches the extensor muscles (in this case the muscles that straighten the fingers and wrist) to the humerus. The condition results from overuse of these muscles, causing constant tugging of the tendon at its point of attachment to the humerus.

Causes

Tennis elbow may be caused by playing tennis or other raquet sports with a faulty grip, but more commonly due to other activities such as gardening, manual labour (screwdriving).

Treatment

- Ultrasound

- RICE

- NSAIDS

- corticosteroid injection

- surgery to release the tendon

If it keeps recurring it's wise to take a break for a couple of weeks from raquet sports to see if that's definately what's causing it and then if it is seek professional advice is playing technique and equipment.

Contraindications to massage

1. Open wounds

2. Muscle ruptures

(In the acute stage these may still be bleeding. Massage will increase bleeding and tissue damage at this stage and prolong recovery. After the initial 0-72 hrs of acute phase massage may be possible but depends on extent of injury)

3. Tendon ruptures

(Complete ruptures will require surgery not massage. The above also applies)

4. Contusions

(These are impact injuries within the muscle - intramuscular - Massage to a contusion may cause further damage and possibly bone growth within the muscle aka myositis ossificans)

5. Burns, chillblains and broken bones

6. RA and gout

(These are active inflammatory conditions, so massage may cause further inflammation)

7. Bursitis

8. Myositis Ossificans

9. Infections of skin and soft tissue

(Bacterial, viral, fungal infections can be spread to other areas of the body)

10. DVT (thrombosis)

(If dislodged can lead to pulmonary embelism, heart attack, stroke)

11. Artificial blood vessels

(Implanted through surgery should be avoided)

12. Bleeding disorders such as heamophillia

(May cause tissue damage and further bleeding)

13. Tumors

14. Anything else you're not sure of!

Tissue Proliferation (fibrous repair) 1-10 days + post injury - Pathophysiology

• Ongoing phagocytosis
• Angiogenesis
• Production of collagen fibres (initially produced in random fashion)
• Absorption of inflammatory exudate

Angiogenesis

FORMATION OF NEW BLOOD VESSELS

Factors influencing the rate of healing in the stages of proliferation and remodelling

• Severity of initial trauma: A severe second degree ligament sprain of the lateral ligament complex of the ankle will have a more prolonged proliferation and remodelling period than a first degree ligament sprain affecting the same structure.

• Early Management: When the necessary foundations have been set in place (e.g. protection, rest of tissues etc) for proliferation and repair can potentially reduce onset of chronic inflammation.

• Tissue Vascularity: e.g. skeletal muscle = highly vascular = more potential for repair than a a ligament = avascular

• Age: Younger people are quicker to heal than older

• Nutrition: e.g. protein deficiency, adequate nutrition that is also related to bloodflow is required for healing to take place

• Medication: Use of NSAIDS and steroidal drugs slow down proliferation and remodelling processes.

• Temperature: Colder it is = slower rate of healing

• Appropriate loading of healing tissue during rehab

Stages of the healing process: BIP-R

BLEEDING

INFLAMMATION

PROLIFERATION

REMODELLING

These stages are NOT mutually exclusive (they don't just happen one at a time individually) they overlap!

APOPTOSIS

Programmed cell death

(as opposed to necrosis = uncontrolled cell death)