1
Q
What does HOAC stand for
A
- hypothesis-oriented algorithm for clinicians
2
Q
What is HOAC
A
- method for hypothesis development
- provides a good algorithm to use for reflection of clinical practice
3
Q
Forward Reasoning
A
- have a pre-existing expectation and looking for information that fits
- uses past experiences
- “if, then” pattern recognition
- i.e. if X is a frog then it croaks and eats flies
4
Q
Backward Reasoning
A
- starts with a hypothesis and works backwards
- if X croaks and eats flies, then X is a frog
5
Q
Interactive Reasoning
A
- teaching, patient focused
- getting to know the patient and involving them in the problem solving process
- can be difficult for a novice
6
Q
Conditional Reasoning
A
- reflection time
- good or bad
- exhausting
- difficult for a novice
- hallmark of an expert clinician
7
Q
Two Models of Health and Disability
A
- Nagi model
- international classification of function model
8
Q
Nagi model
A
- pathology
- impairment
- functional limitation
- disability
9
Q
International classification of Function (ICF) Model
A
- ability slant to the nagi model
- body structure and function
- activity
- participation
- contextual factors
10
Q
Coding
A
- certain codes are used and mean different things
- i.e. ICD-9, 742.2 is lumbago
- you can code to reflect the ICF
11
Q
Palpation objectives
A
“can only be learned by palpation”
- detect abnormal tissue texture and location
- detect asymmetries of position
- detect sensitivity to palpation/pressure
- detect changes in findings to note improvements/regressions of symptoms
- fingertips have most sensory
12
Q
3 phases of palpatory sense
A
- reception: proprioceptors and mechanoreceptors of the hand receive stimulation from the tissues palpated
- transmission: information transmitted through peripheral and central nervous system to brain
- interpretation: this information is analyzed and interpreted
13
Q
Roles of different parts of hand in palpation
A
- thumb and fingertips: pressure probes for differences in depth
- finger pads: fine discrimination of textural differences, skin contour temperature
- palm of hand: stereognostic sense of contour and shape
14
Q
Stereognosis
A
- the ability to perceive and recognize the form of an object using cues from texture, size, spatial properties
- testing this involves patients identify common objects placed in hands without visual clues
15
Q
Principles of palpation
A
- move SLOW
- avoid excessive pressure
- layer your palpation, don’t start deep (less is more)
- concentrate/focus
16
Q
Active ROM
A
- the arc of motion attained by a subject during unassisted voluntary joint motion
- allows examiner to screen for abnormal movements
- assess patient’s willingness to move
- assess patients ROM and coordination
- gives an indication of contractile tissue status
17
Q
Passive ROM
A
- the arc of motion attained by an examiner without assistance from the subject
- enables the examiner to detect pain, give an indication of true joint mobility, and assess the tissue that is limiting the motion (end feel)
- provides info about integrity of joint surfaces and extensibility of joint capsule and associated ligs
18
Q
Hard end feel possibilities
A
- bone
19
Q
Soft end feel possibilities
A
- soft tissue approximation (muscle)
20
Q
Firm end feel possibilites
A
- capsular, ligament, muscle stretch
21
Q
Boggy end feel possibilities
A
- edema, synovitis
22
Q
Empty end feel possibilites
A
- pain
23
Q
Capsular Patterns
A
- pathological conditions involving the entire joint capsule cause a particular pattern of restrictions involving all or most of the passive motions of the joint (capsular fibrosis and considerable effusion/synovial inflammation)
24
Q
Factors affecting ROM
A
- age
- gender
- body mass
25
Goniometry
- measurement of angles created at human joints by the bones of the body
- can determine a resting joint position, end range, total amount of motion available at a joint, muscle length
- used to measure and document the amount of active and passive joint motion
26
Validity
- the degree to which an instrument measures what it is purported to measure: the extent to which it fulfills it's purpose
27
Face validity
- the instrument generally appears to measure what it is supposed to measure
28
Content validity
- whether or not an instrument adequately measures and represents the domain of content of the variable of interest
29
Criterion-related validity
- justifies the validity of the instrument by comparing measurements made with the instrument to a well-established gold standard measurement
- i.e. radiography
30
Reliability
- the amount of consistency between successive measurements of the same variable on the same subject under the same conditions
- can vary based on body part being measured
31
goniometric ROM of the extremities
- good to excellent reliability
| - upper greater than lower
32
Goniometric reliability
- fixed position measurements have higher reliability than motion measurements
- intrarater > interrater: 4-5 deg deviation by one examiner, 5-6 deg deviation between examiners
- 6 to 12 deg difference is necessary to show a "true change"
33
How to improve your reliability
- consistency
- well-defined positions
- well-defined anatomical landmarks for alignment
- same device to take successive meausrements
- same examiner taking successive measurements
- use the device that is suitable in size to the joint
34
ROM measurement tools
- universal goniometer
- gravity-dependent goniometer (pendulumn/bubble inclinometer, single/double inclinometer)
- region specific ROM device (CROM, BROM)
- tape measure
- visual estimation
35
Universal Goniometer
- most common instrument used to measure joint motion
- clinical > research
- plastic vs metal // flexible vs rigid
- different sizes, arms vary from 1-14 inches
- built in bubble levels
36
Goni stationary arm
- usually placed on the bone proximal to the joint being tested
- part that is connected to the protractor
37
Goni movement arm
- placed distally to the joint being tested
| - moveable
38
Goni fulcrum
- placed over the axis
- changed during movement...always re-place where supposed to go
- little silver circle holding two arms together
39
Inclinometer
- gravity-dependent goniometers: use gravity on pointer/pendulum and fluid levels/bubbles to measure motion (360deg motion)
- single inclinometer method: good for obtaining total ROM, doesn't eliminate compensations
- digital inclinometer: android play store: clinometer
40
Double inclinometer method
- better when trying to isolate movement to a specific location (i.e. only lumbar ROM, minus thoracic, minus hip flexion)
- eliminates compensations
- a little more difficult to perform
41
CROM / BROM
- joint specific measurement devices
- CROM = cervical
- BROM = back/lumbar
- can be more reliable due to consistency (inter and intra)
42
Tape measure
- typically used for spinal ROM
- skin distraction
- chin to chest
- finger-tip to floor
43
Visual Estimation
- some examiners use this over goniometric measurement
- NOT recommended (subjective vs objective)
- useful in the learning process...help reduce errors due to incorrect reading
44
Optimal testing position for assessing ROM
- place the joint in starting position of 0 degress
- permit complete ROM (against gravity or gravity assist)
- provide stabilization for the proximal joint segment
- normal positions: supine, prone, sitting, standing
45
Alternative testing positions for ROM needed when
- needed when the optimal testing positions cannot be attained because of patient limitations
46
Stabilization when assessing ROM
- when able, stabilize the subjects body and proximal joint so motion can be isolated for a "true measurement"
- ideal when isolating joints, but there are times when you may want combined motions to occur (functional tasks like shoulder IR or ER)
47
Documenting ROM
- paper vs electronic
- end position: 145 deg knee flexion
- actual ROM: elbow flexion 0-50 deg, elbow flexion 20-70 deg
- total ROM: both of the actual ROM examples are 50 deg total ROM
48
Documenting ROM with hypermobility
- neg 20deg elbow extension....open to mis-interpretation.
| - some therapists don't believe in negative ROM
49
WNL
- within normal limit
- normal pain-free ROM during active or passive motion
- need to know normal ROM in order to confidently report this
50
Hypo vs Hyper mobil
- hypomobile ROM: i.e. an elbow that doesn't achieve full extension. Ø - 20 - 50
- hypermobile ROM: i.e. elbow that starts in 20 deg heperextension and ends at 140 deg flex. 20 - 0 - 140
51
Muscle length testing
- not truly assessing joint ROM
- measured indirectly by determining the maximal passive motion of the joints crossed by the muscle (one-joint mm, two-joint mm, multi-jt mm)
- passive insufficiency seen at two joint muscles due to inability of muscle to lengthen and allow full ROM at all joints
52
Manual Muscle Testing (MMT)
- manual resistance applied to a limb or other body part to objectify strength
- should be applied slowly, building up, never sudden or uneven
- applied in the direction of the line of pull of the muscle
- its important to stabilize proximal segments, avoid substitutions/compensations
53
Grade 5 MMT
- Full ROM
- against gravity
- max resistance
- normal
54
Grade 4 MMT
- full ROM
- against gravity
- moderate resistance
- good
55
Grade 3+ MMT
- full ROM
- against gravity
- min resistance
- fair +
56
Grade 3 MMT
- full ROM
- against gravity
- fair
57
Grade 3- MMT
- full ROM
- gravity eliminated
- more than 1/2 ROM against gravity
- fair -
58
Grade 2+ MMT
- full ROM
- gravity eliminated
- less than 1/2 ROM against gravity
- poor+
59
Grade 2 MMT
- full ROM
- gravity eliminated
- poor
60
Grade 2- MMT
- can't complete full ROM with gravity eliminated
| - poor-
61
Grade 1 MMT
- trace motion
- muscle contracts but no seen motion
- trace
62
Grade 0 MMT
- no activity
| - absent
63
MMT Grades for LE
- functionally able to perform ADLs (walking, stairs)
| - need MMT of 4
64
MMT Grades for UE
- functionally able to perform ADLs (feed self)
| - need MMT of 3 or 3+
65
Why no MMT grade 4+ or 5-
- actually all (+) and (-) are discouraged except 2-
- allows to make MMT more defendable
- addition of 4+ and 5- is mostly just inter-tester vs intra-tester reliability
66
Break Test
- most commonly used type of MMT
- patient asked to hold body part at mid-point in ROM and to not allow the examiner to "break" the hold by the manual resistance
67
MMT factors of influence
- positioning (length of muscle being tested, one vs two joint mm)
- proper stabilization
- where resistance force is being applied (long vs short lever arm)
- pain (main not just be mm weakness)
68
MMT Positioning
- pre-positioning of muscle has large influence on strength
| - if positioned by patient vs by therapist
69
Tension curve with MMT
- within about 10% the resting length of the muscle, the tension the muscle exerts is maximum
- HS are strongest in sitting at about 45 deg flexion
- at lengths above or below optimal length, tension decreases, taking away some of its strength
70
Proper Stabilization with MMT
- needed
- improves reliability and validity of MMT
- allows to test what intending to test
- minimizes compensations
- most stabilization is completed by PT but there are other ways
71
Short Vs Long lever resistance
- the longer the lever arm, the greater the challenge for muscle being tested
- longer lever arms may be indicative of more functional demands (hip abd, shoulder flex, scapular mm)
- examiner should apply resist near distal end of segment where muscle attaches
- keep in mind functional demands
- be cautious of excessive strain on joints
72
Pain effecting MMTS
- it's important to note if a weakness is limited by pain or not
- don't be afraid to document as limiting factor
- patient's willingness to endure discomfort may vary
73
Noteworthy factors in MMTS
- fatigue: testing before exercises vs after, testing with certain diagnostic conditions (MS)
- sensory loss: if patient can't feel resistance you may not have consistent/accurate assessment
- hand dominance
- therapist communication: have consistent instructions
- patient: does patient want to show off? does he/she want to seem more impaired?
74
MMT within available ROM
- when condition limits joint ROM, patient can only perform within range available..so if they can still go their full ROM and hold against resistance, even though not "normal" still a grade 5 MMT
75
Limitations of MMT
- MMT have value but has significant limitations
- suffers lack of objectivity
- reliability varies by muscle tested, experience of examiner, strength of examiner, age of patient, condition being tested
- lacks sensitivity
- MMT is more reliable and valid in presence of profound weakness (neuro condition)
76
Handheld dnamometer
- another way to measure hand strength
- set to second handle position from inside
- patient sits, arm resting at side, elbow flex 90deg, wrist between 0&30deg ext and 0&15deg ulnar dev
- record avg of 3 successive trials
- can compare normative values and to other hand
- non-dom is generally 5-10% less
77
Anthropometric Measurements
- anthropos - man, mentron - measure
- comparative measurements of body used in nutritional assess, compared to reference standards
- infants/children growth and development (length, height, weight, head circumf)
- adults (height, weight, BMI, % fat): skin folds and calipers
78
BMI calculation
- (weight (lbs)) / (height (inch)^2) all X 703
79
BMI ranges
- underweight: <18.5
- normal: 18.5-24.9
- overweight: 25-29.9
- obese: 30+
80
Screening and Testing
- can screen both extremities at same time to speed up process, usually not stabilized proximally, not true assessment
- if weakness found should retest unilaterally with stabilization to get more accurate rep
- if loss of motion found retest motion with method of quantification
81
Why do we care about posture?
- ROM
- Function
- Breathing
- Pain
- Weakness
- Organ function
- Vision
- Independence/mobility for life
82
Static Assessment of Posture
- forms the basis for dynamic
- standing
- sitting
- lying down
83
Dynamic Assessment of Posture
- walking
- running
- jumping
84
Proper Assessment of Posture
- patient wears adequate clothes&shoes
- patient should be examined in habitual or relaxed posture
- look for asymmetry (dominant side usually lower due to greater mm mass)
- look for muscle wasting, soft tissue swelling, bony enlargement
85
Normal posture
- position where minimal stress is applied to each joint
86
"good" posture - lateral/sagittal view
- straight line (line of gravity) passing through
- earlobe / EAM
- bodies of the cervical vertebrae
- tip of the shoulder
- midway through the thorax
- bodies of the lumbar vert
- slightly posterior to hip jt
- slightly ant to axis of knee jt
- just ant to lat malleolus
- earlobe is in line with tip of shoulder (acromion) and high pt of iliac crest
- each spinal segment has a normal curve
- no chest deformities
- pelvic angle is normal (PSIS slightly higher than ASIS)
- knee's flexed 0-5deg
87
"Good' posture - Anterior View
- head straight.
- tip of nose in line with manubrium and umbilicus
- upper trap neck line and bulk should be equal, slopes approx equal
- look at arm diff from waist, int/ext rot?
- are the shoulders level? (dom side lower)
- clavicles and AC jts level and equal
- arms equidistant from waist
- palms facing body
- iliac crests level
- ASIS levels
- patellae point straight
- knees straight
- heads of fibulae are level
- arches are present in feet and on two sides
- feet angle out equally
88
"Good" Posture - Posterior View
- head is in midline
- shoulders are level (compare from ant view)
- scap spines and inferior angles are level (base of spine of scap T3-4 & inf angle T7)
- scap medial borders are equidistant from spine
- winging&abduction?
- spine is straight
- ribs are symmetrical on both sides
- arms equidistant from body
- PSIS are level
- gluteal folds are level
- knee joints are level
- both achilles tendons descend straight to calcanei
- heels are straight
89
Posture is what type of muscle activation?
- isometric
90
What type of activity is posture muscular?
- endurance activity
91
Hyperlordosis
- increased lumbar lordosis
- body segment alignment: ant tilt and hip flexion
- muscles elongated and weak: hammies and abs
- muscles shortened and strong: hip flexors, erector spinae
92
Kyphosis/Kypholordosis
- increased thoracic curvature (can accompany lumbar lordosis, scap protraction and abd)
- muscles elongated and weak: rhomboids
- muscles shortened and strong: pec minor, serr ant, teres major
93
Sway Back
- spine bends back sharply at lumbosacral angle
- entire pelvis to shift forward and puts hips into ext
- not ant pelvic tilt
- muscles elongated and weak: abs, hip flexors
- muscles shortened and strong: gluts and hip extensors
94
Flat Back
- decreased pelvic inclination to 20deg and mobile lumbar spine
- body seg aligned
- elongated and weak: lumbar spine, multifidi, hip flexors
- shortened and strong: abs, hip exxtensors
95
Dowager's Hump
- often seen in older patients, esp woman
- 1-3 thoracic vert
- mainly caused by osteoporosis (ant wedging of vert bodies)
- results in flexed head and protruding abdomen (maintain COG)
96
Anterior View Faulty Alignments
- torticollis
- lateral pelvic tilt
- hip anteversion/retroversion
- coxa vara/valga
- genu varum/valgum
- bowing of tibia
- foot pronation/supination
97
Torticollis
- Can be congenital or acquired
- "scoliosis of cervical spine"
- contracted /scm
- could be due to inactivity
- common in orphanages and NICU pts/premis
- stretch SCM to treat
98
Posterior View Faulty Alignments
- Scoilosis
| - Rearfoot Varus/Valgus
99
Scoliosis Test
- Forward flexion "test"
- ask pt to flex forward at hips while both knees straight and feet together
- is there asymmetry? rib hump?
- pathological kyphosis
- lumbar spine straightens/flexes normally
- any restrictions to forward bending
100
Scoliosis & types
- functional vs structural
- functional: caused by postural problems, nerve root irritation, compensation from LLD, contracture. NNON PROGRESSIVE
- structural: bony deformity (congenital or acquired), excessive weakness, lacks normal flexibility, asymmetrical SB, does not disappear on flexion, progressive, idiopathic accounts for 75-85% of all cases
- named superior first (named for first curvature)
- wedging of all vert bodies
- could change shoulder height and scap position
101
Rib Hump
- fixed rotational prominence on the convex side
- seen when patient flexes forward
- spine rotates to one side, ribs push out posterior and appear higher
- narrowing of the thoracic rib cage occurs
- vital capacity is considerably lowered if the lateral curvature exceeds 60deg
- malposition of organs within rib cage can occur
102
Upper Crossed Syndrome
- results from forward head posture
- loss of lower cervical lordosis
- extension of upper cervical spine
- increased kyphosis of cervical thoracic junction
- internal rotation of shoulder girdle
- tight: pec major, pec minor, upper trap, levator scap, SCM
- weak: deep neck flexors, lower middle trap, serr ant, rhomboids
103
Pigeon Chest (Pectus Carinatum)
- sternum projects forward and downward
- protrusion of sternum and ribs
- increased in AP diameter
- congenital deformity
- restricts ventilation volume
104
Funnel Chest
- Sternum is pushed posterior by overgrowth of ribs
- AP diameter is decreased
- congenital deformity
- heart may be displaced
- hollow depression on inspiration
105
Barrel Chest
- sternum projects upward
- large rib cage, round torso
- increased AP diameter
- pathological conditions: emphysema
106
Tilting Scapular Deviation
- when the inferior angle pops out a little bit
| - usually due to tight pec minor
107
Winging Scapular Deviation
- caused by weak serr ant or nerve damage or palsy
108
LE Effect on Posture
- leg length diff (LLD): can cause shoulder height diff
- knee hyperexten: can cause lordosis issues
- knee varus/valgus can cause foot supination/pronation
109
Leg Length Difference (LLD)
- true vs apparent
- True: actual structural change
- Apparent: muscle imbalance, rotation
110
Coxa Vera causes what in knee and foot
- causes genu valgum
| - causes pronated feet
111
Coxa valga causes what in knee and foot
- causes genu verum
| - causes supinated feet
112
Sitting Posture
- ear over acromion
- slight cervical lordosis
- retracted scapula in proper position
- slight thoracic kyphosis
- slight ant tilt with lumbar lordosis
- consider femur support, lumbar support, vision alignment, height of seat, feet position
113
The GH Joint type
- convex humerus
| - concave glenoid fossa
114
GH joint resting positions
- 55 deg abduction
- 30 deg horizontal adduction
- slight ER
115
GH joint closed packed position
- full abduction and ER
116
Capsular pattern for GH joint
- lateral rotation (ER)
- abduction
- medial rotation (IR)
- ER > AB > (Flexion) > IR
117
What is a GH joint diagnosis through goniometry and end-feel
- adhesive capsulitis aka frozen shoulder
118
4 Bones that supports the muscles and ligaments of the shoulder
- 2 clavicles and 2 scapula
119
6 jts of the shoulder girdle
- 2 SC jts
- 2 AC jts
- 2 ST jts
120
SC type of joint and motions
- saddle/sellar joint
- elevation/depression
- retraction/protraction
- rotation
* *has a fibrocartilaginous articular disc (meniscus has 2 compartments)
121
Resting position vs closed packed position of SC joint
- restings: arm at side
| - closed packed: full elevation
122
SC joint Capsular pattern pain at extremes of what
- horizontal adduction
| - full elevation
123
AC joint type
- planar / gliding joint
| - anterior/posterior glide
124
AC joint functionally triaxial
- lax capsule
| - flexible disc (usually present)
125
AC joint resting vs closed pack position
- resting: arm at side
| - closed packed: 90deg abduction
126
AC joint capsular pattern
- pain at extremes of ROM
127
ST joint movement
- concave surface glides over convex thoracic spine
128
ST Joint location in each plane
- sagittal plane: tipped 10deg forward
- transverse plane: 30deg anterior to frontal plane
- frontal plane: essentially parallel to vertebral column
129
Scapular Muscle Influence
- "17" muscles originate or insert onto scap
- muscles "hold" scapula against the chest wall with isometric contractions supporting the arm
- rotate the scap to contribute to full arm ROM (done simultaneously or independent)
- proximal stability to allow distal functional mobility
130
Scapulothoracic Motions (list them)
- elevation
- depression
- abduction/protraction
- adduction/retraction
- upward rotation/glenoid up
- downward rotation/glenoid down
- winging and tipping (considered "other" motions)
131
ROM of scapular upward/downward rotation
about 60 degrees
132
ROM of scapular protraction/retraction
15cm
133
ROM of scapular elevation/depression
12cm
134
Purpose of Scapulohumeral rhythm
- distributes of shoulder elevation between two joints for larger amount of ROM with continued stability
- maintains congruency of the humeral head and decrease shear forces (prevents impingement)
- allows muscles to maintain good length-tension relationship to minimize active insufficiency
- should be smooth, coordinated, and symmetrical
135
Scapulohumeral Rhythm in the first 30deg of abduction
- humeral movement only by RC and deltoid
| - scapula stabilized against rib cage
136
Scapulohumeral rhythm of shoulder elevation
- 60 degrees from ST
- 120 degrees from GH (120 degrees with flexion, 90-120 with abduction)
- this 2:1 ratio is usually after the 30deg of shoulder elevation...0-30deg is mostly scapular setting
137
Summary of Clavicle Movement
- as scap upwardly rotates the distal end of the clavicle elevates 30deg
- here the costoclavicular and coracoclavicular ligaments become taught and cause a posterior roll of clavicle....rotates 45deg to get to the final 60deg of scapular ROM
138
Summary of AC joint Movement
- mainly functions as a pivot point (although technically its a gliding synovial jt)
139
Summary of Scapular movement
- 0-30deg: minimal to no scapular movement, scapular setting, axis at spine of scap near vertebral border
- 30-60deg: fossa rotates upward with GH joint, axis moves towards the glenoid fossa and is at the AC jt by 90-100deg of elevation
140
Contents of Axilla
- lymph nodes
- brachial plexus
- axillary vessels (artery and vein)
141
Anterior border of Axilla
- pec major
- pec minor
- subclavius
142
Posterior border of axilla
- subscapularis above
- teres major
- latissimus below
143
Medial Border of Axilla
- serratus ant
- ribs 2-6
- intercostals
144
Lateral Border of Axilla
- intertubercular groove/bicipital groove of humerus
- coracobrachialis
- short head of biceps
145
Shoulder ROM (flexion, extension, abduction, IR, ER)
- flexion: 180
- extension: 60
- Abduction: 180
- IR/ER: 90 ER 70 IR
146
Co/C1 and C1/C2 AROM
- flexion: 0-10/5
- extension: 0-<30
- coupled SB/rotation
- side bend: 0-22
- rotation: 50%
147
Lower Cervical AROM C2/3 to C7/T1
- flexion: 0-35/45
- extension: 0-<30
- side bending: 0-45
- rotation: 0-60
- coupled SB/rotation
- non-coupled SB/rotation
148
C1/C2 motion segment
- 50% of cervical rotation occurs here
| - 35-45
149
Craniocervical Flexion Test
- uses a stabilizer (pressure cuff) placed under neck abut to occiput to assess deep cervical flexors
150
2 things the craniocervical flexion tests assesses
- the strategy to perform upper cervical flexion
| - isometric endurance of deep cervical flexors
151
Neck Flexor Endurance Test
- Uses observation of neck folds and placement of therapists hand under the occiput to assess cervical endurance
- involved superficial cervical muscles but still assessing control of deep cervical flexors
152
Stage 1 of craniocervical flexion test: Analysis of performance
- patient supine, hooklying with pressure biofeedback under neck just abut to occiput pump,ed to 20 mmHg
- pt requested to say yes so they slide the back of head up the bed with head-nod action to elevate pressure from 20 to 22 mmHg
- hold 2-3 sec then relax to starting position
- repeated through 2 mmHg increments up to 30
- tester analyses motion and palpates activity of SCM or anterior scalenes (minimal activity until last 1-2 stages)
153
Signs of abnormal patterns/poor activation of DNF in craniocervical flexion test
- range of head rotation doesnt increase with increments
- movement strategy is head retraction
- patient lifts head in attempts to reach target pressures
- movement is performed too quickly
- palpable activity of superficial flexors or hyoid muscles in 1st 3 stages
- pressure dial doesnt return to starting position (greater than 20 mmHg)
154
Baseline assessment for stage 1: analysis of performance of craniocervical flexion test
- the stage of the test (increment) that the patient can achieve for the 2-3 sec with correct movement without palpable activity
155
Craniocecrcvical flexion test stage 2: isometric endurance
- patient performs head nod into first target pressure (22 mmHg) and holds for 10 sec
- if patient can perform at least 3 reps of 10 secs without substitutions, it's progressed to next target pressure
- therapist monitors movement strategy and pressure
156
Signs of reduced endurance in stage 2 of craniocervical flexion test
- patient cannot hold pressure steady, decreases even though they seem to be holding the head in the flexed position
- over-recruitment of superficial flexors
- pressure level is held but with a jerky action, suggests an alternate muscle is being used to hold pressure = weakness of deep cervical flexors
157
baseline assessment of stage 2: isometric endurance of craniocervical flexion test
- the pressure level that the patient can hold steady for the repeated 10 sec hold with minimal superficial muscle activity and absence of any other substitution strategies
158
Neck Flexor endurance test
- supine hooklying with hands on stomach
- patient performs a chin-tuck or upper cervical flexion and raises head from table about 1 inch
- therapist starts a timer while he places his hand under the occiput and observes anterior neck skin folds
- preferred way is to use a skin crayon to draw a line across folds
159
Neck flexor endurance test is terminated if....
- edges of the lines drawn no longer touched for more than 1 second
- subjects head touched the rater's hand for more than 1 second
160
Neck flexor endurance test norms
- patients without neck pain: 38.95 seconds
| - patients with neck pain: 24.1 seconds
161
3 Force couples of the shoulder
- upward rotation: serratus ant, upper trap, rotator cuff mm
- downward rotation: levator scap, rhomboid, pec minor
- depression: pec minor, lower trap
162
Somatosensory System
- receives information from environment
| - testing how well individual receives the necessary information
163
3 Main purposes of the sensory exam
- identify the pattern of loss
- identify which sensations are affected
- identify the degree to which sensations are limited
164
Motor Testing
- assessing the efferent response to a stimuli
| - stimuli used: isometric resistance to movement:myotomes, and deep tendon reflexes
165
Myotomes
- representative muscle of a single nerve root
166
Sensory exam results effect
- interventions
- goal setting
- patient/family education
- discharge planning
167
4 Components of Sensory Testing
- Cranial nerve testing
- sensory testing
- myotome testing
- reflex testing
168
Sensory testing options
- peripheral nerve distribution
| - spinal nerve (dermatome) distribution
169
Reflex Testing options
- cranial nerve reflexes: jaw reflex
- UMN reflex testing: hoffman's, babinski, clonus
- deep tendon reflex testing: UE and LE
170
Purpose of a quick screen of cranial nerve testing
- determine if a full cranial nerve screen is necessary. Use optic and facial nerves to quickly screen
171
Dermatome
- area of skin supplied by a single spinal nerve segment
172
Spinal Nerve Root Distribution Area's
- peripheral nerves are composed of spinal nerve roots
- test a peripheral nerve: test sensation in areas in which nerve root reside
- tests a spinal nerve root: test area corresponding to that nerve root
173
Nerve Root Impingements
- will see motor and sensory and reflex loss in: C5, C6, C7, L4, S1
- will just see motor and sensory loss (no reflex) in: C8, T1, L5
174
Axillary Nerve PND
- spinal nerve roots: C5, C6
- sensation: lower deltoid area
- teres minor and deltoid
175
Musculocutaneous PND
- injuries rare
- spinal roots: C5-7
- Motor: corachobrachialis, biceps brachii, brachialis
- sensation: lateral forearm
176
Radial Nerve PND
- spinal roots: C5-T1
- Motor: elbow extension, wrist and finger extension, supination
- Sensory: back of arm, hand
177
Median Nerve PND
- Spinal Nerve Roots C6-T1
- motor: pronation, wrist flexion, long finger flexors
- Sensory: volar surface digits 1,2,3
178
Ulnar Nerve PND
- nerve roots: C8-T1
- moto: little finger abduction, interossei, wrist flexion, finger flexion 4&5
- sensory: volar/dorsal surface 4,5
- injury at elbow most common
179
Femoral Nerve
- spinal roots: L2-L4
- motor: hip flexion, knee extension
- sensation: anterior thigh, medial lower leg/foot
180
Tibial Nerve PND
- nerve rots L4-S3
- motor: ankle plantar flexion, inversion, toe flexion
- sensory: posterior/lateral leg, sole, heel
181
Common Peroneal Nerve PND
- nerve roots: L4-S2
- superficial nerve motor: eversion
- deep peroneal nerve motor: dorsiflexion, toe extension
- foot drop
182
Glove-like or sock-like sensory loss
- cortical lesion
- doesn't follow dermatomes or peripheral nerve patterns
- covers all of hands and wrist both sides and/or same thing with foot
183
Types of sensation
- light touch
- sharp/dull pain
- deep bone vibration
- temperature
- proprioception
184
Sensory Exam Preperation
- testing environment: quiet, well lit, patient seated or semi-recumbent
- gather needed equipment
- prepare patient: explain purpose and tell them not to guess, they should be comfy and well rested, do a trial run, occlude vision
185
Sensory Examination Order
- non-impaired followed by impaired
- superficial to deep
- distal to proximal
- randomly with variation in timing
186
Improve Reliability
- consistent guidelines
- administration of tests by trained, skillful examiner
- subsequent retests by same individual
- ensure patient's understanding of test and ability to communicate
187
2 Purposes of motor exam
- identify the pattern of strength loss
| - identify the degree to which strength is limited
188
Muscle Testing Procedures
- isometric hold of the muscle groups supplied by a particular myotome (nerve root) or peripheral nerve
- use myotome key muscle testing if suspect nerve root compression or SCI
- use peripheral nerve muscle testing if a peripheral nerve lesion is suspected
189
C5 Strength test and motions Myotome
- shoulder abduction and external rotation
| - also elbow flexion
190
C6 Strength test and motions Myotome
- wrist extension
| - also elbow flexion
191
C7 Strength test and motions Myotome
- elbow extension
| - also wrist flexion and finger extension
192
C8 Strength test and motions Myotome
- finger flexion/wrist flexion
- thumb abduction and extension
- also abd/add of fingers and DIP flexion of middle finger
193
T1 Strength test and motions Myotome
- abd and add of fingers
194
L2 Strength Test and motions Myotome
- hip flexion
195
L3 Strength Test and motions Myotome
- knee extension
196
L4 Strength Test and motions Myotome
- ankle dorsiflexion
197
L5 Strength Test and motions Myotome
- great toe extension
198
S1 Strength Test and motions Myotome
- ankle plantar flexion
| - ankle eversion if can't do flexion
199
S2 Strength Test and motions Myotome
- knee flexion
200
Deep Tendon Reflexes
- reflex arc from the muscle spindle to the spinal cord (Ia phasic) and output back to the same muscle (agonist muscle fiber)
- loss or diminished conductivity in the DTR is normal
201
Representative reflexes by spinal segment (C5-S2)
- C5: biceps
- C6: Brachioradialis
- C7: Triceps
- L3,4: quads
- L5-S1: hammies
- S1-2: Achilles
202
DTR Ratings
- 0: absent reflex
- 1+: diminished, hypo-reflexia
- 2+: normal
- 3+: exaggerated, hyper-reflexia
- 4+: clonus
203
Hoffman's Reflex
- hold middle finger, flick distal end
| - +test: IP joint of thumb on same hand flexes
204
Babinski
- stroke the bottom of the foot from a heel to toe direction
- + test: first toe extends and other four toes fan outward
- indicates a presence of an abnormal reflex
205
What to document in sensory tests
- modality tested (light touch, temp, DTR, etc)
- body area affected (R/L, UE/LE, trunk, face, etc)
- degree or severity of involvement (absent, impaired, delayed, etc)
206
What senses do you often lose first after injury?
- Tend to lose light touch and sharp/dull
| - then lose deeper sensations
207
Expectations if UMN injury
- +babinski
- +hoffmans
- DTRs 3+, 4+
- myotome: fatigue
- dermatome: stocking/glove, hypersensativity
208
Expectations if NR injury at C7
- 0 hoffmans
- 0 babinski
- DTRs: C5 :2+, C6: 2+, C7: 0/1+,
- myotome: triceps impaired (C5-T1 (?))
- sensory: impaired at and below C7
209
Expectations if Radial Nerve Peripheral injury
- 0 hoffmans
- 0 babinski
- weak extensors
- weak elbow extensors
210
3 Joints of the elbow
- humeral ulnar
- humeral radial
- proximal radioulnar
211
Humeral ulnar joint
- hinge joint
- trochlea of humerus and trochlear notch of ulna
- axis of movement is downward and medial responsible for the carrying angle
212
resting position of humeral ulnar joint
- 70 deg flexion
| - 10 deg supination
213
Closed pack position of humeralulnar joint
- full extension and supination
214
Capsular Pattern of humeroulnar joint
- flexion/extension
215
Humeral radial joint
- uniaxial synovial hinge joint
| - capitulum of the humerus and the head of radius
216
humeralradial joint resting position
- full extension and supination
217
closed pack position of humeroradial joint
- elbow flexed to 90deg
| - supinated to 5 deg
218
Capsular pattern of humeroradial jt
- flexion
| - extension
219
Proximal Radioulnar joint
- uniaxial pivot joint
| - head of radius on the radial notch of ulna
220
Resting position of proximal radioulnar jt
- 70deg elbow flexion
| - 35 deg supination
221
closed pack position of radioulnar jt
- 5 deg supination
222
capsular pattern of radioulnar jt
- equal limitation of supination and pronation
223
Cubital varus deformity
- gun-stock elbow
- one elbow slightly flexed and sticking out (if carrying rifle)
- decrease in carrying angle, less than 5deg
224
Cubital valgus deformity
- increase in carrying angle, greater than 15deg
| - hand sticks out more
225
Triangle sign
- relationship of medial and lateral epicondyle and the olecranon
- view both flexion and extension of the elbow
- flexoin: these three points will form an equilateral triangle
- extension: these three points should be in a straight line
226
Two elbow ROM needed for most ADLs?
- elbow flexion
| - forearm pronation
227
Elbow normal flexion ROM
- 150 deg
228
Elbow normal extension ROM
- 0deg
229
Elbow normal pronation ROM
- 80deg
230
Elbow normal supination ROM
- 80deg
231
Testing for Hypermobility
- Beighton Score
- Quick and straightforward
- By itself a high score does not mean there is a hypermobility syndrome, need other symptoms and signs
- A low score should be considered with caution; numerous sites are not “counted” in the score
- 1 point if palms on ground with legs straight
- 1 point for each elbow that bends backwards
- 1 point for each knee that bends backwards
- 1 point for each thumb that touches forearm
- 1 point for each little finger that bends > 90°
Total Score: 9
- 6-9 is accepted for hypermobile
232
Distal Radioulnar Joint Resting Position
10 deg supination
233
Distal Radioulnar Joint Closed Pack Position
- 5 deg supination from neutral
234
Distal Radioulnar Joint Capsular Pattern
- full ROM
| - pain at end pronation/supination
235
Radiocarpal (Wrist Joint)
- Radius articulates with scaphoid and lunate and angles 15-20 deg toward ulna
- Lunate and triquetrum articulate with TFCC, which provides stability
- With disc the load bearing is 60% radius and 40% ulna
- Without disc it is 95% radius, ulna 5% of axial load
236
Radiocarpal (Wrist Joint) Resting Position
- neutral with slight ulnar deviation
237
Radiocarpal (Wrist Joint) Closed Packed Position
- extension with radial deviation
238
Radiocarpal (Wrist Joint) Capsular Pattern
- flexion and extension equally limited
239
Wrist Intercarpal Joints
- Joints between the individual bones of the proximal row of carpal bones (scaphoid, lunate, triquetrum) and the joints between the individual bones of the distal row (trapezium, trapezoid, capitate, and hamate)
- Pisotriquetral Joint is considered separate – not a direct part in other intercarpal movement
240
Wrist Intercarpal Joint Resting position
- Neutral or slight flexion
241
Wrist Intercarpal Joint closed pack position
- Extension
242
Wrist intercarpal joint Capsular Pattern
- none
243
Midcarpal Joint
- Compound articulation between proximal and distal rows (except pisiform).
244
Midcarpal Joint Resting Position
- Neutral, slight flexion with ulnar deivation
245
Midcarpal Joint Closed Pack Position
- Extension with ulnar deviation
246
Midcarpal Joint Capsular Pattern
- Equal flexion and extension
247
Carpometacarpal Joints
At the thumb is a sellar (saddle) joint with 3 deg of freedom
2nd-5th are plane joints
248
Carpometacarpal Joints resting position
- Thumb = Midway between abd/adduction, midway between flexion/extension
- Fingers = Midway between flexion and extension
249
Carpometacarpal closed pack position
- Thumb = Full opposition
| - Fingers = Full flexion
250
Carpometacarpal Capsular Pattern
- thumb = Abduction, extension
| - fingers = Equally limited in all directions
251
Metacarpophalangeal MCP Joints Resting Position
- slight flexion
252
Closed Pack Position of MCP jts
- thumb: full opposition
| - fingers: full flexion
253
Capsular Pattern of MCP Jts
- flexion and extension
254
Interphalangeal Joints
- uniaxial hinge joints with 1 deg of freedom
255
Resting position of IP jts
- slight flexion
256
Closed pack position of IP jts
- full extension
257
Capsular pattern of IP jts
- flexion, extension
258
Where to locate Scaphoid
- just distal to radial styloid process
| - ulnarly deviate to feel it pop out
259
Where to locate lunate
- distal to dorsal tubercle
| - next to scaphoid
260
Where to locate triquetrium
- distal to ulnar styloid
- next to lunate
- radially deviate to feel it pop out
261
Where to locate pisiform
- sesmoid bone
- sits on top of triquetrium
- within tendon of FCU
262
Where to locate Trapezium
- trace 1st metacarpal proximally
- just proximal to thumb
- distal to scaphoid
263
Where to locate trapexoid
- trace 2nd met proximally
- just prox to 2nd MC
- medial to trapezium
- dorsal is larger than palmar
264
Where to locate Capitate
- trace 3rd mc proximally
- note slight depression on dorsal side
- feel it move with wrist flexion/extension
- comes up into depression with flexion
265
Where to locate Hamate
- proximal to 5th MC
- place thumbs IP on pisiform pointing towards web space
- roll tip of thumb towards middle of palm to feel hook of hamate
266
What are the articulations of each carpal bone and MC
- 1st MC: trapezium
- 2nd MC: trapezoid
- 3rd MC: Capitate
- 4th MC: hamate
- 5th MC: hamate
267
Phalanges
- 14 on each hand
- thumb has 2
- each other has 3
268
Borders of the carpal tunnel
- ulnar: pisiform, hook of hamate
- radial: scaphoid, trapezium
- palmar: transverse carpal ligament, flexor retinaculum
- dorsal: carpal bones
269
Contents of Carpal tunnel
- median nerve
- FDS tendon
- FDP tendon
- FPL tendon
270
Guyon Canal borders
- at ulnar aspect of the palmar surface
- lateral border: hook of hamate
- medial border: pisiform
- roof: flexor retinaculum/transverse ligament
271
Contents of Guyon Canal
- ulnar nerve and artery
272
Extensor Tunnel 1
- abductor pollicis brevis
- extensor pollicis
- resist abduction to see tendons
273
Extensor Tunnel 2
- extensor carpi radialis longus
- extensor carpi radialis brevis
- while palpating radial side of dorsal tubercle clench fist and exend/radially deviate wrist
274
Extensor Tunnel 3
- extensor pollicis longus
| - takes a 45deg turn at dorsal tubercle, extend thumb while palpating the most dorsal aspect of the tubercle
275
Extensor Tunnel 4
- extensor digitorum: palpate between carpals and MCP extend fingers
- extensor indicis: palpate ulnar side to index finger, resist index finger extension
276
Extensor Tunnel 5
- extensor digitorum m(?)
| - indent next (lateral) to ulnar styloid, over RU articulation, resist 5th finger extension (pinky)
277
Extensor Tunnel 6
- extensor carpi ulnaris
| - inserts on side of 5th met base, extend and ulnarly deviate
278
Volumetric wrist/hand circumference
- water displacement (Archimedes principle)
- reliable and valid for measuring edema in the hand and foot
- tools: hand volumeter (rectangular with flat bottom and dowel)
- overflow container
279
Wrist/Hand Circumference with tape measure for swelling
- figure eight measurement for swelling
- place mark on the distal aspect of the ulnar styloid process
- go across anterior wrist to distal aspect of radial styloid
- bring tape diagonally across the back of the hand and over the 5th mcp
- then across anterior mcps
- bring tape diagonally across back of hand to starting point and record distance
280
Dynomometer Grip Strength average hand position
- hand position #3 is most used
| - has 1-5
281
Pinch strength variables
- pad to pad
- pad to tip
- lateral pinch
- 3-jaw chuck
282
What is gait?
- kinestic, kinematic, spatiotemporal characteristics of bipedal ambulation
- the manner in which a person walks, characterized by rhythm, cadence, step, stride, and speed
283
What is walking?
- falling forward with style and catching yourself
| - likely to be most important skill of humans
284
Rancho Los Amigos Stance phases
- initial contact
- loading response
- midstance
- terminal stance
- preswing
285
Rancho Los Amigos Swing Phases
- initial swing
- mid swing
- terminal swing
286
Stance phase is what % of gait cycle?
- 60%
| - swing phase (foot is not contacting ground) is 40%
287
Step Length
- distance from heel strike of one foot to the heel strike on the opposite foot
288
Stride Length
- distance from heel strike (initial contact) of one foot to the heel strike of the same foot
289
Step Period
- period of time taken for one step
| - seconds
290
Cadence
- rate at which a person walks
| - steps per minute (norm 110 steps/min)
291
Velocity of Gait
- rate of change of linear displacement along the direction of progression measured over one or more strides
- meters per second (norm 1.12-1.34 m/s)
292
What happens in gait at Initial Contact
- ankle dorsiflexors eccentric to prevent foot slap
- quads eccentric controlling knee flexion and prevent body falling down
- hammies and glut max isometric to control hip flexion
- hip abductors eccentric and isometric control drop of contralat pelvis
- erector spinae stabilize trunk during weight transfer and prevent forward flexion during rapid slowing of forward movement at IC
293
Gait cycle initial contact to midstance
- where glut max and med peak
- foot intrinsics ecentrically lengthen as foot pronates...activate to convert foot into rigid structure through supination
- ankle PF eccentric control closed chain ankle DF in form of tibial advancement
- hip abductors continue their activity, becming isometric as they halt contralat hip drop
294
Gait Cycle Midstance to Terminal Stance
- hip mm are quiet and movement is mostly momentum
- foot instrinsics and PF continue eccentric function of midstance becoming isometric around 40% of gait
- hip abductors eccentric to isometrics to concentric, elevate pelvis in preperation for swing
- iliopsoas eccentric to control rate of hip extension
- quads inactive. GFR and PF maintain knee extension
295
Gait Cycle Preswing
- widespread mm activity
- PF concentric push off with foot supinated/rigid. ankle PF mm generate 65-80% energy
- iliopsoas eccentric to concentric advance extremity to swing
- rectus femoris isometric limit knee flexion and augment hip flexion
- knee flexors typically only flex knee when at slower speeds d/t GRF are too small
- erector spinae control unwanted trunk movement vs help initiate pelvic rotation
296
Gait cycle initial swing
- hip flexors and knee extensors concentric for forward leg advancement
- DF concentric for foot clearance
- Hammies controls knee extension as you approach midswing
297
Gait Midswing
- most muscle activity ceases except for DF
| - inertia carries leg through swing like a pendulum
298
Gait Terminal Swing
- hammies eccentric decelerate swinging extremity
- DF hold ankle in position for IC
- quads and hip abductors initiate activity just before foot touches ground, body prepared for large GRF at IC
299
Gait Initial Stance phase
- lower limb mm absorb energy and control body from falling to ground
- lot of eccentric contraction
300
Gait Late stance phase
- lower limb muscles develop tension through eccentric and concentric contractions as well as other leg moving forward
301
Gait Swing Phase
- spring-like recoil of muscles with some concentric contraction top advance let forward and clear foor
302
What ROM for extension of hip is crucial in walking
20deg
303
Abnormal gait
- pathology or specific joints, mm, external factors alters that individuals normal gait pattern
- can be due to pain, mm weakness, impaired balance/proprioception, limited functional ROM
304
Influences on Gait
- posture
- leg length/structure
- gender
- pregnancy
- obesity
- age
- shoes
305
Antalgic Gait Pattern
- remains on involved LE for as short about of time as possible
- decreased stance phase on involved LE
- lack of weight shift over effected LE
- decrease swing phase of uninvolved LE
- decreased cadence
- decreased gait velocity
306
Gluteus Max Weakness/Lurch
- inability to counter flexion moment at hip at point of initial contact
- compensates with extension of trunk
- COG stays behind the hip jt (no flexion occurs at hip)
307
Trendelenburg Gait
- glut med weakness
| - pelvis drops on opposite side during stance of affected side
308
Glut Med Lurch
- lateral trunk flexion over the affected limb during single limb support
- maintains center of gravity of BOS
309
Iliopsoas Weakness
- difficulty initiating swingthrough
- patient will get external rotation of ffemur then adductors will bring leg through in swing
- can also be present to avoid loading knee joing
310
Quad Weakness gait
- inability to contract muscle
- compensate with forward bending of trunk and rapid PF resulting in knee hyperextension
- may compensate by pushing knee posteriorly during stance
- stroke, SCI, severe nerve root impingement, spina bifida
311
Hamstring Weakness gait
- knee maintains extended position
- essentially elongates limb
- decreased shock absorption at knee
- toe off is more difficult
- lose transition between stance and swing
- greater hip and knee flexion is required to clear limb
- not outrageously obvious with normal walking gait
312
Anterior Tib Weakness gait
- toes may scrape ground
- STEPPAGE GAIT
- noticed during swing phase on involved side
- accommodate the patient will excessively bend the knee to get clearance from the ground
- a "foot drop" or slap sound may occur
313
PF weakness gait/flatfoot
- no real propulsion phase at toeoff
| - decrease in stance phase with smaller step length on unaffected side
314
Gait with Limited Hip Extension
- decreased terminal stance/preswing
- may also have constant forward lean in trunk
- can see them go into lordosis to help spread legs out
315
Limited ankle DF ROM Gait
- diminished terminal stance
- early heel off
- compensatory toe-off/lower leg rotation in terminal stance
316
Limited Great Toe Extension ROM Gait
- decreased terminal stance/preswing
| - compensatory toe out/lower leg in terminal stance
317
Common gait deviations with leg length discepencu
- vaulting
- hip hiking
- circumduction
318
Circumduction gait
- "hemiplegic gait"
| - swing leg is stiff/no flexion
319
Normal width of base
- should not be more than 2-4" from heel to heel
- if wider, suspect pathology. dizzy, unsteady
- compensating for diminished balance
320
Step Length in Gait
- approx 15"
| - length of the step may decrease with pathology (fatigue, pain, age)
321
Walking Cadence
- average adult is 90-120 steps per minute
- 100 calories per mile
- changes in pattern reduce efficiency and increase energy cost
- age, fatigue, pain decreases steps per min
- walking surface can be a factor
322
Knee Angle through stance phase
- should remain flexed during all components of gait except heel strike/initial contact
- prevents excessive vertical displacement of COG
- normal is about 40deg
323
Pelvic rotation during gait swing
- pelvis rotates forward 40deg
- opposite extremity (stance leg) is fulcrum
- stiff/painful hip results in less rotation
324
Pelvis and trunk lateral shift in gait
- shift approx 1" to weight bearing side
- centers weight over hip
- pathology results in inc'd lat shift
- gluteus medius weakness
325
Body's COG in Gait
- lies 2" anterior to S2 vert
- normally it oscillates no more than 2" in vertical direction
- controlled vertical oscillations maintain smooth gait
- increased vertical motion may indicate pathology
Tests and Measures
flashcards
Decks in class (2)
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