MUPT Clinical Skills
Slippery Slope of Aging
Fun: unrestricted participation Function: Modification and self-restricting Frailty: ADL consumes physiological capacity, limitations in participation Failure: assistance required for ADL/IADL
irritability during maturation/remodeling stage
- low degree of irritability - pain only with sustained end-range movements or positions - pain with overpressure into tissue resistance
components of irritability
- low, moderate, high - based on vigor of activity required to provoke/aggravate symptoms - based on magnitude (severity) of provoked/aggravated symptoms
advantages of iontophoresis over injection
- no needles = no trauma or risk of infection - less medication goes into blood supply = less systemic effect - relatively painless - eliminates first pass filtering
characteristics of hyaline cartilage
- no nerve, blood vessels, or lymphatics - main source of nutrition is synovial fluid - nutrition by combination of controlled pressure and movement - limited to no ability to heal
Gate Theory
- only a certain amount of information can be processed by the nervous system at a given time - when in pain, touch can compete with receptors to reduce pain
precautions of STM
- osteoporosis - geriatrics: thin, frail skin
can denervation be healed with electrical stimulation?
it does not appear to enhance re-innervation or healing process
positional effect on spinal movement
prone: spinal disc moves ANTERIOR supine: spinal disc moves POSTERIOR
hyperalgesia
- increased sensitivity to pain - small pain = intense pain
benefit of testing RROM (resisted)
- test anatomical and functional movement - establish amount of strength and/or endurance (does not establish cause of weakness) - further information on pain, coordination, crepitus
benefit of testing PROM
- test anatomical and functional movement - establishes available amount of motion - establishes end-feel - further information on pain, coordination, crepitus
provoke vs. aggravate
provoke: no pain until stimulated aggravated: pain at rest (2/10), then made worse with stimulus
triangle sign
- arm at 90 degrees of flexion, mid-pronation/supination = olecranon and epicondyles form an equilateral triangle - when elbow is fully extended, the three structures form a straight line
phase duration
- duration of a phase - expressed in microseconds
Fourth Kinematic Principle
- during full abduction, the scapula posteriorly tilts (by AC joint) and externally rotates (by SC and AC joint) - take glenoid "away" from advancing humerus
peripherlization with traction
- during traction, pain in limb gets WORSE (bad thing)
non-surgical treatment of SCJ congenital hypermobility
- education on avoidance of provocative activities - education on posture: use of posture shirt or scapulothoracic musculature (no muscle strengthens joint directly) - address pain/inflammation: ice, EPAs
non-surgical treatment of SCJ degenerative arthritis
- education on posture - joint mobilization techniques to normalize mobility - address inflammation: ice, EPAs, grade 1 and 2 joint mobilizations
non-surgical treatment of ACJ degenerative arthritis
- education on posture: address GHJ IR motion, if limited - joint mobilization techniques to normalize mobility (grades 3 and 4) - address inflammation: ice, EPAs, grade 1 and 2 joint mobilizations corticosteroid injection could potentially be helpful -- short to moderate duration
Mode of Strength
- elastic bands - tubes - free weights - machines - body weight
Duration of Flexibility
- ideal 30 second hold - 60 second stretch shown most effective
Frequency of Strength
- initially 3x/week - after several months, 1-2x/week
muscle spasm
- pathological (abnormal) end-feel - sudden, dramatic stop of movement "vibrant twang"
PROM of shoulder scapular abduction
- patient in supine - PT supports the arm with both hands and brings to full abduction with thumb leading (ensure ER) - expect 180 degrees
PROM of shoulder flexion
- patient in supine - PT supports the arm with both hands and brings to full flexion with thumb leading (ensure ER) - expect 180 degrees
Mode of Flexibility
- sustained static stretch
snapping
- tendon catching on a bony prominence, then slipping over it (often with active motion) - improper mechanics or rupture of restraining structures
how does NMES improve endurance?
- tends to activate fast twitch (easy to fatigue) - 3-5x/week for a month, fast twitch fibers become less fatigable
benefit of test AROM
- test functional movement - initial impression of willingness to move, strength, amount of motion, pain, coordination, crepitus Requires PROM and RROM for more definite assessment
sharp/dull test
- test sensory discrimination - if guess only 5/10 or less, modalities are contraindicated
Sixth Kinematic Principle
- the clavicle rotates posteriorly about its own axis - occur late in range of abduction/flexion - pull of ligaments, specifically coracoclavicular ligament
Seventh Kinematic Principle
- the humerus naturally externally rotates - allows greater tubercle to pass posterior to acromion = avoid impingement - free rotation in scapular plane
what happens as the arm is moved into more abduction while providing an inferior glide?
- the same force applied along the long axis of the humerus produces progressively less inferior glide and more distraction -- effectively stretches inferior capsule
what are some potential causes of an excessive distance between spine and medial border of scapula?
- tightness of pectoralis major - weakness of retractors
pulse duration
- time elapsed from beginning to end of all phases, plus the interphase interval within one pulse - expressed in microseconds
rise time
- time for the leading edge of the phase to increase to peak amplitude - quick rise = easier activation of nerves - typically about 1 microsecond
evaporation
- transfer of heat from the body by conversion of a volatile liquid into a vapor when the liquid is applied to the skin - Example: Vapocoolant spray (superficial effect, counter-irritant)
nerve activation of conventional TENS
- trying to activate sensory fibers (Gate Theory) if high activation, there might be activation of motor and pain fibers (DEOS)
irritability during repair/healing stage
- typically exhibits moderate irritability - pain experienced with mid-range motions that worsen with end-range movements - pain concurrent with tissue resistance
why is a warm-up important for soft tissues?
- viscoelastic structures that elongate as a result of repeated and sustained stretches -- allowing more movements after a few stretches
Mode for Aerobic Endurance
- walk, jog, run - cycle - jump rope - stairs/climbers - cross country skiing
hydrocollators
- water temperature: 158 to 168 degrees - requires about 2.5 hours to reheat between uses
what are some potential causes of scapular winging?
- weak serratus anterior - tight pectoralis minor
What are the symptoms of SLAP lesions?
-"rotator cuff tendinopathy" that doesn't get better -pain with overhead movements -pain is deep within joint -vague inconsistent pain -inability to perform sports at high level -sensation of popping, clicking, catching
characteristics of stage 4 rotator cuff tears
-patients older than 50 -traumatic event
What are the 4 stages of adhesive capsulitis?
-pre-adhesion: inflammatory stage: pain is limiting factor for motion -freezing stage: motion loss/pain -frozen stage: motion loss/ less pain -Thawing phase: progressive gain in motion/ minimal pain
endurance of muscle is increased due to...
- increase # of glycogen stores - increase # of mitochondria - increase ability to extract oxygen - increase # of capillaries
bone to bone end-feel
- pathological (abnormal) end-feel - sudden hard stop short of normal ROM - occur with myositis ossificans, osteophytes, mal-united fracture, or fracture within joint
four tests for thoarcic outlet syndrome:
1. Adson 2. Allen 3. Costoclavicular 4. Roos PT feels for disappearance/decrease of radial pulse and ask if there is reproduction of symptoms LOSS OF PULSE DOES NOT MEAN POSITIVE TEST
C8 dermatome
fifth finger and ulnar border of hand
capsular pattern of humeroulnar joint
flexion more limited than extension
resting position of radiohumeral joint
full extension and full supination
cold application: soft cast
ice over a soft cast - less swelling = less splitting of cast - less inflammation - fewer hematomas - lower narcotic levels (less pain)
LT Ballotment test
stabilize lunate between thumb and finger while moving pisotriquetral complex volar and dorsal on lunate with other hand (+) if pain is reproduced, crepitus is caused or excessive laxity is noted
interventions for grade 1 and 2 (first and second degree) ligament injury
grade 1: likely need a few days to become asymptomatic grade 2: represent a wide continuum for healing/recovery time BOTH FOLLOW SAME PROGRESSION, but timeline will differ
interventions for grade 1 and 2 (first and second degree) muscle or tendon injury
grade 1: likely need a few days to become asymptomatic grade 2: represent a wide continuum for healing/recovery time BOTH FOLLOW SAME PROGRESSION, but timeline will differ
1+ laxity
if joint opening between 0 and 5 mm greater than contralateral limb
four grades of OA
grade I: softening grade II: fibrillation grade III: fragmentation grade IV: complete cartilage erosion with exposed subchondral bone
T1 myotome testing
hand instrinsics: test interossei (fingers abduction and adduction); lumbricals
what is the purpose of 1+ and 2+ laxity definitions?
help differentiate the range of severity for grade II ligament injury
frequency of mobilization treatment
minimum of 24 hours (preferably 48 hours) treatments limited to grades I and II can be provided more often
if the muscle is strong and painful, then...
minor lesion of some part of muscle or tendon is likely present
SWEEP
modulation of frequency
SCAN
modulation of intensity
expected alignment of scapula
- spine of scapula should be above horizontal from medial to lateral direction - medial border of scapula should be vertical or with inferior portion slightly more lateral than superior portion
surgical treatment of SCJ congenital hypermobility
- stabilization surgery (typically reluctant with not great success rate)
mid-cervical spine downglide mobilization assessment and treatment
- stabilize head on PT abdomen - want to be within "valley" of vertebrae, not peak (TP)
ROM assessment for ACJ or SCJ
- standing or sitting - pain at ACJ or SCJ with active or passive horizontal adduction -- point to area of pain reproduction - comparing amount of pain with shoulder protraction
Reason to Isolate Pectoralis Muscles
- test if observe deviation during screen test above or pain present - CANNOT SEPARATE PORTIONS IN GRAVITY ELIMINATED
difference between hypermobility, instability and laxity
hypermobility: objective finding from therapist instability: subjective feeling by patient -- perceived lack of control of movement laxity: used to describe amount of joint play (specify referring to joint or ligament)
bipolar placement
equal-sized active and dispersive electrodes on same muscle group or in same treatment area
is there a benefit to static stretching compared to PNF techniques?
essentially similar outcomes
What is the recommenced amount of desensitization exercises?
every 2 hours in 15 min sessions once sensation becomes comfortable, progress to the next texture or change the amount of pressure you apply
microstreaming
flow of fluid near vibrating bubbles = makes membrane thinner ALLOW GOOD STUFF IN AND BAD STUFF OUT
how to do GHJ distraction with larger patients
forego stabilization of the scapula and use both hands near proximal end of humerus to provide distraction force
rule of 10 for isometric exercises
- 10 second contraction (2 second ramp-up, hold 6 second, 2 second ramp-down) - 10 second rest - 10 repetitions - completed at multiple angles
dip immersion with wrapping
- 10 to 12 dip immersions, then wrapped in layers - 30 minute period outside while wrapped
platelets
- 1st cells at injury site - promote blood clotting = signaling
chondral lesion
- lesion limited to cartilage - does not involve vascularized or innervated tissue, therefore minimal pain/inflammation - more common in adults
osteochondral lesions
- lesions that extend into subchondral bone - involves vascularized/inntervated tissues, activating an inflammatory response - more common in children: cartilage not yet divided into calcified and non-calcified layers
cross friction massage for muscle (length)
muscle should be in its shortened length to allow movement
action of ultrasound crystal
frequency directed into the crystal, which expands and contracts to create oscillations/sound waves that heat up the tissue (collimates)
close packed position of SCJ joint
full arm elevation
close packed position humeroulnar joint
full elbow extension
thurst manipulation
- high velocity, small amplitude thrust beyond the pathological limit of motion to anatomical limit of motion - often referred as grade 5 mobilization
static stretching
- hold each stretch 15-30 seconds - perform 3 to 5 repetitions - low intensity (about 3 on a scale of 0-10)
Main Function of Rotator Cuff Muscles
- hold humerus against the glenoid - (stabilize humerus in glenohumeral joint)
psychological effects of soft tissue mobilization
- human touch is powerful - relaxation
precautions for cyrotherapy
- hypertensive - poor sensation - poor cognition - very young or very old - healing wounds (slows process) - long duration (frostbite)
placement of lines during ambulation
- ideal to place on same side as affected side
ice cube test
- identifies cold sensitivity - place ice cube on skin for about 3 minutes - if reddish patch is replaced with a wheal (localized skin edema), test is positive
wash cloth wrap
- identifies cold sensitivity - soak wash cloth in cold tap water and wrap around wrist for 20 seconds - once removed, skin should NOT be blotchy, pink AND white, or very white
accomodation
- if patient feels stimulation, but a few minutes later, they no longer feel the effect
efficiency of iontophoresis
- if you put 1-2 mL of medication onto pad, there is about 90-95% of drug left - leave on for several hours and medication will diffuse = effects 25% better
how to distinguish between nerve root and peripheral nerve
- if you removed a nerve root completely, likely muscle still functions with weakness limitation - if you removed a peripheral nerve completely, likely muscle would NOT activate
inflammatory response: vascular
- immediate vasoconstriction (mediated by norepinephrine) - followed by vasodilation (mediated by histamine, Hageman factor, bradykinin, prostaglandins) = increased capillary permeability
cold bath
- immersion of limb in water at 55-64 degrees - lower the temperature = shorter duration - if immersing big area, there is likely to be systemic effects
indications for inferior glide of GHJ
- improve restricted ER performed at side of trunk - help with shoulder abduction -- closer humerus to the body = more long axis traction causes glide in inferior direction (provide stretch to superior part of the capsule)
strength is improved due to...
- improved recruitment of motor units (early phases) - hypertrophy of muscle fibers (6+ weeks to take place)
advantages of action patch
- in clinic for less time - PT performs other interventions that can be reimbursed - increases depth - higher vasoconstriction = drug stays local and lasts longer
thermal effects of ultrasound
- increase tissue extensibility - decrease pain/increase pain threshold - promote re absorption of calcium deposits - promote bone healing - increase local blood flow - increase enzyme activity
complications of fractures
- infection - delayed union: longer than normal to heal - non-union - avascular necrosis - mal-unon: healed in imperfect condition
normal motion of scapula during AROM upward/downward rotation while raising the arm
- initial setting phase for first 30 degrees = scapula should move very LITTLE - from 30 degrees to maximum elevation, smooth motion should occur (best viewed at medial border)
if two congruous resisted movements are painful, then...
- injury is present in the muscle/tendon unit that contributes to these 2 actions - resisted wrist flexion hurts, resisted wrist ulnar deviation hurts, but other wrist motions do not hurt, then likely flexor carpi ulnaris (both movements)
Wrist/Forearm Girth
- make a mark at the distal tip of the ulnar styloid - make marks at 5, 10, 15 cm proximal to ulnar styloid - measure circumference of the wrist/forearm at each of the four marks
contraindications of STM
- malignancy - infectious diseases - phlebitis/thrombophlebitis - over open wounds - acne - ACUTE TRAUMA - pregnancy - cardiac conditions - allergies
respiratory effects of electrical stimulation
- many textbooks state "not to use e-stim on chest wall since it impacts breathing" - instruct the patient that we do NOT want muscle contractions
disadvantages of isotonic exercise
- maximum load is determined by angle of biggest mismatch - does not accomodate to pain, fatigue, - easy to cheat (use momentum) - training once muscle at a time = leads to potential imbalance
amplitude definition
- measure of current magnitude with respect to baseline - usually measured in milliamps - turn up amplitude until desired effect achieved (varies from day to day)
definition of iontophoresis
- method of delivering medication ions through intact skin - alternative to injection or oral delivery
Tendency of Retraction
- middle trapezius can directly retract - elevation of rhomboids is neutralized by depression of lower trapezius
muscle strength after LONG icing
- might decrease muscle strength up to one hour, then increase for 1 to 3 hours
muscle strength after SHORT icing
- might increase muscle strength (not significant) by facilitating alpha motor neuron activity
symptoms and signs of first degree sprain of ACJ
- minimal pain - localized swelling - NO "step deformity"/displacement of distal end of clavicle (best defines 1st degree) - pain at end-range horizontal adduction or protraction - minimal pain and disability with other movement of the shoulder - point tenderness to joint line palpation - distraction test, similar to sulcus sign, while palpating the ACJ is negative - imaging is negative
signs and symptoms of a first degree SCJ sprain
- minimal pain and disability - NO "DEFORMITY" of the joint (key feature) - pain at end-range horizontal adduction or protraction - point tenderness to joint line palpation
application of elastic tape for edema
- minimum to no stretch over edema site - fan shape most common - placed in direction of lymphatic flow
duration of a first degree SCJ joint
- minor injury = few days to be asymptomatic - might wish to protect against further trauma for a few additional days
referred pain mechanism
- mislocalization of pain: perceived in region separate from location of primary source of nociception
stretch articulation
- mobilize to end-range, then hold - less irritating, especially in early stages
DEOS (descending endogenous opiate system)
- originates in neurons in PAG and NRM - pain INHIBITS pain (pinch an arm to distract from headache) - activated by A delta and C fibers
tendon response to exercise
- over the first 24-36 hours, response results in net loss of collagen - followed by a net synthesis of collagen 36-72 hours after exercise REST IS IMPORTANT (2-3 days)
contraindications for electrical stimulation
- pacemaker - malignancy - transcranial - heart disease - cancer - thrombosis - osteomyelitis - where active motion is contraindicated - anterior cervical area (close esophagus and location of baroreceptors) METAL IS NOT A CONTRAINDICATION
pacemaker effects of electrical stimulation
- pacemaker = no stimulation - same for defibrillator or implanted electronic device
signs and symptoms of SCJ degenerative arthritis
- pain aggravated by overhead activities - swelling - pain with horizontal adduction and/or protraction - pain with resisted abduction - tenderness to joint line palpation - pain with inferior glide of clavicle
neuropathic pain mechanism
- pain associated with a lesion of dysfunction of neural structures (nerve root or peripheral nerve)
centralization with traction
- pain diminishes in the limb (GOOD THING) - pain might increase at spin, but decreases in arm/leg
painful arc movement
- pain during middle of the range of motion, but not beginning or end - often signals impingement - useful to describe ROM where pain occurs, but not diagnostic in itself
nociplastic pain mechanism
- pain maintained by neurophysiological processes associated with implication of neural signaling -- NO EVIDENCE OF TISSUE DAMAGE
nociceptive pain mechanism
- pain maintained by ongoing nociceptive input from peripheral nociceptive neurons - might be provoked by mechanical loading, chemical or thermal stimuli
symptoms of STJ dysfunction
- pain of posterior shoulder region: soft tissue related or snapping scapula - expressed difficulty with shoulder motion, especially bringing arm overhead -- there could be no pain - muscular imbalance (weakness or hypertrophy) or tightness (especially pecs)
general motions that will provoke pain in ACJ with NO history of trauma
- pain over ACJ itself - reaching across the body (shoulder adduction) - potentially shoulder protraction, end-range overhead motion
balanced definition
- same amount of charge above and below baseline - if unbalanced, it might irritate the skin
component of peripheral nerves
- sensory function - motor function (strength)
if several/all resisted movements are painful, then...
- severe injury where more than one muscle/tendon unit is injured - injury affecting an inert structure that is placed under stress with activation of any of the surround muscle/tendon units (bursitis) - biopsychosocial presentation where pain with all movements tested (peripheral/central sensitization, fear avoidance, anxiety, etc.)
symptoms and signs of fifth degree sprain of ACJ
- severe pain - gross deformity with distal end of clavicle extremely elevated - loss of shoulder motion due to pain
symptoms and signs of fourth degree sprain of ACJ
- severe pain - gross deformity with distal end of clavicle posterior to acromion - loss of shoulder motion due to pain
irritability during inflammation (acute) stage
- typically highly irritable condition - pain experienced at rest or with initial to mid-range movements - pain before tissue resistance
EPA interventions in proliferation
- ultrasound (fibroblasts) - soft tissue mobilization - controlled motion - heat
treatment parameters for phonophoresis
- ultrasound for 5 minutes to open pores - ultrasound with medication mixed in medium for 5 minutes - wipe off gel and medication from skin - cover skin with occlusive dressing for several hours to further diffuse medication
disadvantage of hot packs
- unable to lay on hot pack - limited range of motion while hot pack applied
pulsed current
- unidirectional or bi-directional flow of charged particles that periodically ceases for a finite amount of time
alternating current
- uninterrupted bi-directional flow of charged particles - symmetrical or asymmetrical relative to baseline
leg strength exertion for frail adults
- use 98% of leg strength to complete single sit to stand
treatment for resistance before pain (or no pain)
- use distraction or glide technique - distraction (applied 5 to 10 times) or steady stretch is preferred for initial treatment (personal opinion) - use grade III or IV or steady stretch (treat for about 10 seconds initially) - stop treatment with positive response: improve joint play and ROM - educate patient on ROM/stretching and end-range functional exercises - repeat and adjust based on initial response advisable to start with distraction to see response
chronic edema parameters
- use pulsed current to induce twitchy contractions to accentuate venous return pulse duration: 200-300 microseconds (waveform that is tolerated) frequency: 5-15 pps intensity: vigorous, tolerable contractions time: 10-30 minute treatment
water immersion ultrasound
- used for abnormal contours - intensity can be increased an additional 0.5 W/cm2 to compensate for absorption by water - use plastic tub, not metal - periodically wipe air bubbles off sound head
acute edema parameters
- used soon post injury/therapy to relieve pain and prevent onset of new edema monophasic pulsed current, cathode on edema-prone area frequency: 100 pps intensity: intensity as tolerated time: 30 minute treatment, several times daily
constant current device - useful or not useful?
- useful - adjust voltage and resistance every second
ramping for motor stimulation
- usually one second, unless need immediate activation
Gait Characteristics of Fall Risk
- velocity less than 0.55m/second - use of assistive device - shortened steps - excessive trunk movement
3+ sulcus score
- very excessive laxity - >2 cm displacement (2 finger width or more)
stretching of cervical spine musculature
- very gently and progressively - move to point of discomfort/tightness (1-2 pain level), holding for 5 to 7 seconds - repeat 3-5x - exercises done several times per day over a few days, hold time (up to 10-15 seconds) and/or stretching for (2-3 pain level) can be progressively increased
manual cervical traction for pain relief/modulation
- very light traction force with grade I or II oscillation - perform/progress as per patient response - potential effects: stimulation of mechanoreceptors to reduce pain
effects of thermotherapy: metabolic
1. increase enzymatic activity 2. increase oxygen uptake 3. increase cellular biochemical processes (accelerates healing) 4. accelerate cartilage destruction in patients with RA
effects of thermotherapy: neuromuscular
1. increase in temperature: - decrease firing rate of type II muscle spindle (settle down) - increase firing rate of type 1b fiber from golgi tendon organ (settle down) - reduction in muscle spasms via alpha motor neurons 2. increases pain threshold (Gate Theory) 3. change in muscle strength and endurance: might decrease after heating
phases of healing
1. inflammatory phase (1 to 6 days) 2. Proliferation phase (3 to 20 days) 3. maturation phase (9 days to 2 years)
mechanism for acute edema
1. injury releases histamine, which casues vasodilation 2. histamine binds to calcium storage 3. calcium storage releases calcium 4. calcium binds to endothelial cells = fine contractile fibers contract and open spaces 5. leakage of fluid and proteins
purpose of effleurage
1. introduce patient to physical contact 2. assess condition of tissue 3. orient therapist to areas of tenderness/tightness 4. distribute lubricant
Proper Posture at Computer Station
1. keyboard at elbow heights 2. upper portion of monitor at eye level
Subtle Adjustments of 4th Principle Helps...
1. maintain scapula against thorax 2. orient scapula in intended plane of shoulder "elevation" 3. maximize the subacromial space
pain generators of back pain
1. muscle 2. facet joint 3. ligaments 4. intervertebral disc 5. nerve root
indications of STM
1. musculoskeletal: muscle spasms, strains, sprains (must be subacute or chronic, NOT ACUTE INJURY) 2. neurological conditions: peripheral nerve injuries, hemiplegia with painful joints (does not cure, but relieves pain) 3. vascular/lymphatic disorders: prevent venostasis and edema
anterior total hip precautions
1. no hip extension 2. no external rotation (small steps while turning) 3. assisted hip abduction allowed
three treatments for grade 3 (third degree) muscle or tendon injury
1. no treatment required (long head of biceps) 2. immobilization, followed by progressive rehab for ROM, strength, function (Achilles' tendon) 3. surgical repair, followed by progressive rehab for ROM, strength, function (biceps tendon at elbow)
indications of thermotherapy
1. pain control: decrease muscle spasms and increase blood flow 2. increase ROM and decrease joint stiffness 3. tissue healing 4. psychological
six key points of pain
1. pain is always a personal experience 2. pain and nociception are DIFFERENT phenomena 3. individuals learn concept of pain from life experiences 4. person's report of pain should be respected 5. while important, pain can effect function and social and psychosocial well-being 6. verbal description is only one of several behaviors to express pain
McClure approach to assess AROM shoulder flexion and abduction
1. perform shoulder flexion 5 times -- 3 second count up, 3 second count down 2. repeat for shoulder abduction 3. repeat movements with patient holding a weight (3 pounds for <150, 5 pounds for >150)
strengthening examples of lower trapezius
1. prone full can 2. prone ER at 90 degrees abduction 3. prone horizontal abduction at 90 degrees abduction with ER 4. bilateral ER
strengthening examples of middle trapezius
1. prone row 2. prone horizontal abduction at 90 degrees of abduction with ER
four steps to good posture
1. seat height (hips should be slightly higher than knees) 2. lumbar spine in neutral position 3. scapular position: down and in 4. head and neck: make yourself tall
strengthening examples for BOTH lower and middle trapezius (not upper)
1. shoulder extension 2. shoulder flexion in sidelying (thumb up) 3. ER in sidelying 4. prone horizontal abduction (thumb up)
Minimize Risk of Injury
1. slow movement 2. full pain free ROM 3. good form
mechanism of injury for SCJ sprain/subluxation/dislocation
1. strong lateral/medial force along the long axis of the clavicle (falling/hitting lateral aspect) --> results in subluxation/dislocation of proximal end in the anterior/superior/medial direction 2. strong posteriorly directed force applied to anterior aspect of clavicle (someone falling on supine person) --> results in posterior subluxation/dislocation
four major functions of elastic taping
1. support the muscle 2. remove congestion to flow of fluid 3. activate DEOS system (more likely Gate Theory) 4. corrects joint problems (sensory feedback)
effects of cryotherapy: hemodynamic
1. vasoconstriction of cutaneous blood vessels: decrease blood vessels 2. reflex vasoconstriction: eventually deeper tissues cooled 3. edema control (apply early, 5 to 10 minutes [textbook states 24 to 48 hours]) 4. increase blood viscosity 5. hunting response: cold-induced vasodilation when tissue temperature lowered to 50 degrees
effects of thermotherapy: hemodynamic
1. vasodilation 2. increases blood flow: improves healing and repair 3. reflex vasodilation: superficial heat radiates to deeper tissues
amount of force to separate lower cervical
25 to 40 pounds
desirable range for BNR
2:1 to 8:1 if high BNR, majority of US energy is concentrated in small area of applicator head
MMT Extensor Pollicis Longus
Action: 1st IP extension Patient position: sitting, forearm supported and in neutral Stabilization: proximal phalanx of thumb Screen for 3/5: extends IP joint of thumb Resistance: one finger on dorsal surface of distal phalanx into flexion Test for < 3/5: forearm pronated with slight bend in fingers (relaxed) -- extend IP Palpate: ulnar side of anatomical snuff box Hint: Some people have a lot of hyperextension, do not resist from hyperextended position
MMT Flexor Pollicis Longus
Action: 1st IP flexion Patient position: sitting, forearm supinated & supported on table, neutral wrist, MCP in extension Stabilization: MCP joint (do not block tendon) Screen for 3/5: patient flexes the IP joint (3/5 for full ROM + small amt. resistance) Resistance: one finger on palmar surface of the distal phalanx into extension Test for < 3/5: full ROM is a 2/5 (because there is no gravity) Palpate: palmar surface of proximal phalanx
MMT Flexor Pollicis Brevis
Action: 1st MCP Flexion Patient position: sitting, forearm supinated, neutral wrist, forearm supported on table Stabilization: 1 st metacarpal to prevent CMC motion Screen for 3/5: patient flexes the MP joint (3/5 for full ROM + small amt. resistance); IP joint must stay extended Resistance: one finger at proximal phalanx into extension, test ends with IP flex (FPL takes over) or cannot hold against resistance Test for < 3/5: full ROM is a 2/5 (because there is no gravity) Palpate: ulnar side of thenar eminence (medial to FPL tendon)
C7 dermatome
middle finger (posterior aspect)
it is common to see _____ dyskinesia with lowering the shoulder compared to elevation
more
What are SLAP lesion tests good for?
more sensitive (better ability to rule out the condition) than specific (ability to rule in the condition)
what would happen if rise time is too long?
more uncomfortable and do not activate nerves
PROM of shoulder flexion with scapula stabilization
- patient in supine - PT supports the arm with one hand at elbow, one hand stabilizing lateral border of scapula - expect 120 degrees
Procedure of Back Scratch Test
- reach one hand above, one below by touching middle fingers - trial each side to determine best side - practice twice, then measure twice (record best)
results of STM
- reduced hypertonicity - reduced swelling - balanced tissue tension: allows vertical posture alignment, allows full ROM through all movement segments
treatment of third degree SCJ sprain
- reduction by physician - relative immobilization with Figure of 8 sling - instruction on good posture - ice and appropriate EPAs for pain/inflammation - progressive return to full function based on symptoms - gradual rehab program aimed at recovery of ROM, strength, function
treatment of sixth degree sprain of ACJ
- reduction followed by surgical reconstruction - rehabilitation
first degree sprain (type I) of ACJ
- stretch (partial tear of AC ligaments) - CC ligaments are intact - deltotrapezial fascia is intact
What position of the arm helps promote tendon circulation?
supporting the arm in a slightly abducted position
What is the Scaphoid shift test?
test for hypermobility at scapholunate joint pt. seated elbow on table flex to 90 apply pressure to scaphoid tubercle w/ thumb and counter pressure with finger on dorsal radius -passively ulnar then radial deviate -scaphoid should flex into examiners thumb, compare to other side (+) pain/hypermobility (scaphoid sublimes over dorsal rim of radius (-) tubercle pushes out on thumb
What is Froment's test?
test for ulnar nerve function, specifically action of adductor pollicus ask pt. to hold sheet of paper while you try and take it away, compare to other side (+) if pt. compensates with flexion of the IP joint, substituting loss of AP strength with FPL
soft tissue mobilization: posterior cuff
position: sidelying - hook patient arm/hand and use passive GH flexion - scapula should NOT protract - standing in front of patient, then reach towards back
soft tissue mobilization: pectoralis major
position: supine - grasp border and perform gentle oscillations or sustained pressure - START with shoulder in horizontal adduction and progress to horizontal abduction
soft tissue mobilization: lateral subscapularis
position: supine - hold arm in slight abduction, then run thumb or fingers down lateral aspect of rib cage to anterior part of scapula - assess mobility and treat entire length - can perform LTR or arm movement - comb in with posterior hand
difference between biceps load test in pronation vs supination
pronated forearm technically places more stretch on long head of biceps
end feels of wrist/hand assessment
pronation: bone on bone supination: firm wrist extension, RD: bone on bone Wrist flexion, UD: firm finger flexion/extension: firm
Acu-Mode TENS parameters
pulse duration: 300 to 500 microseconds frequency: 1 to 10 pps/bps intensity: very high (uncomfortable) duty cycle: ALWAYS ON
Interferential Current (IFC)
pulse duration: N/A (beats of AC, so no pause) frequency: 80 to 150 pps/bps intensity: as high as tolerated
pinch grip test
purpose: anterior interosseous nerve (branch of median nerve) syndrome - patient asked to pinch tips of index finger and thumb together - if patient cannot pinch tip to tip, but rather pulp to pulp, test is positive suggesting compression of nerve as it passes between the 2 heads of pronator teres
elbow flexion test
purpose: test for cubital tunnel syndrome - patient holds elbow in full flexion for up to 30 seconds (video states up to 5 minutes) positive test: tingling or paresthesia in ulnar nerve distribution
proliferation
rebuilds damaged tissue and strengthens the wound
prognosis of tendinopathy
recovery time of days to weeks slightly longer (weeks to months) for late tendon degenerative tendinopathies ("older" patient)
cardinal signs of inflammation
redness, swelling, heat, pain, loss of function
healing timeline for muscle
repair/healing phase is likely 2-3 weeks maturation/remodeling stage takes an additional 2-3 weeks
healing timeline for tendon
repair/healing phase is likely 4-5 weeks maturation/remodeling stage takes an additional 5 weeks to 6 months
healing timeline for ligaments
repair/healing phase is likely 6 weeks maturation/remodeling stage takes an additional 6 weeks to 1+ year
resting position of ACJ
arm along the side -- anatomical position
What are the causes of adhesive capsulitis?
-often idiopathic with insidious onset -sometimes secondary to injury or other shoulder/cervical problems
Sensitivity
tests measures what you are looking for
What is the shoulder total range of motion concept?
the idea that a deficit in internal rotation potentially offset by excessive external rotation for a total range of motion that is equal on both sides
C8 myotome testing
thumb extension: tested with arm along side, elbow at 90 degree flexion, neutral forearm -- resistance applied on dorsal aspect of thumb, stabilized wrist and forearm wrist ulnar deviation: tested with arm along side, elbow at 90 degree flexion, forearm supinated -- resistance applied to ulnar aspect of hand, stabilized distal forearm finger extrinsics: hand grip dynamometer, test DIP and/or PIP flexion patient position: standing/sitting
what is the treatment window after ultrasound?
tissue will stay warm for about 3-4 minutes
effects of cryotherapy: metabolic
1. decrease metabolic rate: reduce potential for further cell death 2. decrease inflammatory process
C1 dermatome
superior aspect of cranium
C4 dermatome
superior aspect of shoulder
the sulcus sign specifically tests the _________ glenohumeral ligament and _______ capsule
superior; superior
Ankle Girth Measurement
- Medial or lateral malleolus 1. At landmark 2. Above: 5 cm, 10 cm, 15 cm
indications for dry needling
- Myofascial pain syndrome (MPS) - Changes in connective tissue and adhesions of fascia and skeletal muscle
how does drug concentration effect delivery?
- NO EFFECT - dependent on available pathways for drug to be delivered
deep STM
- NO movement between fingers and skin - creates movement in deeper tissues = breakdown adhesion
central sensitization
- NOT normal - pain persists well after original tissue damage - responsible for allodynia and enlargement of pain area
characteristics of repair-healing stage
- day 4 to 21 following injury - growth of capillary beds - synthesis and deposition of collagen - immature connective tissue is thin and unorganized
Duration of Gait
- incorporate with aerobic capacity/endurance program
Functional Reach Scoring
- Less than 7: limited functional balance, limited mobility skills, most restricted in ADLs - More than 10: healthy individuals
component on nerve roots
- dermatomes, myotomes, deep tendon reflexes
therapeutic range of thermotherapy
104 to 113 degrees
how to find first rib
C7 will be most prominent, 1st rib is just lateral
Sharpened Romberg
Domain: Body Function - Tandem stance
Tanaka HR Formula
HR max = 208 - (0.7 x age)
deep tendon reflex score of 0
absent
benefit of CPM machine
helps keep joint moving to prevent scar tissue limiting motion
T1 dermatome
medial forearm/arm region
how big should treatment area be in comparison to ERA?
no bigger than 2x ERA (tissue will cool too quickly)
"classic" pain location of ACJ injury/pathology
pain over ACJ
C2 dermatome
occiput and sides of cranium
Conventional TENS parameters
pulse duration: 20 to 60 microseconds frequency: 80 to 150 pps/bps intensity: as high as tolerated
C6 dermatome
thumb and lateral forearm region
is there inflammation with chronic?
typically, NO
disadvantage of whirlpool
- contamination - cost: cleaning and heating water
What is the capsular pattern of GHJ?
ER-ABD-IR
F.I.T.T.
Frequency, Intensity, Time, Type
duty cycle
on time/total time
it is common to see _____ (more or less) dyskinesia with scapular abduction compared to flexion
more
Frequency of Gait
- 5 to 7 days per week
fibroblasts
- found in connective tissue - cells that gives rise to connective tissue = spray silly string
Figure 8 Girth Measurement
1. Distal tip of medial malleolus 2. Distal tip of lateral malleolus 3. Navicular 4. Base of 5th Metatarsal
lumbar spinal precautions
1. Do not bend forward at the waist more than 90 degrees or raise knees higher than hips. 2. Do not side bend at trunk/do not cross knees or ankles while sitting, standing or lying down. 3. Do not twist trunk. 4. Always log roll out of bed 5. Abide by lifting restrictions; vary depending on procedure
process of measuring AROM shoulder rotation
1. ER with arm loosely along side of body 2. IR with arm loosely along side of body 3. ER with arm at 90 degrees of scapular abduction 4. IR with arm at 90 degrees of abduction
Patellar Girth Measurement
1. Midpatella 2. Suprapatella
resting position of humeroulnar joint
70 degrees of flexion and 10 degrees of supination
resting position of proximal radioulnar joint
70 degrees of flexion and 35 degrees of supination
severe/full tension elastic taping
75% and above support or correction
minimum treatment time for ultrasound
8 to 10 minutes
frequency for sensory stimulation (pain relief)
80 to 150 pps
close packed position of radiohumeral joint
90 degrees of flexion and 5 degrees of supination
close packed position of ACJ
90 degrees of shoulder abduction
Gait Speed
< 1.0 m/s (3.28 ft/s) = well functioning 1.2 to 1.3 m/s is usual adult walking speed
acute injury timeline
<1 month
what skin temperature leads to catabolism?
>113 degrees breakdown of macromolecules and cell death
chronic injury timeline
>3 months
nerve fibers stimulated with Acu-Mode TENS
ALL - sensory, motor, pain
open packed position
ANY position of joint that is not closed-packed
MMT Extensor Carpi Radialis Longus/Brevis ONLY
Action: wrist extension Patient position: sitting, forearm supported and pronated, fingers flexed/relaxed to avoid long finger extensor assistance Stabilization: support forearm under wrist Screen: extends and radially deviates, resistance on first two metacarpals into flexion and ulnar deviation Test for < 3/5: forearm in neutral, gravity elim tests ECR/ECU together (don't separate out) Palpate ECRL: dorsum of wrist in line with 2nd metacarpal Palpate ECRB: dorsum of wrist in line with 3rd metacarpal **Important to note: Innervated differently ECRL C6-7; ECRB, ECU C7-8
MMT Extensor Carpi Ulnaris
Action: wrist extension Patient position: sitting, forearm supported and pronated, fingers flexed/relaxed to avoid long finger extensor assistance Stabilization: support forearm under wrist Screen: extends and ulnar deviates, resistance on 5th metacarpal into flexion and radial deviation Test for < 3/5: forearm in neutral, gravity elim tests ECR/ECU together (don't separate out) Palpate ECU: dorsal wrist, proximal to 5th metacarpal **Important to note: Innervated differently ECRL C6-7; ECRB, ECU C7-8
MMT Flexor Carpi Radialis/Ulnaris
Action: wrist flexion Patient position: sitting, forearm supported and supinated, fingers relaxed to avoid assisting Stabilization: support forearm under wrist Screen: flex wrist, resistance given evenly across metacarpals Test for < 3/5: forearm in neutral, gravity elimated tests FCR/FCU together (don't separate out) Palpate FCR: lateral palmar aspect of wrist (lateral to palmaris longus) Palpate FCU: medial palmar aspect of wrist (in line with the 5th metacarpal)
MMT Flexor Carpi Radialis ONLY
Action: wrist flexion Patient position: sitting, forearm supported and supinated, fingers relaxed to avoid assisting Stabilization: support forearm under wrist Screen: flexes and radially deviates, resistance on first two metacrapals into extension and ulnar deviation Test for < 3/5: forearm in neutral, gravity elimated tests FCR/FCU together (don't separate out) Palpate FCR: lateral palmar aspect of wrist (lateral to palmaris longus)
MMT Flexor Carpi Ulnaris
Action: wrist flexion Patient position: sitting, forearm supported and supinated, fingers relaxed to avoid assisting Stabilization: support forearm under wrist Screen: flexes and ulnar deviates, resistance on 5th metacarpal into extension and radial deviation Test for < 3/5: forearm in neutral, gravity elimated tests FCR/FCU together (don't separate out) Palpate FCU: medial palmar aspect of wrist (in line with the 5th metacarpal)
when should heat or cold be used?
Acute/subacute: ice subacute/chronic: heat
Strength Progression
At 30-60%: - 25 reps or more: increase by 10% - More than 12 and less than 25: keep the same At 70-80%: - 12 or more reps: increase by 5% - More than 8 and less than 12: keep the same
icing over a superficial nerve
BE CAREFUL might cause nerve death
Montreal Cognitive Assessment (MoCA)
Domain: Body Structure, Body Function - brief test to detect mild cognitive impairment - measures executive function (driving) - available in many languages - higher level than MMSE and SLUMS
C5 reflex testing
Biceps reflex (C5/C6) tested with arm along side, elbow at 90 degrees flexion, forearm supinated and supported on therapist's forearm; PT identifies biceps tendon by asking patient to perform resisted elbow flexion and apply strong pressure over tendon with thumb using reflex hammer, typically the narrower end, tapping is done on THERAPIST'S THUMB, looking/feeling for muscle response
FSST Scoring
Community Dwelling Adults with Greater than 15 seconds: risk for multiple falls Vestibular Dysfunction with Greater than 12 seconds: risk of falls
Grade 6 Joint Play
HYPERMOBILITY condition: severe (pathological) increase treatment: surgery (no PT intervention)
contraindications for elastic taping
NONE
Berg Balance Scale
Domain: - Gold standard for balance - evaluate static and dynamic balance and fall risk - intended for individuals with some degree of balance impairment - cannot use assistive device
6 Minute Walk Test
Domain: Activity - assess general functioning in older adults - standard words of encouragement - otherwise, NO TALKING
Physical Performance Test
Domain: Activity - assistive device allowed - measures ADL, IADL and physical abilities - 7 Item: no stairs, score of 0-28 - 9 Item: stairs, score of 0-36
Barthel Index
Domain: Activity - established ADL assessment - only test that includes mobility and stairs - Best Score: 100 points - self-administered or interview
Timed Up and Go
Domain: Activity - evaluate basic mobility skills - identifies fall risk - distance of 3 meters
2 Minute Walk Test
Domain: Activity - measures exercise capacity of individuals with moderate to severe CP disease
Lawton Assessment
Domain: Activity - only test to measure IADLs - Higher # = higher function - Best Score: 16 points
Four Square Step Test
Domain: Activity - predict falls: rapid stepping, movement in multiple directions, obstacle avoidance - STRONG predictor of fall risk - both feet must make contact with floor
Modified Physical Performance Test
Domain: Activity - no eating or writing - added balance and chair rise
Signs of rotator cuff injury
External impingement tests: -painful arc between 60° and 120° -Jobe's test (supraspinatus test) -Neer's test (impingmente test) -Hawkins-Kennedy test Internal impingement tests: -Apprehension test -pain and potential weakness with resisted shoulder movements -pain with palpation of tendons possible decrease in shoulder ROM
Cut-Off Score for TUG
Fall Risk: >13.5 seconds in community dwelling adults <10 seconds: completely independent <20 seconds: independent for main transfers >30 seconds: requires assistance
Time Difference of TUG vs. TUG Dual Task
Frail adults with difference of 4.5 second or greater than normal TUG are more prone to falls in a 6 month period
what mobilizations is preferred at the end of treatment?
Grade I and II
Grade 5 Joint Play
HYPERMOBILITY condition: considerable increase treatment: external support (taping, wrapping); education on ADL and posture correction; strengthening, stabilization, coordination (minimum 4-6 weeks); resolve hypomobility of surround joints; sclerosing injections
Grade 4 Joint Play
HYPERMOBILITY condition: slight increase treatment: external support (taping, wrapping); education on ADL and posture correction; strengthening, stabilization, coordination (minimum 4-6 weeks); resolve hypomobility of surround joints
Grade 0 Joint Play
HYPOMOBILITY condition: ankylosis treatment: surgery (no PT intervention)
Grade 1 Joint Play
HYPOMOBILITY condition: considerable limitation treatment: mobilization (primary emphasis); ROM/stretching exercises
Grade 2 Joint Play
HYPOMOBILITY condition: slight limitation treatment: ROM/stretching exercises (primary emphasis); self-mobilization exercises; mobilization/manipulation
fulcrum test
IF APPREHENSION TEST IS INCONCLUSIVE: - PT now supports patient's elbow on thigh -- hand previously supporting elbow positioned behind proximal humerus, promoting anterior displacement of humeral head --> shoulder moved into ER POSITIVE: feeling of apprehension verbalized by patient or clear signs based on facial expression or resistance little purpose (only risks) performing fulcrum test if apprehension test was clearly positive
modified scapular assistance test
IF pain present during flexion or scapular abduction: - patient repeat the movement while providing manual assistance to scapula towards posterior tilting, ER, and upward rotation POSITIVE TEST: assistance reduced or eliminated shoulder pain (suggests weakness of muscle)
wrist movement with brachioradialis reflex
MUSCLE DOES NOT CROSS THE WRIST any movement is due to mechanical tap of hammer on the forearm
Normal Hemoglobin
Male: 13.8-18.0 Female: 11.5-16.6 >10: resistive exercise as tolerated 8-10: concern, light exercise <8: do not get out of bed, no exercise
Normal Hematocrit
Male: 41-52 Female: 37-47 <25: no exercise 25-30: light exercise >30: exercise as tolerated
how to test 10 to 12 section of labrum in compression test
elbow is brought up to table height (shoulder flexion), while force along humerus and circumduction movements are maintained
Ober Test
Muscle: TFL and IT band Stabilization: hip to maintain neutral position Normal: 10 degree of adduction
MMT Hip Adduction
Muscle: adductors Patient position: sidelying with test limb on the table (test limb side down) Stabilization: hold the upper limb into 25 degrees ABD or on padded stool 9-12" − Screen for 3/5: lifts lower leg (full ROM) to meet top leg Resistance: distal femur on medial surface Test for < 3/5: supine (move other limb out of the way); therapist supports weight of leg Palpate: inner aspect of proximal thigh
MMT Dorsiflexion and Inversion
Muscle: anterior tibialis Patient position: sitting or supine Stabilization: posterior leg Screen for 3/5: patient lifts toes through full ROM - "turn your foot up and in" − Resistance: dorsomedial foot into eversion and plantarflexion Test for < 3/5: partial ROM Palpate: - tendon: on the anteromedial aspect of the ankle at the level of the malleoli - muscle: over the muscle belly just lateral to the tibia
MMT Hip ER
Muscle: deep external rotators Patient position: short sitting, can use hands to support trunk Stabilization: lateral aspect of distal thigh; counter pressure Screen for 3/5: patient externally rotates hip (foot in); pt can flex opposite knee out of the way Resistance: medial ankle above malleoli into IR (push OUT LATERALLY) Test for < 3/5: supine, test limb placed into IR, patient move through FULL ER, resist after mid Palpate: not feasible
MMT Hallux Extension
Muscle: extensor hallucis longus Patient position: short sitting (or supine), ankle in neutral Stabilization: heel Screen for 3/5: extends first toe (full ROM) − Test for < 3/5: partial ROM Palpate: dorsum of 1st metatarsal
ROM Elbow Flexion
Normal ROM: 0 - 140 degrees Patient position: supine, full supination, towel under humerus Stabilization: humerus to prevent shoulder flexion Axis of Rotation: lateral epicondyle of the humerus Stationary Arm: lateral midline of humerus toward acromion Moveable Arm: lateral midline of radius (toward radial head/styloid) Active: one hand stabilizing, one hand measuring Passive: remove stabilizing hand to overpressure
ROM Shoulder Abduction (complex)
Normal ROM: 0 - 180 degrees Patient position: supine, hook-lying Stabilization: thorax to prevent lateral flexion Axis of Rotation: anterior aspect of acromion Stationary Arm: parallel to midline of anterior aspect of sternum Moveable Arm: anterior midline of humerus (use med. epicondyle as reference)
ROM Shoulder Flexion (complex)
Normal ROM: 0 - 180 degrees Patient position: supine, hook-lying, palm facing thigh, edge of pillow to allow flexion Stabilization: thorax to prevent spinal extension Axis of Rotation: lateral aspect of greater tubercle Stationary Arm: parallel to midline of thorax Moveable Arm: lateral midline of humerus toward lateral epicondyle
ROM Tarsal Inversion
Normal: 0-35 Patient position: sitting with knee flexed to 90 Stabilization: tibia and fibula (overpressure on dorsum of foot) Axis of Rotation: line bisecting malleoli at anterior aspect of ankle Stationary Arm: mid-aspect of leg bisecting tibial tuberosity Moveable Arm: bisect 2nd metatarsal
ROM Wrist Ulnar Deviation
Normal: 0-35 Patient position: sitting, shoulder abducted to 90, elbow flexed to 90, forearm pronated hand supported by table Stabilization: radius/ulna to prevent supination/pronation and elbow flexion > 90; hand needs to be supported by the table with fingers flat on the table Axis of Rotation: capitate (divet with extended hand, felt with flexion) Stationary Arm: dorsal midline of forearm Moveable Arm: midline of 3rd metacarpal (palpate!)
when gliding a convex surface, it is considered best to perform glide toward the ___ direction as the direction of movement
OPPOSITE - facilitates the normally occurring "relative glide" of convex surface on the concave surface
different responses of peripheral and central
PNS: pathology in PNS (injury and disease) with SOME response to EPAs CNS: pathology in CNS (stroke, MS, Parkinsons) with little help from EPAs
allodynia
Pain due to a stimulus that does not normally provoke pain
current in wire causes ____ to flow
electrons
when gliding a concave surface, it is considered best to perform glide toward the ___ direction as the direction of movement
SAME - facilitates the normally occurring glide of concave surface on the convex surface (MCP finger flexion)
signs and symptoms of a second degree SCJ sprain
SUBLUXATION OF SCJ - pain - swelling - VISIBLE "DEFORMITY" of the joint (key feature) - pain at end-range horizontal adduction or protraction - pain at end-range of shoulder abduction - point tenderness to joint line palpation
Muscle Length: Flexor Digitorum Profundus/Superficialis
Starting position: sitting, upper extremity supported, elbow/MCP/PIP/DIP in full extension, pronate forearm, wrist neutral off the edge of the table (jewelry off) Stabilization: forearm to prevent elbow flexion; need to maintain elbow extension Sequence: hold MCP, PIP, and DIP in extension while extending the wrist Ending: Test ends when resistance felt or further motion causes elbow or finger flexion Axis of rotation: lateral aspect of wrist over triquetrum Stationary arm: lateral midline of ulna Moveable arm: lateral midline of 5th metacarpal (palpate bone!) Hint: Measured as a positive number (bigger is more flexible)
surgical treatment of ACJ degenerative arthritis
arthroscopic surgery, Mumford procedure/distal clavicle excision (if non-surgical not satisfactory) consists of: - arthroscopic surgical debridement of joint - removal of intraarticular disc - removal of distal end of clavicle
key points (timeline) or post surgical rehab of rotator cuff
Sling/abduction pillow: 4-6 weeks first 6 weeks: PROM at 6 weeks: start AROM Initiate light RROM at 12 weeks Full PROM by 10 weeks Full AROM by 14 weeks return to activities in 6-9 months
Classifications of rotator cuff tears
Small: <1 cm Medium: 1-3 cm Large: 3-5 cm Massive: >5 cm
Sensory Dependence in Normal Individuals
Stable Surface: - 70% somatosensory - 20% vestibular - 10% vision Unstable Surface: - 60% vestibular - 30% vision - 10% somatosensory
Muscle Length: Extensor Digitorum, Indicis, and Digiti Minimi
Starting position: sitting, upper extremity supported, elbow in full extension, MCP/PIP/DIP in full flexion (make fist), pronate forearm, wrist neutral with hand off table, jewelry off Stabilization: forearm to prevent elbow flexion Sequence: hold MCP, PIP, and DIP in flexion while flexing the wrist Ending: Test ends when resistance felt or further motion causes elbow flexion or finger extension (hand wants to open/extend) Axis of rotation: lateral aspect of wrist over triquetrum Stationary arm: lateral midline of ulna Moveable arm: lateral midline of 5th metacarpal (palpate bone!) Hint: Measured as a positive number (bigger is more flexible)
neutraphil
associated with acute inflammation
lymphocyte
associated with chronic inflammation
Muscle Length: Triceps Brachii
Starting position: supine, extend the elbow and place shoulder in full flexion, supinate the forearm (arm off edge of the table), patient diagonal on table Stabilization: humerus into full shoulder flexion to patient's end range of motion Sequence: flex the elbow Ending: Test ends when resistance felt or further motion causes shoulder extension or pain Axis of rotation: lateral epicondyle of humerus Stationary arm: lateral midline of humerus Moveable arm: lateral midline of radius to radial styloid Hints: record as positive number (bigger is better)
Muscle Length: Biceps Brachii
Starting position: supine, flex the elbow, forearm pronated and place shoulder in full extension (arm off edge of the table), patient diagonal on table Stabilization: humerus into full shoulder extension Sequence: pronate forearm, fully extend shoulder keeping forearm pronated, finally extend the elbow holding the forearm in pronation Ending: Test ends when resistance felt or further motion causes shoulder flexion or get to 0 degree or pain Axis of rotation: lateral epicondyle of humerus Stationary arm: lateral midline of humerus Moveable arm: lateral midline of ulna (not radius because forearm is pronated) Hints: record as positive number if unable to get full extension (0 deg), smaller number is better
what is the best modulation?
THERE IS NO BEST MODULATION
Keroven THR Formula
THR = [% exercise intensity x HRR] + HR rest HRR = HR max - HR rest
True or False - it is important to perform the structural inspection both in sitting and standing
TRUE, focus especially on position related to symptoms
What nerve is most commonly affected with an anterior dislocation?
axillary nerve
effects of NMES for healthy individuals
better off doing volitional exercise
can ultrasound be used over metal implants?
YES
is acu-mode TENS good for pain relief?
YES appears to be best form, especially for chronic patients (likely diminished DEOS system if opioids used for long periods of time)
can you do shoulder flexion with a second degree ACJ sprain?
YES -- approximates AC joint due to attachment
viscera sensitivities
YES: bladder, stomach, ureter NO: lung, kidney, liver
is a prescription needed for iontophoresis?
Yes physician note with medication and frequency of treatment
can denervated muscle be activated with electrical stimulation?
Yes, but needs HUGE, HUGE charge pulse duration = 1,000 microseconds or more intensity = high frequency = 20 pps
US intensity for acute injury
about 0.5 W/cm2
US intensity for subacute injury
about 0.5 to 1.5 W/cm2
US intensity for chronic injury
about 1.0 to 3.0 W/cm2
duration of soft tissue mobilization
about 10 to 20 minutes per area
length of thermotherapy treatment
about 20 minutes
how can we maximally stimulate muscle contraction?
activate max muscle using stimulation (fast twitch) and volitional/voluntary (slow twitch)
treatment of hypermobility
aims to provide stability/control of motion through full ROM 1. external support with bracing or taping (immediate effect) 2. education (immediate effect): avoid/correct activities that places joint at end range position 3. improve muscle strength/neuromuscular coordination (likely needs 6+ weeks to have an effect) 4. address hypomobility of surround joints and soft tissues: add stress to those with normal motion
charge of albumin
almost impossible to move due to small negative charge
does an anode or cathode have more nerve effects?
cathode
C3 dermatome
lateral aspect of neck
type II mechanoreceptors
myelin: medium speed: 40-70 m/second function: dynamic only (inactive in immobile joint); fast adapting (brief refractory period = lower rate of stimulation, inhibit pain location: deep layers of joint capsule; more numerous in distal joints behavior: dynamic sensation; continuous activity for one minute; mostly active at mid-range) BEST STIMULATED WITH GRADE 2 MOBILIZATION
type III mechanoreceptors
myelin: thick speed: 70-120 m/second function: only become active toward extremes of active or passive joint motion; inactive in immobile joints; very slow adapting, reflex inhibition of muscle tone location: deep and superficial layers of joint ligaments; superficial layers of capsule in lumbar spine behavior: dynamic sensation; continuous activity for several minute; responds to stretch at end of range BEST STIMULATED WITH THRUST MANIPULATION TECHNIQUES (cracking neck, back associated with these)
type I mechanoreceptors
myelin: thin speed: 15-40 m/second function: static and dynamic (ONLY TYPE THAT IS STATIC = where we are in space); slow adapting, inhibit pain location: superficial layers of joint capsule between collagen fibers; in cervical apophyseal joints and proximal extremity joints (posture control) behavior: postural and kinesthetic sensation; continuous activity for one minute; mostly active at beginning and end of range (not active in mid-range) BEST STIMULATED WITH GRADE 1 MOBILIZATION
C1 myotome testing
neck rotation (rarely affected)
duty cycle for motor stimulation
old: 10 seconds on, 50 seconds off -- used huge amount of charge to activate more motor units new: 5 seconds on, 5 seconds off
is grade I or II mobilization better?
one is not necessarily better than the other, both helpful for pain
intervention for bone-to-bone end-feel
optimizing function, while respecting the limitation of joint motion
Secondary Prevention
screening
what structure is most affected by injury to long thoracic nerve?
serratus anterior
if the muscle is weak and painful, then...
severe lesion of some part of the muscle or tendon is likely present (considered as part of a continuum of severity of injury)
C4 myotome testing
shoulder girdle (scapular) elevation patient position: standing/sitting patient "lifts shoulders up," PT applies a force on top of both shoulders
what is pre-mod?
similar to IFC, but only one channel
What is stiff and painful shoulder
similar to adhesive capsulitis but does not follow the capsular pattern of motion loss, and there is normal accessory joint motions -treatment is basically the same
what does TENS stand for?
transcutaneous electrical nerve stimulation
what structure is most affected by injury to spinal accessory nerve?
trapezius
manual cervical traction for cervical radiculopathy
trial intervention before applying mechanical traction
C7 reflex testing
triceps tested with shoulder passively brought into abduction/extension, elbow at 90 degrees of flexion; either aspect of reflex hammer is used to tap tendon just above olecranon process, looking/feeling for muscle response
tissue characteristics: untaped vs taped
untaped: inflammation compresses lymph vessels and pain receptors taped: wrinkles create waves, which moves during movement; inflammation reverses and unloads lymph vessels and pain receptors
timeline for ligamentous injuries (mild to moderate second degree)
up to 6 weeks for repair and healing, another 1+ year for remodeling/maturation
phonophoresis
use of ultrasound waves to introduce medication across the skin and into the subcutaneous tissues (increases skin permeability)
glide
when one articular surface is moved in relationship to the other articular surface in a plane parallel to joint surfaces (requires small amount of distraction)
compression
when two articular surfaces are passively pressed against each other
distraction
when two articular surfaces are passively separated perpendicular to treatment plane
Procedure for Chair Rise Test
- cross arms over chest - start on "GO"
2 Minute Step Test
Domain: Body Function/Activity - # of times right knee reaches mark - limited space option
if Sharp-Purser test is positive, should transverse ligament test be completed?
NO
active trigger point
always tender and refers pain when compressed
etiology of OA
primary risk factor: aging - decrease activity of chondrocytes - decreased number and size of proteoglycans - decreased water concentration - decrased strength and stiffness of cartilage - progressive fraying and softening other factors: mechanical (too little/much stress) and genetic
Muscles of Retraction for Scapulothoracic Joint
primary: middle trapezius -- optimal line of force secondary: rhomboids and lower trapezius
application of elastic tape for overused or acute damage to muscle
- applied with NO TENSION from insertion to origin
ice massage
- apply to small area with overlapping strokes - beneficial for localized area - will experience CBAN (go for numbness)
effective radiating area (ERA)
- area of the transducer from which the ultrasound energy radiates - always smaller than area of the treatment head
Where should electrodes be placed?
- around motor point (with MP inbetween electrodes) - on motor point (with other away from MP)
PROM ER with arm loosely along side of body
- elbow supported on towel or PT hand to keep elbow at same height as shoulder - normal: about 60 degrees - reflective of flexibility of anterior/superior capsule
precautions for ultrasound
- growth plates - acute inflammation - fractures - breast implants - heating of patellar tendon (heat more quickly)
theorized effects of cavitation and microstreaming
- alter membrane permeability and promote soft tissue healing - increase rate of protein synthesis (increased fibroblast activity) - increases intracellular calcium - increases skin permeability = more garbage removed
clinical signs of inflammation
- heat - redness - pain - swelling - loss of function
intermittent traction
- alternative on-off with 1/4 to 1/2 body weight - dependent on goal of treatment (low = muscle relax/stretch; high = distraction) - most appropriate for increasing ROM, muscle spasms or facet joint pain
nociceptors within intervertebral disc
- annulus HAS nociceptors - nucleus pulposus DOES NOT HAVE nociceptors
mechanical cervical traction
- 30 seconds on at 16-24 pounds based on reduction of symptoms - 10 seconds off at 8-12 pounds (so pain does not reoccur) cervical spine should be at about 24 degrees of flexion (less if flexion is limited) treatment = 15-20 minutes
interventions for loose end-feel
- helping, protect against excessive motion, and help optimal control of motion
Duration for Aerobic Endurance
- 30 to 40 minutes - five minutes is better than zero - multiple bouts of short duration can be beneficial
continuous immersion (paraffin)
- 7 dip immersion - continuous 30 minute immersion in bath
continuous immersion with retention (paraffin)
- 7 dip immersion - continuous 30 minute immersion in bath - 30 minutes outside bath with area wrapped
brushing with wrapping (paraffin)
- 7 to 10 coatings brushed over treatment area, then wrapped in layers
other names for conventional TENS
- high frequency - gate based
contraindications for thermotherapy
- ACUTE INJURY - thrombophlebitis: dislodge thrombus or clot - impaired sensation - malignancy: might increase growth rate - pregnancy: avoid heating of trunk or full body - openly draining wound
beats of AC
- AKA IFC premod (incorrect) - action flucutates with NO PAUSE
bursts of AC
- AKA Russian Current (not from Russia) - action, pause, action - multiple bursts/second to activate nerves
Muscles of Elevation through Flexion for Scapulothoracic Joint
- anterior deltoid - coracobrachialis - long head of biceps brachii
causes of trigger points
- Acute overuse - Direct trauma - Persistent muscle contraction: physical or emotional cause - poor posture, repetitive motion, stress response - Prolonged immobility - Systemic biochemical imbalance (rule out blood tests, metabolic panels, MD screenings
danger of constant voltage device
- BEWARE - if voltage stays the same and resistance changes, current will change
Three Components of SPPB
- Balance: side by side; semi-tandem, tandem - Sit to stand: arms fold across chest for 5 chair rises - Four-meter Walk: walk at usual pace; records two trials (best time); begins with 1st step, ends with 1st step PAST tape
Muscles of Elevation through Abduction for GH Joint
- anterior deltoid - middle deltoid - supraspinatus
apprehension test
- PT passively externally rotates to end range or point of apprehension of the patient POSITIVE: feeling of apprehension verbalized by patient or clear signs based on facial expression or resistance
Role of Deltoid and Supraspinatus
- anterior/middle deltoid and supraspinatus are activated at onset of abduction (max at 60-90 degrees) - middle deltoid and supraspinatus contribute equal shares of total torque at GH
Mode of Balance
- 2 legged stance - side stepping - walk on toes/heels - carioca - wobble boards - foam pads
treatment time for conventional TENS
- 20 to 30 minutes - resting, NOT SLEEPING (electrodes can peel) - moving, exercise - application of cryotherapy, heat, ultrasound (gentle treatment, more attentive to skin and placement of electrodes)
Frequency for Aerobic Endurance
- 3 to 7 days per week - more frequent activity with lower intensity
Procedure for 2-Minute Walk
- 30 meter track with marks every 3 meters
Procedure for 6-Minute Walk Test
- 30 meter track with marks every 3 meters
burst
- anything with four or more phases - chunks of PC or AC delivered
Short Physical Performance Battery
- CAN help patient assume the position - no acceleration or deceleration - objective assessment of lower extremity functioning - predicts mobility and ADL disabilities - Low score, less than 9, is strong risk for institutionalization, morbidity, mortality
contraindications of cryotherapy
- COLD SENSITIVITY: cold uticaria (allergic reaction = wheals) - cryoglobulinemia (blood protein causes precipitate) - Raynaud's phenomenon (vasospastic disease) - paroxysmal cold hemoglobinuria (hemoglobin in urine) - compromised circulation - peripheral vascular disease - over areas of nerve regeneration
mechanism of action for Acu-Mode
- DEOS - endogenous opiates released into systemic bloodstream and CSF (half life of about 6 hours)
do erythrocytes migrate during inflammation and healing?
- DO NOT MIGRATE TO INJURY
"separated shoulder"
- DOES NOT REFER TO GH JOINT - ACJ sprain/separation
Scoring of Berg
- FIRST effort is recorded - instructions given as audio and/or visual - patient chooses leg, regardless first attempt recorded
Palpation of Ulnar Styloid
- Just distal and medial to the head of the ulna
Palpation of Capitate
- Just proximal to the base of the metacarpal III - On the posterior surface of the hand, if you press down in the center of the wrist you will feel a hollow spot between the tendons
treatment of second degree sprain of ACJ (conservative approach)
- Kenny-Howard sling for 4-6 weeks: maintains ACJ in position -- STRICT ADHERANCE, 24 hours/day (almost never used; too demanding)
treatment of third degree sprain of ACJ (conservative approach)
- Kenny-Howard sling for 4-6 weeks: maintains ACJ in position -- STRICT ADHERANCE, 24 hours/day (almost never used; too demanding) lengthy and painful -- deformity still might be present
pain sensitivity after an injury
- MORE sensitive (days to weeks) - protective to prevent worsening the injury
TUG Dual Task
- Manual Task: stand, grasp cup of water, walk, set back down and sit - Cognitive Task: count backwards by 3 starting at 100 or alternating letters of alphabet aloud
monocyte/macrophage
- Monocyte = in bloodstream; Macrophage = in tissues. - associated with chronic inflammation - phagocytosis
Palpation of Scaphoid
- On the dorsal side of the wrist, the scaphoid bone can be felt as the floor of the anatomical snuffbox. - On the ventral side of the wrist, feel the scaphoid just distal to the radial styloid process. Ulnarly deviate the wrist to feel the separation between the scaphoid and the radial styloid process
ACJ distraction test
- PT grabs distal end of humerus and provides long axis pull, creating shoulder depression - look for step deformity - ask for pain reproduction
Isolation for Sternal Head of Pectoralis Major
- Patient starts in 120 degree - Lifts arm across body toward opposite hip - Resistance given in an up and out direction (high to low) PALPATION: anterior chest wall (get consent) PT Position: standing close to patient's head to be in line of pull for body mechanics
Isolation for Clavicular Head of Pectoralis Major
- Patient starts in 60 degree of shoulder abduction - Lifts arm across body toward opposite shoulder (movement low to high) - Resistance given in a down and out direction PALPATION: inferior to medial 1/3 of clavicle PT Position: standing close to patient's hip to be in line of pull for body mechanics
absolute contraindications for dry needling
- Patient who refuses treatment - Patient with needle phobia - Unwilling patient; fear or patient belief - Patient unable to give consent - Medical emergency or acute medical condition or bleeding disorder - Patient with an active infection - Fracture site - Over any region with lymphedema
Palpation of Radial Styloid
- Process is on the distal end of the bone at its most lateral aspect. - Somewhat pointed in shape and might be difficult to feel because of overlying soft tissues.
What are some stretches for posterior shoulder tightness?
- Sleeper Stretch - modified sleeper stretch - cross body stretch
Knee Girth Measurement
- Tibial tuberosity, medial tibial tubercle, or fibular head 1. At landmark 2. Below: 5 cm and 10 cm 3. Above: 5 cm, 10 cm, 15 cm
charge of red blood cells
- VERY SLIGHT negative charge - nearly impossible to attract or repel RBCs - if true, RBCs would oscillate when we pass a power line = we explode
motor unit
- a single motor nerve and all of the muscle fibers that it innervates - fast twitch and slow twitch (lot of action with low physiological cost)
First Kinematic Principle
- abduction at the glenohumeral joint requires an arthrokinematic pattern of superior roll combined with a "relative" inferior slide
AROM IR with arm loosely along side of body
- able to reach behind back - provides estimate of flexibility of posterior/superior capsule of GHJ ** look for excessive IR (winging) and anterior tipping (prominent inferior angle) --> if noticed, have patient relax at end ROM (if it rests in better position, flexibility of posterior shoulder is likely adequate)
treatment time for traction
- about 10 minutes (gradually work toward 30 minutes) - although it will feel good, avoid overuse
how long do pathways stay open after iontophoresis?
- about 3-4 hours after electricity is stopped
role of hyaline cartilage
- absorb compression forces - promote gliding of articular surfaces
somatic pain
- activation of nociceptors found in most body tissues - EPAs work very well
visceral pain
- activation of nociceptors found in viscera - "referred pain" - response to EPAs is not great
NMES for wrist stabilization
- activation of only plantar (higher intensity) would contract fingers AND wrist - co-contraction with dorsum of hand to prevent too much wrist flexion
contraindications for traction
- acute injury/inflammation - infectious disease - spinal malignancy - pregnancy (loose ligaments) - spinal fracture or fusion - hypermobility/instability - claustrophobia - respiratory disease
component of stage
- acute, subacute, chronic - follows stages of healing or timeline of insidious onset
indications for cold therapy
- acute/subacute and post-surgical injuries - pain - muscle spasm - spasticity disorders
interventions for grade 3 ligament injury
- address initial swelling/inflammation/pain related to injury - subsequent management will vary according to involved ligament
factors that affect rate of union of fractures
- age - blood supply - immobilization - infection: hinders healing - interposition of soft tissue: hinders healing - pathological diseases
interventions for muscle spasms
- aimed at decreasing excessive pain, muscle guarding and inflammation, if present
interventions for empty end-feel
- aimed at decreasing excessive pain, muscle guarding, and inflammation, if present
interventions for capsular tightness
- aimed at stretching joint capsule
Frequency of Flexibility
- all major muscle groups - 2 to 7 days per week
inert structures include...
- all other soft tissue: ligaments, joint capsules, bursae, dura, nerve root, peripheral nerves, fascia, skin
surgical treatment of SCJ degenerative arthritis
- arthroscopic surgery, if non-surgical not satisfactory (surgical removal of proximal clavicle) -- does NOT affect ligamentous structure - education on posture - slign for 2 days, AAROM at day 3, full ROM at 7 days - lifting and carrying at 6 weeks - address inflammation: ice, EPAs LONG TERM RESULTS ARE TYPICALLY POSITIVE
pre-test screening of vertebral arteries
- ask patient for symptoms of dizziness and/or fainting, especially related to neck movement - ask if they've experienced visual disturbances, nystagmus, blurred vision, nausea, facial or intraoral numbness, diplopia (double vision), dysarthria (difficulty with speech), or dysphagia (difficulty swallowing) if symptoms, especially combined with positive medical history suggesting arterial disease, referral should be considered without further testing
osteochondritis dissecans
- associated with subchondral bone necrosis - cartilage overlying area remains relatively intact as it receives nutrition from synovial fluid - as necrotic bone is resorbed, cartilage becomes lose = loose body
impact of immobilization on muscle
- atrophy - shortening (loss of sarcomeres in series)
important notes of nerve tension tests
- be consistent with shoulder height - standardize foot width - place opposite hand on patient's stomach with elbow bent to avoid potential tension from contralateral side
Procedure for FSST
- begins when patients foot hits the first square - ends when last foot hits the last square
tendon cell response model in tendinopathy
- believed to be the cause - changes in tendon load will be sensed by the tendon (increase # of tenocytes) and result in cascade of responses (cell activation, GAG expression, more type III instead of type I collagen) --> imbalance between degradation and synthesis
why do some clinicians still prefer IFC?
- believed to cover larger area: true, but so does other methods - goes deeper: capacitance is reduced at higher frequency SIMILAR TO OTHER METHODS - just another way to deliver charge
vapocoolant spray
- beneficial for localized trigger point - spray area 3-5 times, then passively stretch (NOT spray, stretch, spray, stretch, etc.)
guarding on the stairs
- best to use railing on affected side and assistive device on unaffected side - if using single rail, guard to open side of stair case
Rotator Interval
- between the subscapularis and supraspinatus tendons - inherent weakness in the anterior capsule
how does amplitude vary?
- body or machine impedance - placement of electrodes DOES NOT DIRECTLY VARY DUE TO PATIENT DOING/NOT DOING EXERCISES
PROM cervical extension
- both hands behind occiput, PT passively brings cervical spine into extension - done over edge of table - do not do if there are signs/history of fainting/dizziness and/or headaches (vertebral artery testing first)
impact on mechanical mobilization
- break-up cross links - stretch out restrictions with minimal stress - guide orientation of newly formed collagen fibers - restore normal joint motion and position
contraindications for ultrasound
- cancer: tumor growth - hemorrhagic regions: might increase bleeding - ischemic peripheral regions: unable to meet metabolic demand - impair skin sensation - infected lesions (spread) - pregnancy - thrombophlebitis - implanted medical devices (joint cement, plastic) - gonads (crease fertility) - spinal cord after laminectomy (risk cavitation within CSF)
non-thermal effects of ultrasound
- cavitation - microstreaming - promotes enzymatic activity (frequency response hypothesis) - degranulation of mast cells: release histamine and triggers inflammatory response
impact of immobilization on articular cartilage
- cellular death (decrease # of chondrocytes) = lesser ability for cartilage regeneration - decrease GAG and water content = roughened artciular surface and decreased ability to absorb shock - decreased nutrition (no compression that helps squeeze out "sponge") - formation of intra-articular adhesions
Balance Progression
- change base of support - speed of activity - change floor surface - shoes to barefoot - change arm assist - change vision
duration modulation
- changing the pulse or phase duration - intensity remains the same, but more spaced out = amount of charge (area) per pulse changes
strength duration modulation
- charge per time stays the same - area remains the same
signs and symptoms of cartilage trauma
- chronic pain that increase with weight bearing - swelling - joint locking/catching (loose body) - instability feeling
precautions with thermotherapy
- chronically inflamed joint - impaired circulation/poor thermal regulation - edema - cardiac insufficiency (might not tolerate demand) - metal implants (internal bleeding) - areas that topical counter-irritants have been applied (avoid further vasodilation)
what is microcurrent?
- claim to create current similar to endogenous injury current, sends signal to healing cells - NOT THE CASE, D- for evidence
grade 3 (third degree) ligament injury
- classically defined as 100% of fibers injured - severe localized swelling and tenderness with palpation - potentially (not always) minimal on stress testing -- in theory, if all fibers torn, there should be no pain - complete loss of functional integrity of ligament (not a complete loss) - laxity with stress testing = no demonstrable end-feel still present
grade 3 (third degree) muscle or tendon injury
- classically defined as 100% of fibers injured (some define between 80-100%) - minimal pain with resisted motion or passive stretching (if all fibers torn, there should be no pain) - substantial weakness (in theory, should be complete loss of strength, but there could be a few remaining fibers) - mild/severe localized swelling and tenderness with palpation - possible ecchymosis (might show up 2-3 days later at more distal site) - possible palpable muscle disruption (damage) - visible abnormal appearance of muscle belly - likely positive findings on MRI or US imaging
grade 2 (second degree) ligament injury
- classically defined as >10% to 99% of fibers injured - mild/severe localized swelling and tenderness with palpation - mild/severe pain on stress testing - partial loss of functional integrity of ligament (not a complete loss) - laxity with stress testing = firm end-feel still present
grade 2 (second degree) muscle and tendon injury
- classically defined as >10% to 99% of fibers injured - pain (mild to substantial) with resisted motion or passive stretching - mild to substantial weakness - mild/severe localized swelling and tenderness with palpation - possible ecchymosis (might show up 2-3 days later at more distal site) - possible palpable muscle disruption (damage) - likely positive findings on MRI or US imaging
grade 1 (first degree) ligament injury
- classically defined as less than 10% of fibers injured - minimal/mild localized swelling and tenderness with palpation - pain on stress testing - no loss of functional integrity of ligament -- no laxity with stress testing
grade 1 (first degree) muscle and tendon injury
- classically defined as less than 10% of fibers injured - pain (minimal) with resisted motion or passive stretching - some (minimal) weakness - minimal/mild localized swelling and tenderness with palpation - no observable/palpable muscle disruption (damage) - may be negative findings on MRI or US imaging
Fifth Kinematic Principle
- clavicle retracts, about 20 degrees, at the SC joint during full abduction = assists the AC joint for optimal positioning of scapula
application of iontophoresis
- clean skin with alcohol - hair should be trimmed with scissors or clippers - avoid pressure on electrodes and minimize movement - EDUCATE PATIENT
three types of cervical traction
- clinical units - home traction units - manual traction
NMES for post ACL repair
- co-activation of hamstring AND quads (VMO) to minimize anterior translation - if quads only, anterior translation of tibia would stress the ACL (runs over patella, which creates horizontal pull)
if the muscle is weak and painless, then...
- complete rupture of muscle or tendon (movement might occur if other muscles have similar action) - neurological disorder from minor/partial to complete paralysis due to peripheral nerve lesion or central nervous disorder - atrophy
scattering of ultrasound
- conductive gel/water helps minimize loss of sound energy at the skin - refraction will focus energy along skin
post-operative rehabilitation for third degree sprain of ACJ
- consists of wearing brace/sling for 6-8 weeks followed by progressive PROM/AROM exercises - light resistance/strengthening exercises at 12 weeks - return to full activity requires full ROM and strength
static traction
- constant force for 1/2 hour - force equal to or greater than 1/2 body weight (start with 1/4 of weight and progress) - most appropriate for bulged disc
direct current
- continuous, unidirectional flow of charged particles - does NOT reverse or cease overtime
interventions for inflammation
- control pain, inflammation, guarding - protect from further injury - promote biological healing - limit morbidity (maintain integrity and function)
Ankle Balance Strategies
- corrects small perturbation, slower velocity - standing on "normal" support surface - distal to proximal activation
acupuncture points with Acu-Mode
- correlated with pain (very low impedance) web space of thumb = headaches lateral aspect of hand below 5th metacarpal = low back pain
desensitization exercise materials
- cotton material - Terry cloth - corduroy - velvet - polyester - wool - empty roll-on deodorant bottle
"cracking" or "pop" of joint with manipulation
- creation of synovial gas bubble - breaking a capsular adhesion
three questions for pain
- current amount of pain - least pain in past 48 hours - most pain in past 48 hours 48 hours is appropriate for acute condition, one week window appropriate for chronic condition
cardiac effects of electrical stimulation
- current follows the path of least resistance, which typically avoids the heart - avoid if patient has some sort of arrhythmia
contraindications for iontopohoresis
- damaged/broken skin - decreased skin sensation - sensitivity to drug or direct current - cardiac pacemakers or other implanted evices - cardiac arrhythmias
impact of immobilization on capsule
- decrease GAG and water content = decrease open space between fibers = less distance for fibers to travel - decrease nutrition and thickening of capsule (lack of stretch) - collagen fiber alignment occurs at random = cross fibers and adhesions
impact of immobilization on synovial lining
- decreased diffusion leading to decrease joint nutrition - thickening of lining
key features of nociplastic pain
- diffuse area of pain/tenderness - inconsistent relationship to movement and posture - disproportionate to expected level from injury mechanism - associated with maladaptive psychological features
compression STM
- direct static pressure - hold 5 to 30 seconds - obstructs blood flow, which creates ischemic condition, which sends signals to vasodilate = rush of blood when pressure removed
Gait Speed Test
- distance of 4, 5, or 10 meters - allow distance of 2 meters for acceleration/deceleration - trial run at comfortable pace - measure at comfortable speed and fast speed - two trials of each
Duration for Balance
- done as specified balance exercise (10-15 minutes) - incorporated into daily activites
indications for GHJ distraction
- due to amount of physical effort needed, probably best for pain modulation with grades I and II - grades III and IV can be used to address hypomobility (difficult to do)
PROM ER with arm at 90 degrees of scapular abduction
- elbow supported on towel or PT hand to keep elbow at same height as shoulder - normal: about 90 degrees - reflective of flexibility of anterior/inferior capsule BE CAREFUL WITH HISTORY OF SHOULDER DISLOCATION
PROM IR with arm loosely along side of body
- elbow supported on towel or PT hand to keep elbow at same height as shoulder - normal: hand reaches stomach - reflective of flexibility of posterior/superior capsule
PROM IR with arm at 90 degree of scapular abduction
- elbow supported on towel or PT hand to keep elbow at same height as shoulder - to monitor compensations, PT uses one hand to palpate tip of coracoid process and spine of scapula (looks like a C over top of shoulder) - other hand holds distal forearm for motion - normal: about 50-60 degrees - reflective of flexibility of posterior/inferior capsule
NMES assisted lumbar stabilization
- electrodes placed on rectus abdominus and low back for proper lifting
RROM scapulothoracic joint quick screen
- elevation: applies resistance at top of shoulders; test both sides together (NO HANDS ON THIGHS) - depression: patient with elbow bent at 90 and kept near body, PT applies resistance at elbows in upward direction; test both sides together - retraction: bilateral shoulder retraction; resistance applied anteriorly on posterior aspect of acromions; test both sides together - protraction: bilateral shoulder protraction; resistance applied posteriorly on anterior aspect of acromions; test both sides together
normal response to iontophoresis
- errythemia due to histamine response (should resolve in a few hours) - sweat retention vesicles might form -- DO NOT PICK AT THEM (should resolve)
two types of vapocoolant spray
- ethyl chloride: no longer used (flammable, volatile) - fluori-methane: safe, non-flammable
ligaments without expectation of tissue healing -- considered "critical"
- example: anterior cruciate ligament - address inflammation/pain and progressive pre-surgical rehabilitation of ROM, strength, and function - surgical construction or repair - followed by progressive rehab, ROM, strength and function
ligaments with expectation of tissue healing
- example: medial collateral ligament - address inflammation/pain (potential immobilization) - progressive rehabilitation of ROM, strength, and function
ligaments without expectation of tissue healing -- considered "non-critical"
- example: posterior cruciate ligament - address inflammation/pain - progressive rehabilitation of ROM, strength, and function
2+ sulcus score
- excessive laxity - 1 to 2 cm displacement (more than 1 finger width)
injurious factors for tendons
- excessive repetitive training or workload - direct trauma - previous injury less than optimal biomechanical function - ergonomic conditions
what muscles are involved with lateral elbow tendinopathy?
- extensor carpi radialis brevis - extensor carpi ulnaris - supinator - extensor digitorum
Hip Balance Strategy
- fast or large displacements, narrow base of support, high velocity - proximal to distal activation
Procedure for Romberg
- feet touching - hands crossed and touching opposite shoulders - stay in position for 30 seconds
what muscles are involved with medial elbow tendinopathy?
- flexor digitorum superficialis - flexor carpi radialis - flexor carpi ulnaris - palmaris longus - pronator teres
contract-relax-contract stretching
- form of proprioceptive neuromuscular facilitation (PNF) - antagonist muscle/tendon unit is contracted (rather than passive stretch from PT) - patient pushes 7-8 seconds against the PT, then relaxes --> patient moves joint to "new" end range (should gain a few degrees) - repeated 2 more times
hold-relax stretching
- form of proprioceptive neuromuscular facilitation (PNF) - muscle/tendon unit is placed under passive stretch and held at end range - patient pushes 7-8 seconds against the PT, then relaxes --> PT slowly moves joint to "new" end range (should gain a few degrees) - repeated 2 more times
cavitation
- formation of tiny gas bubbles in tissues = gentle oscillation of bubbles opens space in endothelial cells ALLOW GOOD STUFF IN AND BAD STUFF OUT
mast cells
- found in connective tissue - release substances (histamine, heparin) in response to tissue injury and inflammation
quadripolar placement
- four electrodes (most common for big area) - crossed to maximally activate nerves
characteristics of matruation/remodeling
- from day 21 to several weeks or months based on injured tissue - collagen production peaks within first 2 months of healing -- may persist at a reduced rate up to 6 months after injury - NEW SCAR TISSUE WILL ALWAYS SHORTEN UNLESS IT IS REPEATEDLY STRETCHED
normal motion of scapula during AROM upward/downward rotation while lowering the arm
- from maximum elevation to 0 degrees, smooth motion should occur (best viewed at medial border)
how can different parts of the capsule be stretched during inferior GHJ glide?
- further finetune slightly by lowering the elbow towards the floor to stretch anterior part (or raise to stretch posterior capsule) - changing the amount of rotation to ER will add stretch to anterior capsule (or IR to stretch posterior capsule)
improper names for electrical current
- galvanic current - H-wave current - formadic - diadynamic - IFC premod
Second Kinematic Principle
- generalized 2:1 scapulohumeral rhythm - 120 degrees of GH abduction and 60 degrees of scapulothoracic upward rotation
tinel sign
- gentle tapping is applied over nerve positive: tingling in related nerve distribution
treatment of second degree SCJ sprain
- instruction on good posture - relative rest for a few days and protection against further trauma -- Figure of 8 sling may be necessary for 1-2 weeks - ice and appropriate EPAs for pain/inflammation - progressive return to full function based on symptoms
treatment of first degree SCJ sprain
- instruction on good posture - relative rest for a few days and protection against further trauma -- sling for a few days, only if needed for comfort - ice and appropriate EPAs for pain/inflammation
treatment of first degree sprain of ACJ
- instruction on good posture - relative rest for a few days and protection against further trauma: sling, taping, or hand in pocket for a few days - ice and appropriate EPAs for pain/inflammation - AROM exercises within pain tolerance treated as an acute sprain with goal to decrease pain and inflammation -- only a few days to be asymptomatic
treatment of second degree sprain of ACJ (symptomatic approach)
- instruction on good posture - relative rest for several days and protection against further trauma: sling, taping, or hand in pocket for 7-14 days (protect 5-6 weeks for healing to occur) - ice and appropriate EPAs for pain/inflammation - AROM exercises within pain tolerance - likely 4-6 weeks prior to return to play residual symptoms may be present in as high as 60% of cases -- no exercises to "fix" symptoms
treatment of third degree sprain of ACJ (symptomatic approach)
- instruction on good posture - relative rest for several days and protection against further trauma: sling, taping, or hand in pocket for 7-14 days (protect several weeks for healing to occur) - ice and appropriate EPAs for pain/inflammation - AROM exercises within pain tolerance - likely several weeks prior to return to play minimal time and expense -- leads to permanent "step deformity" (possible residual pain and loss of function)
limitations of iontophoresis
- ions must be charged - must be relatively small - must be a solution (no cream or suspension) - should have NO systemic effects
what is direct current used for?
- iontophoresis - hyperhidorsis (sweating palms/feet)
resting postion (maximum open packed position)
- joint surfaces are least congruous - capsule and ligaments are least taut = allows maximum gliding or distraction of articular surfaces
close packed position
- joint surfaces are most congruous - capsule and ligaments are most taut = limits gliding or distraction of articular surfaces
Beighton Hypermobility Scale
- knee hyperextension >10 degrees (1 point for each) - elbow hyperextension >10 degrees (1 point for each) - thumb to forearm (1 point for each) - fifth MCP extension >90 degrees (1 point for each) - palm flat to ground (1 point 0-3 is considered normal 4 or more considered hypermobility in adults 5 or more for children
grade III mobilization
- large amplitude at end-range, slower (1 cycle/second) oscillations - create mechanical effects to treat joint restrictions
grade II mobilization
- large amplitude at mid-range, slower (1 cycle/second) oscillations - create neurophysiological effects to treat pain typically activate type II mechanoreceptors
physiology of gate theory
- large fiber: touch (fast) = turns ON substantia gelatinoas (SG), which reduces touch and pain signal - small fiber: pain, turns OFF SG = more pain signal
downward rotators of scapula
- levator scapula - rhomboids - pectoralis minor
duration of a third degree SCJ joint
- likely 3 to 6 weeks for healing to occur - severe injury that may require several weeks to heal and require more formal rehab to recover ROM, strength, and function
duration of a second degree SCJ joint
- likely 4 to 6 weeks prior to return to play - moderate to severe injury that may require several weeks to heal and require more formal rehab to recover ROM, strength, and function
pain at one extreme of range
- likely due to structure being stretched or compressed, or OA - not diagnostic in itself
advantages of isometric exercise
- little to no equipment - easily taught/learned - helps reduce atrophy - maintains neural association - decrease pain - can be used early in rehab process - decreases capsular adhesions
key features of nociceptive pain
- localized to specific body region - responds in a predictable manner - usually intermittent and sharp
general motions that will provoke pain in SCJ with history of trauma
- location of pain over SCJ itself - likely report pain with reaching across the body - potentially with shoulder protraction and end-range overhead motion
general motions that will provoke pain in SCJ with NO history of trauma -- older individuals (OA related pain)
- location of pain over SCJ itself - likely report pain with reaching across the body and potentially with shoulder protraction and end-range overhead motion
C fibers
- long, dull pain (1 m/s): less myelin = slower transmission - less than 10% reach sensory cortex
movement limitation due to intra-articular changes
- loose bodies in joint space (knee and elbow) - typically limited in one direction - can be intermittent and not always same direction
why can paraffin wax be hotter than water?
- lower thermal conductivity - low specific heat: ability of substance to give up heat/energy (water has high heat)
Self-suboccipital release
- lying on back with towel roll under back of neck - relax in this position - as muscles relax, perform a gentle forward nod of head, holding for a few seconds, elongating the back of neck. - relax and repeat based on comfort and response
Angular Vestibular Ocular Reflex
- maintains stable vision during head motion - sensed by the semicircular canals
Intensity for Strength
- majority of adults are able to exercise at 80% of 1 rep max - higher intensity = lower reps
symptoms and signs of second degree sprain of ACJ
- moderate/severe pain - localized swelling - definite "step deformity"/displacement of distal end of clavicle - pain at end-range horizontal adduction or protraction - potentially pain with full shoulder abduction - decreased shoulder ROM - tenderness to joint line palpation - distraction test, similar to sulcus sign, while palpating the ACJ is positive - imaging is not necessary, but can be done (weights to increase gaping of ACJ)
components of naming a PC current
- mono/bi/tri phasic - symmetrical/asymmetrical - balanced/unbalanced
Intensity of Strength
- most adults can safely exercise at 70-80% of 1 RM - 70-80%: 8 to 12 reps - 30-60%: 13 to 25 reps
contractile structures include...
- muscle - muscle tendon junction - tendon - tendon periosteal junction
movement limitation due to extra-articular changes
- muscle (injuries or tightness) - bursa (due to inflammation) - fascia (due to adhesion/restriction)
tissues involved in stretching
- muscle/tendon units - capsule - connective tissue
Intensity of Gait
- must challenge limits of gait and locomotion: change speed, surface, stride length, vision, BOS, etc.
Intensity for Balance
- must challenge the limits of stability both statically and dynamically
ketoprofen
- negative charge - anti-inflammatory
dexamathose
- negative charge - anti-inflammatory by reducing synthesis of prostaglandins - takes about 36-48 hours, so every other day treatment recommended (usually 6 treatments)
acetic acid
- negative charge - breakdown calcium deposits (myositis ossificans) into solumble compound - treatment for 3x/week for 3-6 weeks (usually 10-15 treatments)
potassium iodide
- negative charge - interacts with cross-binding of collagen in scars and adhesions, which makes it softer - CONTRAINDICATION = seafood allergy
indications of traction
- nerve root impingement - joint hypermobility (facets stuck) - degenerative joint disease (DJD) - muscle spasm/guarding - discogenic pain
referred pain convergence
- neurons in spinal cord receive afferent fibers from 2 distinct peripheral sites --> signal from common neuron relayed to cortex
viscerosomatic convergence
- no direct signal from viscera to brain - signal converges with another pathway, which signals to brain
0 laxity
- normal (grade 1) - if joint opening is equal to joint on contralateral limb
1+ sulcus score
- normal amount of displacement - <1 cm displacement (less than finger width)
peripheral sensitization
- normal for days to weeks - reduction of nociceptor threshold = more sensitive
AROM ER with arm loosely along side of body
- normal range: 60 degrees - provides estimate of flexibility of anterior/superior capsule of GHJ
AROM IR with arm at 90 degrees of abduction
- normal: 50-60 degrees - often see more motion because of anterior tilt of scapula - provides estimate of flexibility of posterior/inferior capsule of GHJ
AROM ER with arm at 90 degrees of scapular abduction
- normal: 90 degrees - estimate of flexibility of anterior/inferior capsule of GHJ - pain in back of shoulder could indicate internal impairment - apprehension could be indicative of shoulder instability/laxity
AROM of shoulder horizontal abduction
- normal: approximately 20 degrees - provides estimate of flexibility of anterior capsule of GHJ
AROM of shoulder horizontal adduction
- normal: elbow at midline of body (sternum) - provides an estimate of flexibility of posterior shoulder capsule - lack of stabilization of scapula allows for compensation with shoulder protraction
potential signs and symptoms to look for during vertebral artery test
- nystagmus - pupil dilation/constriction - vertigo - headache - voice change - memory loss - fainting - dizziness or nausea
compensations seen with cranio-cervical flexion test
- obvious activation of more superficial neck muscles (scalenes, SCM) - head retraction, pushing directly on table with occiput
mechanism of capsular contracture
- occur secondary to injury, immobilization or surgery - may be idiopathic
monopolar placement
- one electrode is big (dispersive, low current density) - active electrode placed directly over target tissue, often smaller in size, greatest perception (high current density) will be over target tissue
Procedure for Sharpened Romberg
- one foot directly in front of other (tandem) - hands crossed and touching opposite shoulders - stay in position for 60 seconds
PROM shoulder horizontal adduction at 90 degree of flexion
- one hand behind elbow, one hand around wrist of patient - bring shoulder to 90 degree of scapular abduction with 90 degree flexion - hand brought across body, like reaching to opposite shoulder - more accurate to stabilize lateral border of scapula: about 40 degree expected - reflective of flexibility of posterior shoulder capsule POTENTIALLY PROVOCATIVE of pain if SCJ/ACJ pathology or rotator cuff tendionpathy
electrode application for conventional TENS
- one on painful area, one somewhere else - around painful area - paraspinals or dermatomes - peripheral nerve that innervates area - placed on opposite limb if patient cannot tolerate on one side (flood area with stimulation) PLACEMENT IS TRIAL AND ERROR
benefits of stretching
- optimal function - enhance work/athletic performance for those that require greater flexibility - prevention of work/leisure/sports injuries by improving mechanics and improving soft tissue elasticity/reducing stiffness DOES NOT inherently prevent injuries -- example, long distance running does not require high amounts of flexibility (so stretching does not prevent)
general motions that will provoke pain in ACJ with history of trauma
- pain over ACJ itself - reaching across the body (shoulder adduction) - potentially shoulder protraction, end-range overhead motion, and carrying something in related hand
key features of neuropathic pain
- pain provoked by movements and postures that compress/move/tension a nerve - pins and needles/numbness - muscle weakness - burning, shooting, electric-like pain
signs and symptoms of ACJ degenerative arthritis
- pain with horizontal adduction or protraction - pain with full shoulder abduction - tenderness to joint line palpation - positive compression (shear) test - likely hypomobility
superficial STM
- palm of hand is rubbed briskly over the skin OR sawing motion with knuckles - little to no lubricant - slight thermal effect
additional tests to evaluate ACJ
- palpation of joint line for pain - compression/shear test - joint play assessment
additional tests to evaluate SCJ
- palpation of joint line for pain and potential clicking - palpate for symmetry of movement during shoulder girdle movement - joint play assessment
three connective tissue sheaths of tendon
- paratenon: loose areolar CT (type I and II) - epitenon: loose CT containing vascular, lymphatic and nerve supply to tendon = surrounds all fascicles within tendon - endotenon: thin reticular network of CT = surrounds each fascicle
loose end-feel
- pathological (abnormal) end-feel - absence of resistance where there SHOULD BE resistance (ligamentous laxity)
springy rebound end-feel
- pathological (abnormal) end-feel - attributed to intraarticular structures (defects, meniscus tear/fold) --> often require surgery
capsular (abnormal) end-feel
- pathological (abnormal) end-feel - similar to normal capsular, but before normal joint ROM is achieved - can occur secondary to injury, immobilization or surgery
pannus end-feel
- pathological (abnormal) end-feel - soft, crunchy squelch (sticking nail into rubberband) - attributed to inflammation and thickening of synovial lining of capsule
empty (painful) end-feel
- pathological (abnormal) end-feel - soft, not limited mechanically - stopped due to PATIENT EXPRESSING PAIN
posterior apprehension test
- patient is supine - to start, shoulder is passively position in 90 degrees of flexion with elbow allowed to bed as comfortable (horizontal adduction) - one hand of PT is behind shoulder palpating along posterior aspect of glenoid rim - other hand is at tip of elbow providing posteriorly directed force along the long axis of humerus POSITIVE: feeling of apprehension verbalized by patient or clear signs based on facial expression or resistance
neck flexors muscle endurance test
- patient performs end range cranio-cervical neck flexion, then lift their head off the table while maintain that position (bottom of nod) - head lifted just enough to slide hand underneath - average time WITHOUT neck pain = 40 seconds; WITH neck pain = 24 seconds
ACJ anterior glide
- patient position: seated with forearm relaxed and well supported on thigh - PT stands behind patient and fixates the acromion and scapula with hand corresponding to patient's shoulder (patient right shoulder = PT right hand): palm of hand around acromion, thumb along spine of scapula, index finger palpating ACJ line - fingers of PT's other hand contact the anterior aspect of the distal end of the clavicle and apply a anteriorly directed force
ACJ inferior glide
- patient position: seated with forearm relaxed and well supported on thigh - PT stands behind patient and fixates the acromion and scapula with hand corresponding to patient's shoulder (patient right shoulder = PT right hand): palm of hand around acromion, thumb along spine of scapula, index finger palpating ACJ line - fingers of PT's other hand contact the anterior aspect of the distal end of the clavicle and apply a inferiorly directed force
ACJ posterior glide
- patient position: seated with forearm relaxed and well supported on thigh - PT stands behind patient and fixates the acromion and scapula with hand corresponding to patient's shoulder (patient right shoulder = PT right hand): palm of hand around acromion, thumb along spine of scapula, index finger palpating ACJ line - fingers of PT's other hand contact the anterior aspect of the distal end of the clavicle and apply a posteriorly directed force
assessment of STJ mobility
- patient position: sidelying on uninvolved side - STAND BEHIND PATIENT
Hawkins-Kennedy Test
- patient position: sitting or standing - PT stands in front of patient, bends the patient's elbow to 90 degrees of flexion and 90 degrees of shoulder flexion - therapist passively internally rotates the shoulder -- movement stopped if pain; otherwise, apply overpressure more provacative: more horizontal adduction less provacative: less horizontal adduction reproduction of pain during movement or at end range suggests a rotator cuff injury
Neer impingement test
- patient position: sitting or standing - therapist places one hand behind patient's shoulder (on scapula) to stabilize the patient and prevent rotation and extension of trunk - other hand holds posterior aspect of distal humerus and elbow - PT passively elevates the arm in forward flexion (thumb up) -- movement stopped if pain; otherwise, apply overpressure - if no pain, test can be made more provocative by repeating the test with arm internally rotated (thumb down) -- movement stopped if pain; otherwise, apply overpressure reproduction of pain during movement or at end range suggests a rotator cuff injury
Speed's Test
- patient position: sitting or standing - therapist passively brings arm of patient to 90 degrees of shoulder flexion and positions elbow in slight flexion (10-20 degrees) with forearm supinated (palm up) - one hand behind shoulder to stabilize trunk, other hand applies resistance to anterior aspect of distal forearm - prior to application of force, patient is instructed to initially resist PT force without movement of shoulder or elbow - after verbal instruction from PT, patient slowly lowers arm as therapist continues to apply force (letting PT win) reproduction of any part of test suggests a long head of biceps injury or SLAP lesion
supraspinatus test (AKA empty can test or Jobe's test)
- patient position: standing or sitting - therapist places one hand behind patient's trunk to stabilize patient STEP 1: - resist abduction at 90 degrees (palm down) STEP 2 -- ACTUAL TEST (further isolate supraspinatus): - repeat with arm at 80 degrees of shoulder abduction and shoulder medially rotated (thumb down) IN EITHER, pain or weakness suggests a supraspinatus injury
SCJ superior glide
- patient position: supine with arm at side - purpose: improve scapular depression - to assess: use one thumb over caudal aspect of clavicle and push in cranial direction, while palpating joint line with index finger of opposite hand - to treat: use both thumbs over caudal aspect of clavicle and push in cranial direction
SCJ inferior glide
- patient position: supine with arm at side - purpose: improve scapular elevation - to assess: use one thumb over cranial aspect of clavicle and push in caudal direction, while palpating joint line with index finger of opposite hand - to treat: use both thumbs over cranial aspect of clavicle and push in caudal direction
SCJ anterior glide
- patient position: supine with arm at side - purpose: improve scapular protraction - to assess: use one thumb over anterior aspect of clavicle and push in posterior direction, while palpating joint line with index finger of opposite hand - to treat: use both thumbs over anterior aspect of clavicle and push in posterior direction
SCJ posterior glide
- patient position: supine with arm at side - purpose: improve scapular retraction - to assess: use one thumb over anterior aspect of clavicle and push in posterior direction, while palpating joint line with index finger of opposite hand - to treat: use both thumbs over anterior aspect of clavicle and push in posterior direction
PROM of scapulothoracic joint
- patient sidelying on opposite shoulder - PT stands behind patient: uses one hand on top of acromion, one hand at inferior angle --> assess movement of protraction, retraction, elevation, depression, potential upward/downward rotation
AC shear test
- patient sitting - PT cups hands over acromion/clavicle area (one palm or clavicle, other over spine of scapula) - squeeze heels of hands together POSITIVE: pain reproduction
sulcus sign for inferior laxity
- patient sitting "relaxed" with arm along side - patient's forearm should be supported on patient's thigh to relax long head of biceps - PATIENT LOOK STRAIGHT AHEAD - therapist stabilizes superior aspect of shoulder with one hand on top of acromion - PT grasps distal end of humerus, just above the elbow, to apply a downward pull to the arm good test for multidirectional laxity and related instability of shoulder
compression test
- patient supine lying very near edge of table (able to extend arm) - one arm grasps the elbow, other hand stabilizes above the shoulder - distal to proximal force applied through the long axis of humerus: move humeral head toward superior aspect of glenoid (scapula will naturally move upward) - finally, distal end of humerus is moved in small circumduction movement POSITIVE: reproduction of pain at any time during test INDICATIVE OF SLAP LESION
cranio-cervical flexion test (CCFT)
- patient supine with head/neck in neutral - pressure biofeedback unit is placed under mid-cervical region and inflated to 20 mmHg - patient asked to perform slight amount of cranio-cervical flexion until biofeedback reads 22mmHg, then hold for 10 seconds - after a few seconds of rest, process is repeated until unit reads 2 mmHg higher (26 mmHg is normal, but 28 or 30 mmHg is ideal) - highest level patient can hold for 10 seconds is used for repeated testing -- repeated up to 10 times
clunk test
- patient supine with top of head near edge of table (allows clearance for arm to go over table) -- cervical spine is slightly flexed in opposite direction of side tested - PT is at head of table and use one hand to stabilize superior aspect of scapula, other hand grasps patient's elbow and brings the arm in full flexion while applying a little traction to the arm - arm is brought back down making a circle toward abduction (away from the body) -- creates circumduction of shoulder POSITIVE: reproduction of pain -- there may be a "clunk," but not positive unless accompanied with pain INDICATIVE OF SLAP LESION
Bean Nonuniformity Ratio (BNR)
- peak intensity/average intensity - depends on quality of piezoelectric transducer - NOTHING TO DO WITH SIGNAL DEPTH
inflammation stage
- peaks within 24-48 hours (lasts 4-6 days) - response serves as protective mechanism
isotonic exercises
- performed through an arc of motion using a constant or variable form of resistance - resistance VARIES based on gravity, lever arm, tension, etc.
capsular tissue stretch
- physiological (normal) end-feel - "hardish" stop of movement with some give (shoulder external rotation)
muscular tissue stretch
- physiological (normal) end-feel - elastic resistance "with slight discomfort" (straight leg raise)
ligamentous tissue stretch
- physiological (normal) end-feel - firm stop of movement with no give/creep (abduction of knee in full extension)
soft tissue approximation
- physiological (normal) end-feel - soft, spongy (elbow flexion)
cartilaginous end-feel
- physiological (normal) end-feel - sudden stop, but "not hard" (elbow extension) - different than pathological "bone to bone" end-feel
how do you assess tendionopathy?
- pinch middle of tendon = if painful, it is tendinopathy - easy to diagnose, but difficult to treat
Eighth Kinematic Principle
- plane of scapular abduction
where is penetration for iontophoresis the easiest?
- pores - hair follicles - sebaceous (oil) glands
lidocaine
- positive charge - decrease pain: numbing, help reduce spasms - settles down nociceptors
if muscle is painful on repetition, then...
- potential vascular issue leading to local ischemia
"POP" at time of injury
- ruptured ligament or tendon - dislocation/subluxation of joint - fracture
treatment of pain synchronous with resistance
- preferably use distraction, but can also use glide technique - use grade I or II (treat for about 10 seconds initially), repeat 3 to 5 times - if pain resolves with initial mobilization, but reduced motion is still present, use gentle distraction with steady stretch one or twice (hold 5-10 seconds) - end treatment with grade I or II distractions for 10 seconds, repeat 3 to 5 times - perform exercises within painfree range - treatment with EPAs to decrease pain and swelling, if present - educate patient on elminating potential cause/aggravating factors - repeat and adjust based on initial response IF ROM and/or joint play are still limited, apply concepts for resistance before pain
treatment for pain before resistance
- preferably use distraction, but can use glide technique - use grade I or II (treat for about 10 seconds initially), repeat 3 to 5 times - stop with positive response: improved joint play, ROM, less pain with joint play and/or motion - perform exercises within painfree range - treatment with EPAs to decrease pain and swelling, if present - educate patient on elminating potential cause/aggravating factors - repeat and adjust based on initial response PAIN likely limiting factor
mechanical effects of soft tissue mobilization
- prevent/break up adhesion - stretch tissue - assist with venous and lymphatic flow
Fall Risk Factors
- previous fall - medications - assistive device - pain - depression - decreased cognition
ground areas to avoid during electrical stimulation
- puddle of water - big metal board, such as a plinth any place that there is 0 V
what is hi-volt?
- pulses above baseline at positive, below baseline at negative - accumulation of base at negative electrode
A-delta fibers
- quick, sharp pain (15 m/s) - over 90% of signals reach brain's sensory cortex
scapulothoracic joint pathologies
- rarely primary site of pathology - potentially soft tissue related pain (upper trapezius, levator scapulae); snapping scapula (bursa or scar tissue); peripheral nerve injury
Procedure for Functional Reach
- reach as far forward as possible parallel to measuring device
Apley's Scratch Test
- reach behind and up back as far as possible (shoulder extension, IR, adduction) - reach behind head and down back as far as possible (shoulder flexion, ER, abduction) BILATERAL assessment for comparison
treatment of fourth degree sprain of ACJ
- reduction of distal end of clavicle to return to normal alignment (difficult since it is trapped in trapezius) - surgical reconstruciton - rehabilitation
interventions for tendinopathy
- relative rest: appropriate for low level activities like cycling and slow lifting - EPAs - isometrics: analgesic effect - NSAIDS: ibuprofen is potentially useful to control cellular activity that leads to tendon swelling
advantages of isotonic action
- relatively inexpensive - patient can see strength increase - variable and adjustable - work through full ROM - improve endurance or strength
indications for iontophoresis
- relatively superficial locations - inflammation: any -itis or -osis - scarring - calcium deposits - myositis ossificans - antifungal, wound healing, infected wounds - trigger points
indications for electrical stimulation
- relaxation of spasm or spasticity - prevention of tissue atrophy - increase local blood circulation - muscle re-training
histamine response
- released by mast cells, platelets and basophils - cause vasodilation = increased permeability
cryotherapy
- removing heat from the body thicker the subcutaneous layer = greater the thermal barrier = increased cooling time
stretching for chronic contractures
- require low-load, long-duration (up to 20 minutes)
anterior glide of GHJ with patient prone
- requires careful positioning to anteriorly stabilize the scapula - follows similar process to posterior (dorsal) glide
process of mytome testing
- resistance is applied gradually over a period of at least 5 seconds - pain is not expected with testing, except when testing cervical spine - more time efficient to use a break test as opposed to make test -- goal is not to make a grade, but test "obvious" differences - test unaffected side, then affected side
changes of skin resistance
- resistance of skin can increase/decrease in seconds - sweat = decrease resistance - dryness = increase resistance
cold application: RICE
- rest, ice, compression, elevation - used for acute trauma M.I.C.E more common: motion (controlled), ice, compression, elevation
physiological effects of soft tissue mobilization
- rid muscle of toxic products (lactic acid) - decrease pain via Gate Theory or breaking pain-spasm-pain cycle
abnormal function of STJ can lead/contribute to...
- rotator cuff tendinopathy - SLAP lesion
fifth degree sprain (type V) of ACJ
- rupture of AC and CC ligaments - complete disruption of the deltotrapezial fascia with deltoid and trapezius muscles detached from distal half or 2/3 of clavicle
fourth degree sprain (type IV) of ACJ
- rupture of AC and CC ligaments - deltotrapezial fascia detached from distal end of clavicle - posterior displacement of distal end of clavicle through trapezius
sixth degree sprain (type VI) of ACJ
- rupture of AC and CC ligaments - disruption of SCJ: requires extreme downward force to superior aspect of distal end of clavicle with arm in abduction and shoulder retraction
third degree sprain (type III) of ACJ
- rupture of AC ligaments - rupture of CC ligaments - injury to deltotrapezial fascia; partially detached from distal end of clavicle
second degree sprain (type II) of ACJ
- rupture of supporting superior and inferior AC ligaments - stretch (partial tear) of CC ligaments - potential injury to deltotrapezial fascia
symptoms and signs of third degree sprain of ACJ
- severe pain - localized swelling - definite "step deformity"/displacement of distal end of clavicle - decreased shoulder ROM in all directions due to pain - tenderness to joint line palpation - distraction test, similar to sulcus sign, while palpating the ACJ is positive - laxity of ACJ - imaging is potentially useful to rule-out fractures (weights to increase gaping of ACJ)
symptoms and signs of sixth degree sprain of ACJ
- severe pain - unlike other types of ACJ sprain, the distal end of clavicle is displaced inferiorly - loss of shoulder motion due to pain
screen test for SCJ and ACJ
- shoulder horizontal adduction - if horizontal adduction is pain free, joint is likely asymptomatic
strength duration curve
- shows the relationship between the stimulus duration and the stimulus intensity - as pulse duration increases, less stimulus intensity is need to excite tissue denervated muscle would not respond to short pulse duration (need a large duration)
Procedure of Chair Sit and Reach
- sit at edge of chair with one foot flat and one leg extended - trial each side to determine best - practice twice, then measure twice (record best)
OA mobility (nodding)
- sit up straight with shoulders back and down - AOR = level of ears - gently tilt head forward around that axis, movement is small
AA mobility (rotation)
- sit up straight with shoulders back and down, bring chin as close as possible to chest - maintain this position, rotate neck to right, then left
OA mobility (side bending)
- sit up straight with shoulders back and down, keeping eyes and chin level - AOR = through the nose - gently tilt head head side to side around this axis, movement is small
precautions for elastic taping
- skin integrity/tape sensitivity - DVT - cancer - post injection site - risk of spreading infection - CHF (tape might move fluid) - new scars (too much stress) - open wounds
skin is naturally _____, so ____ will have a greater impact on the skin
- skin is naturally acidic (help protect against bacteria) - base will be more harmful to the skin (NaOH)
superficial evaluation of tissue
- skin slide: start with broad hand contact, move around in clock-like direction (6-12, 3-9), then check diagonally --> reduce to 2-3 fingers, then 1 finger (based on evaluation) - finger gliding: push or pull fingers through skin looking for dysfunction (any slowly or stopping)
grade I mobilization
- small amplitude at beginning of range, "faster" oscillations - create neurophysiological effects to treat pain typically activate type I mechanoreceptors
grade IV mobilization
- small amplitude at end-range, faster oscillations - create mechanical effects to treat joint restrictions
progressive oscillations
- small amplitude starting at mid-range and progressively go to end-range - slower (1 cycle/second) oscillations - create neurophysiological effect, followed by mechanical effects
Procedure for TUG
- starts on "GO" - walk 3 meters at safe and comfortable pace, turn back and sit down - stops when patient is seated - one practice trial allowed
manual cervical traction for increased mobility
- static stretch to achieve stretching of soft tissues: in neutral or various amounts of sidebending or rotation
commercial cold pack
- stays cold 5-20 minutes - beneficial for big area - apply over a moist towel - CAUTION: if pack splits, alkaline pH can burn skin
disadvantages of isometric exercises
- strength gains are fairly specific to joint angle exercises - little or no improvement in "functional force" - no eccentric muscle action - not very exciting
indications for inferior glide with arm at 90 degrees of abduction of GHJ
- stretching inferior capsule to improve abduction and likely ER - rotating the humerus will provide further stretch
indications for posterior (dorsal) glide of GHJ
- stretching posterior capsule to improve IR, horizontal adduction and potentially flexion - pre-positioning the shoulder in some IR may provide further stretch of posterior/inferior capsule
Intensity for Flexibility
- sufficient to maintain ROM with slight sensation of resistance and mild discomfort
pain before resistance
- suggest an acute inflammatory process, not suitable for stretching
whirlpool
- superficial heat (conduction and convection) - able to adjust turbine to project water pressure toward or away from area - able to perform therapeutic exercise
paraffin wax
- superficial heat (conduction) - great for small body parts: hand, elbow, back (possible) - temperature: 113 to 122 degrees
hot packs
- superficial heat (conduction) - requires medium to avoid tissue damage (6-12 layers of towel, depending on heat)
fluidotherapy
- superficial heat (convection) - contains natural cellulose (corn) circulating in dry, warm air - able to do exercise or manual therapy - stimulate thermo and mechanoreceptors (heat and movement)
application of elastic tape for weak muscle
- support with full range of motion is needed - tape is applied from origin to insertion - area, joint, or muscle is placed in elongated position, but with LIGHT TENSION
treatment of third degree sprain of ACJ (surgical approach)
- surgery followed by progressive rehab - probably leads to best long-term results, despite disadvantages
treatment of fifth degree sprain of ACJ
- surgical reconstruction - rehabilitation
Ideal Posture Landmarks
- through lobe of ear - through bodies of cervical vertebrae - through shoulder joint - midway through trunk - approximately through greater trochanter - slightly anterior to axis of knee - slightly anterior to lateral malleolus
Palpation of Triquetrum
-Felt just medial to the pisiform
what do you doing during the subacute/chronic stage of a rotator cuff tendinopathy?
-Tissue re-loading -progressive resistance exercises -activity management continues with progressive return to full function
what do you doing during the acute/subacute stage of a rotator cuff tendinopathy?
-activity management -RELATIVE REST -reduce pain/inflammation (ice, EPAs, support arm whenever possible)
Benefits of phonophoresis
1. higher drug concentration at site 2. prevent gastric irritation 3. prevent first-pass liver metabolism
Internal impingement
-compression/shear of the rotator cuff tendons against the posterior-superior glenoid labrum/rim -primarily affects the infraspinatus and maybe posterior aspect of supraspinatus (~120° elevation) -described as an inside out wear of cuff starting on the articular surface of the tendon
treatment of bicipital tendinopathy
-decrease pain and inflammation -eliminate causative factors -establish normal ROM -optimize scapular position and strength -improve dynamic stabilization -gradual return to activities/function
nonsurgical management of high irritability adhesive capsulitis
-education of activity modification -moist hear/ice/EPAs can be used extensively for pain modulation -P/AAROM, pain free range, 1-5 sec hold at end -low grade (1&2) joint mobs -isometric exercises -small amp of exercises several times a day -intraarticualr sterion injection for pain if affecting sleep
nonsurgical management of low irritability adhesive capsulitis
-education of exercises to maintain/gain motion -P/AA/AROM to end-range with overpressure, increased duration, cyclic loading -high grade joint mobs with sustained hold -low to high resistance strengthening exercises at end range -functional movement that require end range motion -formal stretching once/twice a day -manual therapy and exercises to end range
What are the general guidelines for treatment of adhesive capsulitis
-education of the patient -management based on irritability of the condition
nonsurgical management of moderate irritability adhesive capsulitis
-education on progressive increase in activity -moist heat/ice/ EPAs can be used as needed for pain modulation -P/AAROM and initiate AROM w/ 5-15 sec hold at end-range -low to high grade joint mobs -isometric/isotonic exercises -small pmts of exercises several times a day -moderate intensity manual therapy
What are symptoms and signs of bicipital tendinopathy?
-generally related to overuse and overhead activities -anterior shoulder pain (worse with overhead) -painful arc in flexion and abduction -site of pain moves with GHJ ER/IR -positive speed's test -positive active compression test -tenderness in bicipital groove -pain with shoulder rotation
What is the CMC grind test?
-grip pt. 1st metacarpal while stabilizing trapezium -apply axial load through metacarpal to gently grind at the CMC (+) reproduction of pain at CMC joint
What are symptoms of adhesive capsulitis?
-insidious slow onset of diffuse pain on the lateral arm area -stiffness -inability to sleep on affected arm -related neck and thoracic region pain (d/t compensations)
What is subacromial (external) impingement?
-irritation/wear of the rotator cuff tendons secondary to compression under the coracoacromial arch -primarily affects the supraspinatus tendon and possibly anterior portion of infraspinatus -outside-in or extra-articular wear starting on the subacromial surface (burial side) of the tendon
What are signs of adhesive capsulitis
-loss of ROM -decreased accessory joint motion at GHJ -presence of muscular tenderness and trigger points is common due to prolonged guarding
What surgical options are there for adhesive capsulitis
-mobilization under anesthesia followed by intensive treatment of pain medication and ROM exercise -arthroscopic surgical release of scar tissue followed by intensive treatment of pain medication and ROM exercise
Symptoms of rotator cuff injury
-pain associated with overhead activities -pain pattern consistent with typical tendinopathies and their stages -supraspinatus: pain over greater tuberosity (lateral/anterolateral shoulder) -infraspinatus/teres minor: pain over posterior shoulder region, below posterior acromion
characteristics of Stage 3 rotator cuff tears (tendon degeneration/microtears)
-patients older than 40 -may present with long history of shoulder pain -partial thickness tears of the tendons
characteristics of Stage 2 tears rotator cuff (degenerative)
-typically in patients between 25-40 years of age -sports or work related -characterized by degenerative changes, inflammation, and pain
characteristics of Stage 1 rotator cuff tears (acute reactive)
-typically in younger populations -sports or work related -characterized by cellular activity (inflammation) and pain -has no prior history of shoulder pain
effect of angle of pull for traction
0 degree flexion = separation of atlanto-acciptal and atlanto-axial joint 25-30 degree flexion = separation of lower cervical (C3-C7)
very light tension elastic taping
0 to 15% edema, lymphedema
distance of ultrasound frequencies
1 mHz: about 3-5 cm deep 3 mHz: about 2-3 cm deep
frequency for Acu-mode TENS stimulation (pain = DEOS)
1 to 10 pps
frequency for motor stimulation (pump)
1 to 10 pps helps create pump to move fluid
subacute injury timeline
1 to 3 months
Frequency of Balance
1-7 days/week
causes of fractures
1. direct trauma (most common) 2. fatigue or stress fracture: repetitive stress (do not show up on radiographs for 2-3 weeks) 3. pathological fractures: fracture through bone already weakened
Postural Correction Tips
1. if seated, feet flat on floor and knees slightly lower than lips 2. normal neutral lumbar lordosis 3. shoulder position: retracted and adducted 4. neck axial extension - make yourself tall
healing stages of fractures
1. hematoma: bleeding between and around fracture 2. subperiostal and endosteal cellular proliferation 3. callus: gives rise to osteoblasts, which lay down intercellular substance 4. consolidation: continue repair; transform into more mature bone 5. remodeling
effects of traction
1. distraction/separation of vertebral bodies 2. distraction and gliding of facet joint (activates touch receptors = Gate Theory) 3. tensing of ligamentous structure = stimulate collagen repair 4. widening of intervertebral foramen = takes pressure off nerve 5. stretch of spinal musculature (relieves spasm and pain)
posterior total hip precautions
1. do not bend forward at waist in more than 90 degrees 2. do not allow surgical leg to cross midline of body (use pillow to prevent) 3. do not allow internal rotation
PT Goals during inflammatory phase
1. Protect: little structural support 2. Prevent: control inflammation EPAs: ice, compression, pulsed US, pulsed diathermy, decrease exercise + splint
Potential Sources of Pain
1. Referred from discs or posterior joints (similar distribution of referred pain) 2. Referred from visceral disease/internal organs 3. Referred from trigger points in muscles
mechanism of muscle and tendon injuries
1. eccentric muscle action (most common) 2. excessive passive elongation/stretch 3. excessive maximum concentric action
four steps of proliferation
1. epithelization (if skin damaged) 2. collagen production 3. wound contraction 4. neovascularization/angiogenesis OCCUR SIMULTANEOUSLY
vertebral artery test
1. explain test to patient 2. patient supine with head over edge of table resting in PT hands 3. rotate neck in one direction of end range, then gently drop head back into extension to end range 4. as position is held for 15-30 seconds, ask patient if they feel dizzy, faint or nauseous and ask them to count backward from 10 if symptoms, return to neutral position immediately if no symptoms, repeat on other side
contraindications to mobilization
1. active infection or systemic disease 2. undiagnosed pain or poor general health: fever, weight loss, malaise 3. use of medication 4. severe pain and deformity 5. post-surgery 6. pregnancy 7. fractures, recent trauma 8. hypermobility/laxity 9. signs and symptoms of significant nerve root irritation 10. teenager or younger
effects of cryotherapy: neuromuscular
1. alters peripheral nerve activity 2. decreases sensory and motor conduction velocity
three parts of testing anterior laxity
1. apprehension test 2. relocation test 3. fulcrum test to start, patient supine with shoulder passively positioned in 90 degrees abduction and neutral shoulder rotation (upper arm supported by table, elbow just over edge)
why does cold decrease pain?
1. counter irritation: distract pain with cold 2. reduces release of pain-sensitizing substances 3. blocking conduction velocity of pain nerve fibers
Signs of Fatigue
1. deteriorating form 2. speed change 3. inability to complete full range of motion
mechanism of injury to ACJ
1. direct blow to tip of shoulder pushing acromion inferiorly and medially 2. force directed downward, scapula is driven downward while clavicle is blocked against the first rib 3. these forces result in failure of the AC ligament, CC ligaments, deltotrapezial fascia is intact
amount of force to separate upper cervical
10 pounds
length of cold treatment
10 to 30 minutes
after ___ weeks, scar tissue becomes resistant to additional remodeling if sub-optimal scar formation was created
14 weeks WE WANT TO START EARLY
light tension elastic taping
15 to 25% placed insertion to origin
FDA cleared a treatment dosage of ____ mA*min for iontophoresis
160 mA*min
acute on chronic pain
2-3/10 pain most of time, but after activity like hiking, 7/10 pain for week or so
pulse duration time for motor nerve
200 to 400 microseconds
how much time constitutes as chronic edema?
24+ hours
pulse duration time for sensory nerve
20 to 60 microseconds
pulse duration time for pain nerve
300 to 500 microseconds
frequency for motor stimulation (tetany)
35 to 50 pps
ideal sound head speed
4 cm/s
what is the typical dosage for iontophoresis?
40-80 mA*min
Interpretation of Berg
48-56 = low fall risk 40-47 = medium fall risk <39 = high fall risk Score less than 44 increases likelihood of multiple falls
Normal WBC
5,000-11,000 >20: no exercise >11: exercise with caution 5.0-11: light exercise <5.0: with temp/fever, no PT due to risk of infection <4.0: no exercise
moderate tension elastic taping
50% placed origin to insertion
Third Kinematic Principle
60 degrees of upward rotation of the scapula during full shoulder abduction is result of: - elevation of clavicle at SC joint - upward rotation of scapula at AC joint
MMT Extensor Pollicis Brevis
Action: 1st MCP extension Patient position: sitting, forearm supported and in neutral Stabilization: 1st metacarpal to prevent CMC motion Screen for 3/5: patient extends MCP joint keeping IP joint slightly flexed; test stops if it "breaks" or if IP joint extends Resistance: one finger on dorsal aspect of proximal phalanx into flexion Test for < 3/5: partial ROM Palpate: base of the 1st metacarpal between abductor pollicis longus and extensor pollicis longus (tends to be weak)
MMT Flexor Digitorum Profundus
Action: DIP flexion Patient position: sitting, forearm supinated, test each finger separately Stabilization: middle phalanx by holding each side of finger (no pressure on palmar aspect) Screen for 3/5: patient flexes the DIP joint Resistance: palmar surface of the distal phalanx into extension Test for < 3/5: forearm in neutral Palpate: palmar surface of middle phalanx
MMT Dorsal Interossei, Abductor Digiti Minimi
Action: MCP abduction Patient position: sitting, forearm pronated Stabilization: wrist in neutral Screen for 3/5: patient abducts fingers Description: examiner tries to pinch fingers together, observe the response (should rebound) Test for < 3/5 (NO G.E.): partial ROM Palpate (dorsal interossei): base of proximal phalanx of digit II Palpate (abductor digiti minimi): outside of 5th MC
MMT Palmar Interossei
Action: MCP adduction Patient position: sitting, forearm pronated Stabilization: none Screen for 3/5: patient brings fingers together Description: examiner tries to pull fingers apart (should rebound) Test for < 3/5 (NO G.E.): partial ROM Palpate: cannot be palpated
MMT Extensor Digitorum, Extensor Digiti Minimi, Extensor Indicis
Action: MCP extension Patient position: sitting, forearm pronated Stabilization: the wrist into neutral Screen for 3/5: extends MCP joints allowing IP joints to be in slight flexion Resistance (extensor digitorum): across dorsum of proximal phalanx Resistance (extensor digiti minimi): dorsum of proximal phalanx of 5th digit Resistance (extensor indicis): dorsum of proximal phalanx of 2nd digit Test for < 3/5: forearm in neutral Palpate: tendons apparent on dorsum of hand
MMT Lumbricals, Interossei
Action: MCP flexion Patient position: sitting, forearm supinated, MCP extended and IP flexed "uncurl fingers while bending knuckles" (looking at nails) Stabilization: metacarpals to keep wrist in neutral Screen for 3/5: patient flexes the MP joint and extends the IP joints Description: resistance given on palmar surface of the proximal phalanges into extension -- test stops if IP joint flexes (long finger flexors help) Test for < 3/5: forearm in neutral (same process) Palpate: cannot be palpated
MMT Flexor Digitorum Superficialis
Action: PIP flexion Patient position: sitting, forearm supinated, test each finger separately Stabilization: all other fingers into extension (one finger free to move) Screen for 3/5: patient flexes the PIP joint, DIP loose (flick terminal end to check) Resistance: palmar surface of the middle phalanx into extension Test for < 3/5: forearm in neutral Palpate: palmar surface of wrist between palmaris longus and FCU
MMT Serratus Anterior
Action: Scapular abduction and upward rotation Patient position: sitting with good posture & feet flat, shoulder flexed to 130 degrees, watch for winging at rest Stabilization: inferior angle of scapula within your web space (cup inferior angle) Screen for 3/5: scapula smoothly moves in ABD/upward rotation with shoulder flexion Resistance: distal humerus downward toward floor, watch for scapula to move (PT stand behind or next to patient to observe scapula); test ends if scapula moves Test for <3/5: hold arm in position, instruct patient to "lift your arm from this position" 2-/5: if motion is not smooth 2+/5: not for this test Palpate: in front of inferior angle along axial border; use thumb to palpate, ensure patient is relaxed
MMT Middle Trapezius
Action: Scapular adduction Patient position: prone, shoulder abduct to 90, elbow flexed to 90 Stabilization: contralateral scapula (different from posterior deltoid) Screen for 3/5: patient lifts elbow towards ceiling bringing scapula toward spine Resistance: elbow down toward the floor (at shoulder if deltoid is weak) Test for <3/5: PT supports the weight of the arm, patient tries to bring scapula toward spine 2+/5: not for this test Palpate: at spine of scapula from acromion to vertebral column
MMT Rhomboid Major/Minor
Action: Scapular adduction/downard rotation Patient position: prone, elbow flexed, humerus adducted, shoulder slightly extended and slight ER, head facing test side ("chicken wing") Stabilization: none Screen for 3/5: patient pulls arm into this position with scapula adduct/downward rotation Resistance: superior shoulder downward and elbow pulling out of adduction (into abduction and upward rotation) Test for <3/5: no gravity eliminated position Palpate: under vertebral border of scapula
MMT Lower Trapezius
Action: Scapular depression/adduction Patient position: prone, shoulder abduction to 145 degrees, elbow straight, neutral forearm (thumb up) Stabilization: opposite scapula Screen for 3/5: patient lifts arm toward ceiling bringing scapula down (put scapula in opposite pocket with one motion) Tips: might need to assist patient to get movement; watch for trunk rotation and shoulder adduction Resistance: distal humerus straight down, watch for scapular movement Test for < 3/5: therapist supports weight of arm, patient lifts supported arm, watch for depression/adduction 2+/5: not for this test Palpate: below spine of scapula to lower thoracic vertebrae
MMT Upper Trapezius, Levator Scapulae
Action: Scapular elevation Patient position: sitting; therapist stand behind or on side of patient to see Stabilization: none Screen for 3/5: patient shrugs shoulders bilaterally; if symmetric can resist together, resist separately if asymmetric Resistance: superior aspect of shoulders downward Test for <3/5: prone or supine, support under test shoulder to remove friction from table 2+/5: withstands resistance in gravity eliminated Palpate for Upper Trap: insertion above clavicle Palpate for Levator Scapulae: insertion on the (medial) vertebral border of the scapula superior the scapular spine
MMT Middle Deltoid, Supraspinatus
Action: Shoulder abduction Patient position: sitting, arm out to the side, thumb up, elbow slightly bent Stabilization: ipsilateral shoulder Screen for 3/5: patient performs full ROM Resistance: distal humerus with shoulder at 90 degrees ABD Test for <3/5: supine Palpate for Deltoid: lateral to acromion Palpate for Supraspinatus: under trap in supraspinatus fossa Tips: compensation with shoulder elevation, lateral lean, ER (allows substit. with biceps)
MMT Posterior Deltoid, Latissimus Doris, Teres Major
Action: Shoulder extension Patient position: prone, shoulder IR (palm up) Stabilization: ipsilateral shoulder/scapula Screen for 3/5: patient performs full shoulder extension Resistance: distal humerus Test for <3/5: sidelying with arm supported with partial ROM Palpate for Deltoid: posterior shoulder just superior to axilla Palpate for Teres Major: lateral border of scapula (posterior rim of axilla)
MMT Anterior Deltoid, Coracobrachialis
Action: Shoulder flexion Patient position: sitting, shoulder flexed to 90 degree, elbow slightly bent, forearm pronated Stabilization: ipsilateral shoulder Screen for 3/5: patient performs full shoulder flexion (compensation with shoulder elevated or posterior trunk lean) Resistance: distal humerus with shoulder at 90 degrees flexion Test for < 3/5: sidelying, cradle arm and keep in neutral plane Palpate: superior and anterior shoulder
MMT Posterior Deltoid
Action: Shoulder horizontal abduction Patient position: prone, shoulder in 90 degree, elbow flexed to 90 degree with forearm off the table Stabilization: Ipsilateral scapula (different from scapular adduction for middle trapezius) Screen for 3/5: patient performs full ROM Resistance: downward at distal humerus Test for <3/5: sitting with forearm supported shoulder abducted to 90, elbow flexed, patient brings elbow backward into horizontal abduction: 2+/5: withstand resistance Palpate: below and lateral to the spine of the scapula
MMT Pectoralis Major
Action: Shoulder horizontal adduction Patient position: supine, shoulder in 90 degree abduction, elbow flexed to 90 degree Stabilization: opposite shoulder to prevent trunk rotation Screen for 3/5: patient performs full ROM Resistance: wrist unless elbow flexors are weak if elbow flexors are weak (<4/5); provide resistance at distal humerus Test for < 3/5: seated with arm supported Palpate: anterior aspect of chest wall, medial to shoulder
MMT Cervical Extensors
Action: cervical extension Patient position: prone with relaxed head off end of table, hands down at side Stabilization: none (catch hand under chin) Screen for 3/5: patients lifts head until parallel to the floor, eyes stay facing down toward floor -- push with hand only, do not lean with body weight Resistance: parieto-occipital area down toward floor Test for < 3/5: supine with head in PT hands (fingers distal to occiput); patient pushes head straight down into hands (avoid lifting chin) 2/5: pressure from patients head 1/5 activation only (trace) Palpate: lateral to spinous processes of cervical vertebrae
MMT Cervical Flexors
Action: cervical flexion (not capital flexion) Patient position: supine head supported by table, with arms at sides Stabilization: thorax when patient very weak (must have a catch hand under head) Screen for 3/5: patient lifts head off of table without tucking chin Resistance: two fingers given at forehead; NEVER YOUR WHOLE HAND Test for < 3/5: patient rolls head to right or to the left Palpate: SCM on the opposite side of rotation; palpate gently (carotid arteries)
MMT Sternocleidomastoid
Action: cervical flexion to isolate SCM Patient position: supine, with arms at sides Stabilization: none (must have a catch hand under head) Screen for 3/5: patient rotates away from the SCM being tested, lifts head off of table Resistance: down toward the floor at temple with whole hand Test for < 3/5: patient rolls head to right or to the left 2/5 full rotation to the side Palpate: palpate SCM on the opposite side of rotation
MMT Triceps
Action: elbow extension Patient position: prone, shoulder abducted to 90 degree , elbow flexed Stabilization: support the arm with hand under humerus Screen for 3/5: performs full ROM Resistance: down at posterior forearm; unlock elbow prior to giving resistance Test for < 3/5: sitting, shoulder at 90 degree abduction, humerus supported by examiner Palpate: posterior surface of arm Tips: Avoid holding wrist, watch horizontal ADD or shoulder ER for compensation, do not allow <90 ABD (gravity will assist)
MMT Brachialis
Action: elbow flexion Patient position: sitting, forearm in full pronation Stabilization: ipsilateral shoulder Screen for 3/5: performs full ROM Resistance: distal forearm into extension with elbow between 90 and 135 deg flex Test for < 3/5: sitting, shoulder at 90 abduction, humerus supported by examiner Tips: do not allow ABD >90 (will get grav assist. flex) Palpate: medial to biceps brachii
MMT Biceps Brachii
Action: elbow flexion Patient position: sitting, forearm in full supination Stabilization: ipsilateral shoulder Screen for 3/5: performs full ROM Resistance: distal forearm into extension with elbow between 90 and 135 deg flex Test for < 3/5: sitting, shoulder at 90 abduction, humerus supported by examiner Tips: do not allow ABD >90 (will get grav assist. flex) Palpate: antecubital space
MMT Brachioradialis
Action: elbow flexion Patient position: sitting, forearm in neutral Stabilization: ipsilateral shoulder Screen for 3/5: performs full ROM Resistance: distal forearm into extension with elbow between 90 and 135 deg flex Test for < 3/5: sitting, shoulder at 90 abduction, humerus supported by examiner Tips: do not allow ABD >90 (will get grav assist. flex) Palpate: lateral border of cubital fossa
MMT Pronator Teres, Quadratus
Action: forearm pronation Patient position: sitting, elbow flexed to 90 degree, forearm supinated Stabilization: support elbow Screen for 3/5: starting in supination, turn your palm toward the floor Resistance: proximal to wrist Test for < 3/5: flex shoulder to 45-90, elbow at 90, flexion, support elbow Palpate Teres: upper 1/3 of volar forearm on diagonal from medial epicondyle to lateral radius Palpate Quadratus: not possible
MMT Supinator (biceps brachii)
Action: forearm supination Patient position: sitting, elbow flexed to 90 degree, forearm pronated Stabilization: support elbow Screen for 3/5: starting in pronation, turn your palm toward the ceiling Resistance: proximal to wrist Test for < 3/5: flex shoulder to 45-90, elbow at 90, flexion, support elbow Palpate: distal to head of radius on dorsal aspect of forearm
Endurance Test for Longus Capitus, Longus Colli
Action: neck flexor endurance test for craniocervical flexion Patient position: hooklying position, arms at side, no pillow, pt's head placed in slight upper cervical flexion (bottom of nod) Therapist position: one hand on the table underneath patient occiput Stabilization: none Test is complete when patient is unable to hold the position any longer or head touches PT hand for more than 1 sec and/or patient starts to lose the folds in the front of neck Recorded as amount of time patient was able to hold Male: 38.9 seconds Female: 29.4 seconds
MMT Opponens Pollicis, Opponens Digiti Minimi
Action: opposition Patient position: sitting, supinated, hand supported on the table Stabilization: hold the wrist on the dorsal surface Screen for 3/5: patient brings tip of thumb to meet tip of 5th digit Resistance: both 1st and 5th metacarpals (try to pull apart) Test for < 3/5 (No G.E.): partial ROM Palpate (opponens pollicis): radial shaft of 1st metacarpal Palpate (opponens digiti minimi): hypothenar eminence
MMT Quadratus Lumborum
Action: pelvic elevation Patient position: supine or prone, PT holds test limb above the ankle Stabilization: patient holds onto table Screen for 3/5: patient hikes hip, PT pull leg downward toward their feet Test for < 3/5: partial ROM Palpate: not feasible (cannot rate 1/5)
MMT Infraspinatus, Teres Minor
Action: shoulder external rotation Patient position: prone, shoulder in 90 abduction, elbow bent, head towards test side Stabilization: hold elbow (counter resistance), use towel for support Screen for 3/5: patient performs full ROM Resistance: dorsal aspect of distal radius/ulna Test for < 3/5: sitting, shoulder in 0 degree flex/abd, elbow bent to 90 Palpate Infraspinatus: over body of scapula Palpate Teres minor: axillary border of scapula
MMT Subscapularis (pec major, lats, teres major)
Action: shoulder internal rotation Patient position: prone, shoulder in 90 abduction, elbow bent, head towards test side Stabilization: hold elbow (counter resistance), use towel for support Screen for 3/5: patient performs full ROM Resistance: ventral aspect of distal radius/ulna Test for < 3/5: sitting, shoulder in 0 degree flex/abd, elbow bent to 90 Palpate: posterior aspect of axilla and anterior surface of scapula
MMT Trunk Extensors
Action: thoracolumbar extension Patient position: prone, head and upper trunk flexed over table with arms at side Stabilization: legs above the ankle Screen for 3/5: lifts body to clear xiphoid process 4/5: raises trunk with hands at the head with difficulty 5/5: able to extend fully with hands at the head with ease Test for < 3/5: partial ROM with arms at side Palpate: along the length of the spine
MMT Abductor Pollicis Longus and Brevis
Action: thumb abduction Patient position: sitting, supinated, hand supported on the table Stabilization: II-V metacarpals and wrist to avoid wrist flex (not needed) Screen for 3/5: full ROM Resistance (abductor pollicis longus): one finger at distal end of 1st metacarpal Resistance (abductor pollicis brevis): one finger at lateral aspect of proximal phalanx Test for < 3/5: neutral wrist Palpate (abductor pollicis longus): most lateral wrist tendon of snuffbox (longer but inserts more proximal) Palpate (abductor pollicis brevis): middle muscle in the thenar eminence (shortest but inserts more distal)
MMT Adductor Pollicis
Action: thumb adduction Patient position: pronated, hand off table, thumb hangs down Stabilization: metacarpals Screen for 3/5: lifts thumb towards hand (meet fingers) Resistance: medial side of proximal phalanx Test for < 3/5: neutral forearm on table Palpate: palmar side of web space
MMT Rectus Abdominus
Action: trunk flexion Patient position: hooklying, no pillow Stabilization: none unless hip flexors are weak Screen for 3/5: clear inferior angle of scapula with arms at their side 4/5: arms across chest 5/5: arms at ears (not head) Test for < 3/5: patient supine with knees flexed; observation of any: 1) Partial ROM, 2) Supporting head and shoulders, observe rib depression, 3) Cough with rib cage depression Palpate: along either side of the linea alba
MMT Oblique Abdominus
Action: trunk rotation Oblique externus abdominis: opposite rotation Oblique internus abdominis: ipsilateral rotation (INternal = IPsilateral) Patient position: hooklying Stabilization: none Screen for 3/5: clears inferior angle of scapula on the side of the external oblique, arms at side 4/5: arms across chest 5/5: arms at ears Test for < 3/5: support the head and shoulders, visual rib depression Palpate Internal oblique: inferior to rib cage on the side toward rotation Palpate External oblique: inferior to rib cage on side away from direction the patient is turning
MMT Extensor Carpi Radialis Longus/Brevis and Extensor Carpi Ulnaris
Action: wrist extension Patient position: sitting, forearm supported and pronated, fingers flexed/relaxed to avoid long finger extensor assistance Stabilization: support forearm under wrist Screen: extend wrist, resistance given evenly across metacarpals Test for < 3/5: forearm in neutral, gravity elim tests ECR/ECU together (don't separate out) Palpate ECRL: dorsum of wrist in line with 2nd metacarpal Palpate ECRB: dorsum of wrist in line with 3rd metacarpal Palpate ECU: dorsal wrist, proximal to 5th metacarpal **Important to note: Innervated differently ECRL C6-7; ECRB, ECU C7-8
ROM DIP Joint Flexion
Normal: 0 - 90 Patient position: neutral forearm; allow 70-90 degrees of PIP flexion to avoid passive tension in finger flexors; stabilize MCP at 0 Stabilization: middle phalanx to prevent motion of PIP joint Axis of Rotation: dorsal aspect of DIP joint Stationary Arm: dorsal midline of middle phalanx Moveable Arm: dorsal midline of distal phalanx
Thomas Test:
Muscle: hip flexors Normal: 10 degrees of hip extension
MMT Knee Flexion - lateral
Muscle: lateral hamstring Patient position: prone, knee flexed to 90, leg external rotation (toes out heel in) Stabilization: none Screen for 3/5: flexes knee (full ROM) Resistance: applied in a down and in direction Test for < 3/5: sidelying with limb supported (can only grade them for all hamstrings together) Palpate: lateral distal thigh
MMT Toe Flexion (2-5)
Muscle: lumbricals Patient position: short sitting (or supine), ankle in neutral Stabilization: dorsum of foot below ankle Screen for 3/5: flexes toes (full ROM) Resistance: index finger under MCP joints of the 4 lateral toes Test for < 3/5: partial ROM Palpate: not feasible
MMT Knee Flexion - Medial
Muscle: medial hamstring Patient position: prone, knee flexed to 90, leg internal rotation (toes in heel out) Stabilization: none Screen for 3/5: flexes knee (full ROM) Resistance: applied in a down and out direction Test for < 3/5: sidelying with limb supported (can only grade them for all hamstrings together) Palpate: medial distal thigh
MMT Inversion
Muscle: posterior tibialis Patient position: short sitting, ankle slightly plantarflexed Stabilization: ankle, above malleoli Screen for 3/5: patient inverts foot (full ROM) Resistance: plantar/medial foot into eversion and slight dorsiflexion Test for < 3/5: partial ROM Palpate: between medial malleolus and navicular
MMT Knee Extension
Muscle: quadriceps femoris Patient position: short sitting Stabilization: wedge under distal femur (hand or towel) Screen for 3/5: patient straightens leg Resistance: ankle with knee "unlocked" Test for < 3/5: sidelying, test limb supported Palpate: patient perform quad set in prone
Ely Test
Muscle: rectus femoris Stabilization: hip to maintain neutral position Normal: greater or equal to 90 degrees of knee flexion
ROM Tarsal Eversion
Normal: 0-12 Patient position: sitting with knee flexed to 90 Stabilization: tibia and fibula (overpressure on dorsum of foot) Axis of Rotation: line bisecting malleoli at anterior aspect of ankle Stationary Arm: mid-aspect of leg bisecting tibial tuberosity Moveable Arm: bisect 2nd metatarsal
MMT Flexion/Abduction/ER
Muscle: sartorius Patient position: sitting, arms can be used for support Screen for 3/5: patient flexes, abducts, and ER the hip and flexes the knee Resistance: distal femur into extension and adduction and at the medial ankle into hip internal rotation and knee extension Test for < 3/5: supine, patient slides test heel upward along shin towards knee ( Palpate: just distal to ASIS
ROM Hip Flexion
Normal: 0-120 Patient position: supine Stabilization: pelvis to prevent posterior pelvic tilt Axis of Rotation: greater trochanter of femur Stationary Arm: midline of pelvis Moveable Arm: lateral aspect midline of femur
MMT Plantarflexion (soleus)
Muscle: soleus Patient position: single leg stance, knee slightly flexed, patient can use 2 fingers for support Stabilization: none Screen for 3/5: lifts heel off floor (full PF ROM) 5/5: 20 heel raises 4/5: 10-19 heel raises 3/5: 1-9 heel raise Test for < 3/5: - 2/5: can NOT clear heel from the floor OR full ROM + resistance in prone with knee flexed to 90 - 2-/5: partial ROM in prone Palpate: posterior lateral surface of distal calf
MMT Hip Abduction from Flexed Position
Muscle: tensor fascia latae Patient position: sidelying with hip flexed to 45 Stabilization: crest of ilium Screen for 3/5: abducts hip approximately 30 Resistance: distal femur downward Test for < 3/5: long sit with trunk leaning back, 45 deg support with arm, therapist support limb Palpate: insertion at lateral aspect of knee or muscle belly at anterolateral thigh
MMT Hip Extension
Muscles: gluteus maximus, hamstrings Patient position: prone with leg straight Stabilization: may be needed at pelvis Screen for 3/5: lift leg off table (full ROM) Resistance: posterior leg just above the ankle Test for < 3/5: sidelying, with test limb supported bottom leg bent Where to Palpate Gluteus maximus: center of buttocks Where to Palpate Hamstrings: ischial tuberosity
MMT Hip Flexion
Muscles: psoas major, iliacus Patient position: short sitting, arms can be used for support Stabilization: none Screen for 3/5: lift leg off table (full ROM) − Resistance: distal femur Test for < 3/5: sidelying with limb supported (stand behind patient) Where to Palpate: distal to inguinal ligament medial to Sartorius
should there be an increase in pain and swelling during inflammation and repair/healing stage?
NO not like a good workout -- there should not be an increase in soreness or pain
should cyrotherapy and ultrasound be used together?
NO - cold tissue does not transmit sound energy as well
should traction be used as a stand alone treatment?
NO - should be combined with others things exercise, posture education, soft tissue work
can you fall asleep or shower with an electrical stimulation device?
NO = BURNS (most common is acid/base reaction) sleeping: patch can peel off = concentrated current density shower: water creates path of least resistance
should pain occur during mobilization?
NO, PAIN SHOULD NOT OCCUR
will a symmetrical AC irritate the skin?
NO, there is equal distribution of positive and negative charge
will muscle fibers return during healing?
NO, will likely "heal" as intramuscular tendinous/fibrotic tissues (appears to be permanent) complete healing takes up to 6 weeks (3 weeks for repair and healing, 3 more weeks for remodeling)
ROM MCP Joint Flexion
Normal: 0 - 90 Patient position: neutral forearm (thumb up) with forearm supported on table Stabilization: metacarpal to prevent wrist motion (videos said wrist) Axis of Rotation: dorsal aspect of MCP joint Stationary Arm: dorsal midline of metacarpal Moveable Arm: dorsal midline of proximal phalanx
pain synchronous with resistance
suggests a subacute condition
signs and symptoms of a third degree SCJ sprain
DISLOCATION OF SCJ - pain - significant related disability - swelling - VERY VISIBLE "DEFORMITY" of the joint - point tenderness to joint line palpation
Katz
Domain: Activity - assess status of ability to perform ADLs - administered through observation - does NOT contain stairs and mobility High # = high function/independent
Dynamic Gait Index
Domain: Activity - likelihood of falling - assess gait characteristics - Best Score: 24 points - Score less than 19: increased risk of falls in community living adults
Functional Reach Test
Domain: Activity - measure stability while standing in a fixed/static position - closed fist - Test OVER: move feet - two practice trails, then three additional trails measured
Chair Sit and Reach
Domain: Body Function - assess lower body flexibility - measure # of inches or centimeters between extended middle fingers
Back Scratch Test
Domain: Body Function - assess upper body flexibility - measure # of inches or centimeters between extended middle fingers - trial each side to determine best side - practice twice, then measure
Arm Curl Test
Domain: Body Function - assess upper extremity strength - # of completed curls in 30 seconds - 5# for women, 8# for men
Mini Mental State Exam (MMSE)
Domain: Body Function - brief screen for cognitive impairment and cognitive changes over time, no cause of impairment - Used if not fully independent and executive function is not main need - only in English - Score of 19 or less: indicative of depression
Beck Depression Inventory
Domain: Body Function - identifies characteristics of depression - self-administered (13 questions) in reverse order or interview (21 statements) - Score greater than 13: indicative of depression - TIME CONSUMING and Cost
St. Louis University Mental Status Exam (SLUMS)
Domain: Body Function - identify dementia or mild cognitive disorder - Used if not fully independent and executive function is not main need - higher level than MMSE
Geriatric Depression Scale
Domain: Body Function - identify depression in about everyone - brief: yes or no questions - 30 Item: score of 0-9 = normal; score of 10-19 = mild depression; score of 20-30 = severe depression - 15 Item: score greater than 5 indicates depression
Romberg Test
Domain: Body Function - static balance - feet touching = smaller base of support - repeated with eyes open and eyes closed
Single Leg Stance
Domain: Body Function - static single leg balance and stability - Test Stopped: moves feet, changes arm position, suspended foot touches ground, or suspended limb supports balance limb - Stop test at 30 seconds
Chair Rise Test
Domain: Body Function/Activity - assess lower extremity strength - # of reps in 30 seconds or time to complete 5 rises
relocation test
IF APPREHENSION TEST IS POSITIVE: - PT now supports patient's elbow on thigh -- hand previously supporting elbow positioned on anterior aspect of shoulder, providing a posteriorly directed force over anterior aspect of humeral head --> shoulder moved into ER POSITIVE: reduction of the feeling of apprehension and/or ability to go further into ER before apprehension RETURN TO NEUTRAL BEFORE REMOVING EXTERNAL FORCE
MMT Toe Extension
Muscle: extensor digitorum longus and brevis Patient position: short sitting (or supine), ankle in neutral Stabilization: metatarsals Screen for 3/5: extends toes (full ROM) Resistance over proximal phalanges Test for < 3/5: partial ROM Palpate: - EDL: dorsum of metatarsals - EDB: lateral side of the dorsum of foot just in front of malleolus
MMT Dorsiflexion and Eversion
Muscle: extensor digitorum longus, fibularis tertius Patient position: short sitting (or supine) with ankle in neutral Stabilization: ankle, above malleoli Screen for 3/5: patient everts and DF (full ROM) Resistance: dorsolateral foot into inversion and plantarflexion Test for < 3/5: partial ROM Palpate: - Extensor Digitorum Longus: palpate common tendon anterior aspect of ankle lateral to tibialis anterior - Fibularis Tertius (if present): lateral aspect of dorsum of foot, lateral to tendon of EDL slip to 5th digit
MMT Eversion and Plantarflexion
Muscle: fibularis longus and brevis Patient position: short sitting (or supine) with ankle in neutral Stabilization: ankle, above malleoli Screen for 3/5: patient everts and PF (full ROM) - "turn your foot down and out" Resistance: dorsolateral foot into inversion and dorsiflexion Test for < 3/5: partial ROM Palpate: - Longus: below fibular head (or the tendon posterior to lateral malleolus) - Brevis: between lateral malleolus and 5th metatarsal
MMT Hallux Flexion
Muscle: flexor hallucis brevis Patient position: short sitting (or supine), ankle in neutral Stabilization: dorsum of foot below ankle Screen for 3/5: flexes first toe (full ROM) Resistance: index finger beneath proximal phalanx of great toe Test for < 3/5: partial ROM Palpate: not feasible
Gastrocnemius Length Test
Muscle: gastroc Stabilization: knee fully extended Normal: about 20 degrees
MMT Plantar Flexion
Muscle: gastrocnemius and soleus Patient position: single leg stance, patient can use 2 fingers for support Stabilization: none Screen for 3/5: lifts heel off floor (full PF ROM) 5/5: 25 heel raises 4/5: 2-24 heel raises 3/5: 1 heel raise Test for < 3/5: - 2/5: can NOT clear heel from the floor OR full ROM + resistance in prone knee extended - 2-/5: partial ROM in prone − Palpate: just above Achilles
MMT Hip Extension (Gluteus Maximus)
Muscle: gluteus maximus Patient position: prone, knee bent to 90 Stabilization: may be needed on the pelvis Screen for 3/5: lift leg off table keeping knee bent Resistance: distal femur in a downward direction Test for < 3/5: sidelying, test limb supported, knee bent Palpate: center of buttocks
MMT Hip Abduction
Muscle: gluteus medius, gluteus minimus Patient position: sidelying with test limb slightly extended at hip Stabilization: pelvis (crest of ilium); keep pelvis rotated forward Screen for 3/5: lift leg toward the ceiling maintain slight hip extension Resistance for 4/5: distal femus Resistance for 5/5: Test for < 3/5: supine, support the limb to reduce friction Palpate: gluteus medius: lateral aspect of hip just above the greater trochanter
MMT Hip IR
Muscle: gluteus minimus/medius, TFL Patient position: short sitting, can use hands to support trunk Stabilization: medial aspect of distal thigh; counter pressure Screen for 3/5: patient externally rotates hip (foot out) Resistance: medial ankle above malleoli into ER (push OUT MEDIALLY) Test for < 3/5: supine, test limb placed into ER, patient move through FULL IR, resist after mid
MMT Knee Flexion
Muscle: hamstrings Patient position: prone, knee flexed to 45 Stabilization: none Screen for 3/5: flexes knee (full ROM) Resistance: ankle Test for < 3/5: sidelying with limb supported (can only grade them for all hamstrings together) Palpate: posterior knee (palpate both medial and lateral when testing together)
90/90 Test
Muscle: hamstrings Stabilization: femur Normal: <20 degree of knee flexion
Straight Leg Test
Muscle: hamstrings Stabilization: hip/knee Normal: 70-80 of hip flexion
ROM Cervical Side-bending (goniometry)
Normal ROM: 0 - 22 degrees Patient position: sitting with good posture Stabilization: shoulder girdle and chest, opposite scapula Axis of Rotation: C7 spinous process Stationary Arm: perpendicular to the floor Moveable Arm: line bisecting head Watch for rotation, shoulder elevation, flex/extension, lateral trunk flex
ROM Lumbar Extension (inclinometer)
Normal ROM: 0 - 30 degrees Patient position: standing; mark spinous processes of T12 and S2 vertebrae; shoulder width apart during testing Stabilization: none Inclinometer alignment: 1) place and zero inclinometer on T12, ask patient to bend backward through available ROM 2) repeat process again with inclinometer placed at S2 Inclinometer reading: subtract S2 (hip motion) from T12 measurement
ROM Lumbar Sidebending (inclinometer)
Normal ROM: 0 - 30 degrees Patient position: standing; mark spinous processes of T12 and S2 vertebrae; shoulder width apart during testing with hands at side Stabilization: none Inclinometer alignment: 1) place and zero inclinometer on T12, ask patient to bend to side without raising heel through available ROM 2) repeat process again with inclinometer placed at S2 Inclinometer reading: subtract S2 (hip motion) from T12 measurement
ROM Cervical Side-bending (inclinometer)
Normal ROM: 0 - 40 degrees Patient position: sitting with good posture Stabilization: shoulder girdle and chest, opposite scapula Inclinometer alignment: on the top of patient's head in the frontal plane so dial is facing posteriorly, adjust the dial to 0 degree Inclinometer reading: at end of motion, read and record the degrees Hints: Watch for rotation, shoulder elevation, flex/extension, lateral trunk flex
ROM Cervical Flexion (goniometry)
Normal ROM: 0 - 40 degrees Patient position: sitting with good posture, feet flat on floor Stabilization: shoulder girdle and chest Axis of Rotation: external auditory meatus (axis shifts forward and down) Stationary Arm: perpendicular or parallel to the floor Moveable Arm: base of nares Hints: Avoid thoracic flexion, can provide gentle overpressure
ROM Thoracolumbar Rotation (goniometry)
Normal ROM: 0 - 45 degrees Patient position: sitting, arms across chest at shoulders Stabilization: feet flat on floor, thighs supported by table Axis of Rotation: center of cranium Stationary Arm: imaginary line between iliac crests Moveable Arm: imaginary line between acromion processes look at femur for compensation
ROM Cervical Rotation (goniometry)
Normal ROM: 0 - 50 degrees Patient position: sitting with good posture Stabilization: shoulder girdle and chest Axis of Rotation: center of cranial aspect of head Stationary Arm: imaginary line between acromion processes Moveable Arm: in line with nose Hints: lead turn with chin, watch for trunk rotation, need extra assist for passive ROM due to inability to prevent trunk rotation
ROM Cervical Extension (inclinometer)
Normal ROM: 0 - 50 degrees Patient position: sitting with good posture Stabilization: shoulder girdle and chest to avoid thoracic spine extension Inclinometer alignment: on the top of patient's head in the sagittal plane, adjust the dial to 0 deg, instruct patient to raise chin first and move head backward as far as possible without moving the trunk Inclinometer reading: at end of motion, read and record the degrees NO OVERPRESSURE
ROM Cervical Extension (goniometry)
Normal ROM: 0 - 50 degrees Patient position: sitting with good posture, feet flat on floor Stabilization: shoulder girdle and chest Axis of Rotation: external auditory meatus (axis shifts forward and down) Stationary Arm: perpendicular or parallel to the floor Moveable Arm: base of nares Hints: NO overpressure
ROM Lumbar Flexion (inclinometer)
Normal ROM: 0 - 50 degrees Patient position: standing; mark spinous processes of T12 and S2 vertebrae; shoulder width apart during testing Stabilization: none Inclinometer alignment: 1) place and zero inclinometer on T12, ask patient to bend forward through available ROM keeping knees straight 2) repeat process again with inclinometer placed at S2 Inclinometer reading: subtract S2 (hip motion) from T12 measurement
ROM Shoulder Extension (complex)
Normal ROM: 0 - 60 degrees Patient position: prone (can be tested supine), NO PILLOW Stabilization: trunk to prevent rotation of the spine Axis of Rotation: lateral aspect of greater tubercle Stationary Arm: parallel to midline of thorax Moveable Arm: lateral midline of humerus toward lateral epicondyle, elbow flexion allowed
ROM Shoulder IR
Normal ROM: 0 - 70 degrees Patient position: supine, shoulder abducted to 90 (towel under humerus, neutral/bent forearm Stabilization: acromion and coracoid process of scapula Axis of Rotation: olecranon process Stationary Arm: perpendicular or parallel to the floor Moveable Arm: midline of ulna (lined up with olecranon and ulnar styloid process)
ROM Forearm Supination
Normal ROM: 0 - 80 degrees Patient position: sitting, shoulder at 0, elbow at 90 Stabilization: distal end of humerus to prevent ER and adduction Axis of Rotation: medial and proximal to ulnar styloid Stationary Arm: parallel to anterior midline of humerus (NOT BODY) Moveable Arm: dorsal aspect of forearm proximal to styloid process Overpressure placed on forearm, not hand
ROM Forearm Pronation
Normal ROM: 0 - 80 degrees Patient position: sitting, shoulder at 0, elbow at 90 Stabilization: distal end of humerus to prevent IR and abduction Axis of Rotation: lateral and proximal to ulnar styloid Stationary Arm: parallel to anterior midline of humerus (NOT BODY) Moveable Arm: dorsal aspect of forearm proximal to styloid process Overpressure placed on forearm, not hand
ROM Shoulder ER
Normal ROM: 0 - 90 degrees Patient position: supine, shoulder abducted to 90 (towel under humerus), neutral/bent forearm Stabilization: acromion and coracoid process of scapula Axis of Rotation: olecranon process Stationary Arm: perpendicular or parallel to the floor Moveable Arm: midline of ulna (lined up with olecranon and ulnar styloid process) Active: one hand stabilizing, one hand measuring Passive: remove stabilizing hand to overpressure
ROM Elbow Extension
Normal ROM: 0 degree Patient position: supine, full supination, towel under humerus Stabilization: humerus to prevent shoulder flexion Axis of Rotation: lateral epicondyle of the humerus Stationary Arm: lateral midline of humerus toward acromion Moveable Arm: lateral midline of radius (toward radial head/styloid) Do NOT give overpressure beyond 0; use negative number if unable to get into extension
ROM TMJ Lateral Deviation
Normal ROM: 10-12 mm Patient position: sitting, 0 degree of cervical spine movement Stabilization: posterior head to prevent extension, watch for good posture Starting point: center of upper incisor Ending point: center of lower incisor Instructions: Subtract starting value from final measurement if deviation is toward the same side as the measurement and add if deviation is away from the side of the measurement.
ROM TMJ Opening
Normal ROM: 35-50 mm Patient position: sitting, 0 degrees of cervical spine movement Stabilization: posterior head to prevent extension Starting measurement point: bottom of upper incisor Ending point: top of lower incisor Instructions: Measure in millimeters or with Therabite
ROM TMJ Protrusion
Normal ROM: 6-9 mm Patient position: sitting, 0 degree of cervical spine movement Stabilization: posterior head to prevent extension, watch for good posture Starting point: bottom of upper incisor Ending point: top of lower incisor Instructions: Measure in millimeters
ROM Thoracolumbar Side-bending (tape measure)
Normal ROM: N/A Patient position: standing with feet shoulder width apart, arm hanging freely, shoes off Stabilization: pelvis to prevent lateral tilt Starting measurement: distal end of 3rd finger Ending measurement: floor Instructions: record distance in centimeters
ROM Thoracolumbar Side-bending (fingertip-to-thigh)
Normal ROM: N/A Patient position: standing with feet shoulder width apart, hand against thigh, shoes off Stabilization: pelvis to prevent lateral tilt Starting measurement: mark on lateral thigh the position of distal end of 3rd finger Ending measurement: mark on lateral thigh the position of distal end of 3rd finger Instructions: record distance between markings in centimeters
ROM Thoracolumbar Flexion (tape measure)
Normal ROM: N/A Patient position: standing with feet shoulder width apart, shoes off Stabilization: pelvis to prevent anterior tipping Starting measurement: distal end of 3rd finger Ending measurement: floor Instructions: record distance in centimeters
ROM Cervical Flexion (inclinometer)
Normal ROM: ranges from 0-60 to 0-90 degrees Patient position: sitting with good posture, feet flat on floor Stabilization: shoulder girdle and chest Inclinometer alignment: on the top of patient's head in the sagittal plane so dial is facing laterally, adjust the dial to 0 degree Inclinometer reading: at end of motion, read and record the degrees on the inclinometer Helpful hints: Avoid thoracic flexion, can provide gentle overpressure
ROM PIP Joint Extension
Normal: 0 Patient position: neutral forearm, with forearm supported on table; MCP at 0 Stabilization: proximal phalanx to prevent motion of MCP; keep wrist stabilized at neutral Axis of Rotation: dorsal aspect of PIP joint Stationary Arm: dorsal midline of proximal phalanx Moveable Arm: dorsal midline of middle phalanx
ROM Knee Extension
Normal: 0 (over 5 is hyperextension) Patient position: supine with towel under calf − Stabilization: none Axis of Rotation: lateral epicondyle of the femur Stationary Arm: lateral midline of femur in line with greater trochanter Moveable Arm: lateral midline of fibula in line with lateral malleolus
ROM DIP Joint Extension
Normal: 0 - 10 Patient position: neutral forearm; allow 70-90 degrees of PIP flexion to avoid passive tension in finger flexors; stabilize MCP at 0 Stabilization: middle phalanx to prevent motion of PIP joint Axis of Rotation: dorsal aspect of DIP joint Stationary Arm: dorsal midline of middle phalanx Moveable Arm: dorsal midline of distal phalanx
ROM PIP Joint Flexion
Normal: 0 - 100 (might be resisted by soft tissue) Patient position: neutral forearm, with forearm supported on table; MCP at 0 Stabilization: proximal phalanx to prevent motion of MCP; keep wrist stabilized at neutral Axis of Rotation: dorsal aspect of PIP joint Stationary Arm: dorsal midline of proximal phalanx Moveable Arm: dorsal midline of middle phalanx
ROM 1st CMC Flexion
Normal: 0 - 15 Patient position: full supination, hand supported on table Stabilization: carpals, radius and ulna to prevent wrist motion Axis of Rotation: 1 st CMC joint (palmar surface) Stationary Arm: midline of radius Moveable Arm: midline of 1st metacarpal (ventral surface) **Special Instructions: Measure starting position, move into full CMC flexion and measure again. Subtract final from starting for ROM.
ROM MCP Joint Abduction
Normal: 0 - 20 Patient position: pronated with hand flat on table Stabilization: metacarpal to prevent wrist motion (radial or ulnar deviation) Axis of Rotation: dorsal aspect of MCP joint Stationary Arm: dorsal midline of metacarpal Moveable Arm: dorsal midline of proximal phalanx "Slide finger across the table"
ROM MCP Joint Extension
Normal: 0 - 45 Patient position: neutral forearm (thumb up) with forearm supported on table Stabilization: metacarpal to prevent wrist motion (videos said wrist) Axis of Rotation: dorsal aspect of MCP joint Stationary Arm: dorsal midline of metacarpal Moveable Arm: dorsal midline of proximal phalanx
ROM 1st CMC Abduction
Normal: 0 - 70 Patient position: neutral forearm, hand supported on table Stabilization: carpals and the 2nd metacarpal to prevent wrist motions Axis of Rotation: radial styloid Stationary Arm: 2nd metacarpal Moveable Arm: 1st metacarpal (lateral midline) **Note: goniometer will not read zero to start, okay to record at 0 if thumb and 1st finger touch at start; this is an exception to needing to see the zero (NO MATH NEEDED)
ROM Knee Flexion
Normal: 0-140 Patient position: supine with towel under calf; patient flexes hip to 90 degrees and flexes knee Stabilization: femur to prevent movement at the hip >90 Axis of Rotation: lateral epicondyle of the femur Stationary Arm: lateral midline of femur in line with greater trochanter Moveable Arm: lateral midline of fibula in line with lateral malleolus
ROM Subtalar Inversion
Normal: 0-15 Patient position: prone, foot in neutral (can use PT thigh to support pt foot) Stabilization: tibia and fibula Axis of Rotation: line bisecting malleoli at posterior aspect of ankle (mark on skin) Stationary Arm: posterior midline of lower leg (mark on skin) Moveable Arm: bisect calcaneus
ROM 1st CMC Extension
Normal: 0-20 Patient position: full supination, hand supported on table Stabilization: carpals, radius and ulna to prevent wrist motion Axis of Rotation: 1 st CMC joint (palmar surface) Stationary Arm: midline of radius Moveable Arm: midline of 1st metacarpal (ventral surface) **Special Instructions: Measure starting position, move into full CMC extension and measure again. Subtract final from starting for ROM.
ROM Hip Extension
Normal: 0-20 Patient position: prone Stabilization: pelvis to prevent anterior pelvic tilt Axis of Rotation: greater trochanter of femur Stationary Arm: midline of pelvis Moveable Arm: lateral aspect of femur
ROM Ankle Dorsiflexion
Normal: 0-20 Patient position: sitting with knee flexed to 90 Stabilization: tibia and fibula Axis of Rotation: lateral malleolus Stationary Arm: lateral midline of fibula toward fibular head Moveable Arm: parallel to the 5th metatarsal - If patient doesn't get to zero, the DF measurement is recorded as a single negative number
ROM Wrist Radial Deviation
Normal: 0-20 Patient position: sitting, shoulder abducted to 90, elbow flexed to 90, forearm pronated hand supported by table Stabilization: radius/ulna to prevent supination/pronation and elbow flexion > 90; hand needs to be supported by the table with fingers flat on the table Axis of Rotation: capitate (divet with extended hand, felt with flexion) Stationary Arm: dorsal midline of forearm Moveable Arm: midline of 3rd metacarpal (palpate!)
ROM Hip Adduction
Normal: 0-30 Patient position: supine, toes pointed toward ceiling, move opposite limb out of the way Stabilization: pelvis Axis of Rotation: anterior to ASIS, on side you are measuring Stationary Arm: in line between both ASIS Moveable Arm: anterior aspect of femur lined up with patella
ROM Hip IR/ER
Normal: 0-35 Patient position: sitting, sock and shoe off, towel under distal femur Stabilization: distal end of femur to prevent hip hiking, flex, ABD, lateral WS etc Axis of Rotation: anterior aspect of patella Stationary Arm: perpendicular to the floor Moveable Arm: along tibia between malleoli (bisect) - SOCKS MUST BE OFF to observe!
ROM 1st MTP Flexion
Normal: 0-45 Patient position: sitting or supine with neutral ankle Stabilization: metatarsals Axis of Rotation: 1 st MTP joint Stationary Arm: 1 st metatarsal along dorsal or medial aspect (NOT extensor tendon!) Moveable Arm: dorsal or medial aspect of proximal phalanx
ROM Hip Abdcution
Normal: 0-45 Patient position: supine, toes pointed toward ceiling, patient positioned to opposite side of table to allow enough room to move leg with leg supported Stabilization: pelvis (watch for hip hiking, lateral flexion) Axis of Rotation: anterior to ASIS on the side you are measuring Stationary Arm: connecting both ASIS Moveable Arm: anterior aspect of femur lined up with patella
ROM 1st MCP Flexion
Normal: 0-50 Patient position: full supination, hand supported on table Stabilization: 1st metacarpal to prevent wrist motion and flexion of CMC Axis of Rotation: 1st MCP joint Stationary Arm: 1st metacarpal (dorsal midline) Moveable Arm: Proximal phalanx (dorsal midline)
ROM Ankle Plantarflexion
Normal: 0-55 Patient position: sitting with knee flexed to 90 Stabilization: tibia and fibula (overpressure on dorsum of foot down into PF) Axis of Rotation: lateral malleolus Stationary Arm: lateral midline of fibula toward fibular head Moveable Arm: parallel to the 5th metatarsal
ROM 1st MTP Extension
Normal: 0-70 Patient position: sitting or supine with neutral ankle Stabilization: metatarsals Axis of Rotation: 1st MTP joint Stationary Arm: 1 st metatarsal along dorsal or medial aspect (NOT extensor tendon!) Moveable Arm: dorsal or medial aspect of proximal phalanx
ROM Wrist Extension
Normal: 0-75 degrees Patient position: sitting, shoulder abducted to 90 (as close, okay if less); elbow flexed to 90; forearm pronated; ALLOW FINGERS TO CURL (to limit impact of flexor digitorum length) with hand over edge of table Stabilization: radius/ulna to prevent supination/pronation; shoulder ER; overpressure provided at 3rd MC Axis of Rotation: lateral wrist over triquetrum Stationary Arm: lateral midline of ulna (between olecranon and ulnar styloid) Moveable Arm: lateral midline of 5th metacarpal (must palpate bone)
ROM Wrist Flexion
Normal: 0-75 degrees Patient position: sitting, shoulder abducted to 90 (as close, okay if less); elbow flexed to 90; forearm pronated; FINGERS STRAIGHT (to prevent limitations from extensor digitorum) with hand over edge of table Stabilization: radius/ulna to prevent supination/pronation; shoulder IR overpressure provided at 3rd MC Axis of Rotation: lateral wrist over triquetrum Stationary Arm: lateral midline of ulna (between olecranon and ulnar styloid) Moveable Arm: lateral midline of 5th metacarpal (must palpate bone)
ROM Subtalar Eversion
Normal: 0-8 Patient position: prone, foot in neutral Stabilization: tibia and fibula Axis of Rotation: line bisecting malleoli at posterior aspect of ankle Stationary Arm: posterior midline of lower leg Moveable Arm: bisect calcaneus
ROM 1st IP Flexion
Normal: 0-80 Patient position: full supination, hand supported on table Stabilization: proximal phalanx to prevent MCP joint movement Axis of Rotation: IP joint (dorsal) Stationary Arm: Proximal phalanx (dorsal midline) Moveable Arm: Distal phalanx (dorsal midline)
ROM Hallux Valgus
Normal: <15 Patient position: sitting or supine with foot supported Stabilization: none Axis of Rotation: 1st MTP joint Stationary Arm: 1 st metatarsal along dorsal aspect (NOT extensor tendon!) Moveable Arm: dorsal aspect of proximal phalanx
ROM Opposition
Normal: N/A (measured in cm) Patient position: full supination, hand supported on table Stabilization: 5th metacarpal to prevent motion at the 5th CMC joint Starting measurement point: tip of thumb Ending measurement point: proximal digital crease of 5th digit **Special instructions: no measurement needed if tip of thumb can reach tip of 5th finger (without stabilization)
resisted movements stress...
all contractile structures (requires an isometric test at mid-range of motion)
AAA
anode attracts acid
effects of NMES for weak subjects
any injury or weakness, NMES with exercise shoes positive gains
resting position of SCJ joint
arm along the side -- anatomical position
C5 myotome testing
biceps: tested with arm along side, elbow at 90 degrees of flexion, forearm supinated -- resistance applied to distal forearm, stabilized behind elbow shoulder abduction (deltoid): tested with shoulder at 90 degrees abduction, elbow straight, palm facing down -- resistance applied just proximal to elbow or wrist, stabilized on top of shoulder patient position: standing/sitting
effect of electrode size on current density
big electrode = low density (comfortable, but not specific to target) small electrode = high density (not as comfortable, but more specific)
active movements stress...
both inert and contractile structures (does not discriminate structure at fault)
C6 reflex testing
brachioradialis tested with arm along side, elbow at 90 degrees flexion, forearm neutral and supported on therapist's forearm; PT identifies biceps tendon by asking patient to perform resisted elbow flexion using reflex hammer, typically the broader end, tapping is done on tendon at mid-forearm, looking for muscle response
when treating for reducing pain/inflammation, EPAs...
can be done prior (except for ice and heat) or after (ice, but not heat) - ROM exercises in painfree range
CAB
cathode attracts base = harmful
Tertiary Prevention
clinical intervention to prevent condition worsening
deep tendon reflex score of 4
clonus (repeated "beats")
what does CBAN stand for?
cold, burning, aching, numbness
TUG Cognitive in Community Dwelling Elderly
completed in more than 15 seconds are classified as fallers
What is thoracic outlet syndrome?
compression of the neurovascular bundle in the neck/shoulder region. triangular channel bordered by the scalenus anterior, first rib, and scalenus medius
retraction/protraction occurs with a _____ clavicle on ______ sternum in transverse plane
concave; convex
Grade 3 Joint Play
condition: normal treatment: none
difference between continuous and pulsed ultrasound
continuous: great thermal effects pulsed: better for acute injury
if active and resisted movement is painful in one direction, and passive movement is painfree in the SAME direction, then...
contractile tissue is at fault - most useful of the two rules - minor injuries may NOT be painful with active movement where resistance is limited - not always possible to isolate muscle action perfectly
if the muscle is strong and painless, then...
contractile tissues are normal (no injury)
elevation/depression occurs with a _____ clavicle on ______ sternum in frontal plane
convex; concave
deep tendon reflex score of 1
decreased (diminished)
C5 dermatome
deltoid area and lateral forearm region
what stage of depolarization process is the reason that electrical stimulation works?
depolarization negative charge attracts the positive dipole of the Na+ gate
what medication is the first line defense for localized inflammation?
dexamethasone with ionotophoresis
"classic" pain location of adhesive capsulits
diffuse pain in deltoid insertion (mid-upper arm) region
general motions that will provoke pain in SCJ with NO history of trauma -- younger individuals
disc related pain or hypermobility - location of pain over SCJ itself - likely report pain and potential "clicking" with reaching across the body and potentially with shoulder protraction and end-range overhead motion
C7 myotome testing
elbow extension: tested at 90 degrees shoulder flexion, elbow at 90 degrees flexion, forearm neutral -- resistance applied to distal forearm, stabilized under distal humerus wrist flexion: tested with arm along side, elbow at 90 degree flexion, forearm supinated -- resistance applied on volar aspect of hand, stabilized under dorsal aspect of distal forearm patient position: standing/sitting
how to test 12 to 2 section of labrum in compression test
elbow is dropped down along the edge of the table, while force along humerus and circumduction movements are maintained
AROM cervical assessment with shoulders unloaded - limitation of movement
if ROM does NOT increase, articular limitation is suspected if ROM increases, muscular limitation is suspected
how does the electrode distance impact motor point stimulation?
if electrodes are further apart, more motor points reached = more motor units activated
2+ laxity
if joint opening between 5 and 10 mm greater than contralateral limb
3+ laxity
if joint opening more than 10 mm greater than contralateral limb
pre-testing for vertebral artery
if no history of symptoms and no concerns from medical history - explain process to patient, let me know if you have any sensation of dizziness, fainting, nausea - with patient supine, turn head to right to end range, hold for 10 seconds, ask for changes in symptoms, then return to neutral - if first step negative, after 10 seconds in neutral, repeat to left side - if still negative, extend head over edge of table for 10 seconds, then return to neutral if symptoms, especially combined with positive medical history suggesting arterial disease, referral should be considered without further testing
Jendrassik maneuver
if no reflex is noted, patient could be asked to do something like: - clench teeth - squeeze thighs together - hooks fingers together and try to pull hands apart INCREASES NEURAL DRIVE (not distraction)
AROM cervical assessment with shoulders unloaded - source of nociception
if pain increases, articular source of pain is suspected if pain is reduced, muscular source of pain is suspected
when is neck compression test used over neck distraction test?
in the presence of moderate/severe symptoms, it is preferred to perform neck distraction test first
deep tendon reflex score of 3
increased (exaggerated)
if active and passive movement is painful in one direction, and resisted movement is painfree in that SAME direction, then...
inert structure is at fault - useful to rule-out muscle/tendon/insertion injuries
passive movements stress...
inert structures
What is adhesive capsulitis (frozen shoulder)?
inflammatory reaction of the capsule and/or synovium that subsequently leads to formation of fibrosis/adhesions predominantly of the coracohumeral ligament and rotator cuff interval as well as axillary folds
C3 myotome testing
lateral neck flexion (rarely affected)
Sharp-Purser Test
intended as structural test, but step 1 = provocative and step 2 = alleviating patient position: seated one hand of PT is placed on forehead, other hand contacts tip of spinous process of C2 with pinch grip 1. PT passively brings patient's head into small amount of cranio-cervical flexion (similar to transverse ligament test -- no movement should occur) 2. hand on forehead applies a force in posterior direction to translate cranium and C1 posteriorly on C2 (C2 stabilized by PT's hand) positive: perception of excessive motion during step 2 is considered positive for laxity of transverse ligament (any laxity occurring in step 1 is "corrected" in step 2) specificity is better, therefore better at ruling in condition with positive
Prescription
intensity, duration, frequency, mode, progression
recurrent pain
involves episodes of discomfort interspersed with periods in which the individual is relatively pain-free, that recur for more than three months
current in body causes ____ to flow
ions
why is use of dexamthasone a concern for a diabetic patient?
it is a glucosteriod, so glucose would be added to the system
how to determine best treatment option for third degree sprain of ACJ?
lack of consensus on best option: symptomatic, conservative or surgical based on: - age: surgery for younger patients - hand dominance: surgery preferred for dominant side - activities: more active = surgery
healing with absence of normal mechanical forces
leads to adhesions, dysfunction, and chronic state immobilization results in no stress to structures, which leads to random arrangement of fibers
specificity of electrode placement ACROSS muscle fibers
less specific
if someone is unable to keep looking straight when sidebending, what does that indicate?
limited C1/C2 contralateral rotation
if someone is unable to keep eyes level when rotating, what does that indicate?
limited occiput/C1 contralateral side bending
how is iontophoresis dosage measured?
mA*min
normal carrying angles: men vs. women
male: 5 degrees valgus female: 10-15 degrees valgus
what are sclerosing injections?
material that causes inflammation = assist with hypermobility
close packed position of proximal radioulnar joint
maximum pronation or supination
type IV mechanoreceptors
myelin: A-delta = thin; B fiber = unmyelinated; C fiber = unmyelinated speed: A-delta = 5-15 m/sec; B fiber = 3-14 m/sec; C fiber = 0.2-2 m/sec (very slow conduction = Gate Theory) function: nociceptors; non-adapting (do not want to adapt to pain; high threshold location: almost all tissues: joint capsule, blood vessels, fat pads, ALL, PLL, etc. behavior: tonic reflexogenic effects; inform about nociception (stimuli perceived as being potentially dangerous/harmful)
C1-C2 myotome testing
neck flexion (rarely affected) -- unable to differentiate between right and left side
nerves respond best to _______ charge
negative
cathode polarity: positive or negative
negative (settle for C-)
deep tendon reflex score of 2
normal (average)
PROM upper cervical flexion/extension
normal ROM: 15-30 degrees in each direction - both hands behind occiput with thumbs assisting at zygomatic arch (alternate - one hand on occiput and other hand on forehead) - ear canal serves as AOR
AROM upper cervical flexion/extension
normal ROM: 15-30 degrees in each direction - patient claps hands behind their neck to provide a cervical collar for lower cervical spine and isolate motion to upper cervical spine region - ear canal serves as AOR
AROM upper cervical rotation
normal ROM: 35-40 degrees in each direction - patient goes into full flexion of cervical spine, then while keeping end range flexion, rotate to left and right - top of occiput serves as AOR
PROM cervical lateral flexion
normal ROM: 35-55 degrees - both hands behind occiput, PT passively brings cervical spine into lateral flexion - try to maintain head in relatively neutral flexion/extension position
AROM cervical lateral flexion
normal ROM: 35-55 degrees (best with inclinometer) - keep contralateral shoulder down - NO flexion/extension - palpate interspinous spaces between C7 and T4 to appreciate movement overpressure: stabilize opposite shoulder with one hand and apply overpressure with other hand -- ONLY IF NO/MINIMAL PAIN WITH AROM
PROM upper cervical rotation (also called flexion/rotation test)
normal ROM: 44 degrees in each direction (cut-off point of 30 degrees and/or reproduction of headache with testing) - both hands behind occiput, PT moves into full flexion - while maintaining full cervical spine flexion, PT gently rotates the neck to right and left - top of head serves as AOR
PROM cervical flexion
normal ROM: 45-65 degrees (best with inclinometer) - both hands behind occiput, PT passively brings cervical spine into flexion - in this position, it is possible to palpate segmental motion using the space between vertebrae (further down cervical spine = neck into more flexion)
AROM cervical flexion
normal ROM: 45-65 degrees (best with inclinometer) overpressure: stabilize the mid-thoracic spine with one hand and apply overpressure with other hand -- ONLY IF NO/MINIMAL PAIN WITH AROM
PROM upper cervical lateral flexion
normal ROM: 5-10 degrees in each direction - both hands behind occiput with thumbs assisting at zygomatic arch - nose serves as AOR
AROM upper cervical lateral flexion
normal ROM: 5-10 degrees in each direction - patient claps hands behind their neck to provide a cervical collar for lower cervical spine and isolate motion to upper cervical spine region - nose serves as AOR
AROM cervical rotation
normal ROM: 65-75 degrees (best with goniometer) - palpate interspinous spaces between C7 and T4 to appreciate movement overpressure: use both hands (each side of temporal area) to apply overpressure while stabilizing ipsilateral shoulder with elbow -- ONLY IF NO/MINIMAL PAIN WITH AROM
PROM cervical rotation
normal ROM: 65-75 degrees in each direction - both hands behind occiput, PT passively brings cervical spine into rotation - try to maintain head in relatively neutral flexion/extension position
AROM cervical extension
normal ROM: 65-90 degrees - do not do if there are signs or history of fainting/dizziness and headaches (vertebral artery test first) overpressure: use both hands to apply overpressure -- ONLY IF NO/MINIMAL PAIN WITH AROM
ramp time
number of second it takes for amplitude to gradually increase or decrease
"classic" pain location of GHJ anterior laxity/instability
pain anterior and/or posterior shoulder region
"classic" pain location of SLAP lesion
pain deep under acromion = cannot reach with finger
"classic" pain location of long head of biceps injury
pain localized over anterolateral shoulder (vertical)
"classic" pain location of suprapsinatus/rotator cuff injury
pain localized over greater tuberosity
latent trigger point
painful when pressed, otherwise unknown until stimulated
what is another way to test lateral elbow tendinopathy?
palpate common insertion of wrist extensors and supinator over and just distal to lateral epicondyle for pain and tenderness
what is another way to test medial elbow tendinopathy?
palpate common insertion of wrist flexors and pronator teres over and just distal to medial epicondyle for pain and tenderness
reactive tendinopathy
pathological features: - non-inflammatory response in cell and matrix - short-term adapative and thickening of tendon that reduces stress by increasing cross-sectional area (collagen integrity mostly maintained - no change in neurovascular changes - tendon has potential to revert to normal if overload is reduced or sufficient time between loading clinical features: - more common in younger athletic population or overuse in underloaded tendon - might require 3-4 days to "settle-down" if aggravated
palpation of infraspinatus and teres minor tendon
patient position: prone with arm over edge of table - PT stands next to patient - PT holds patient at elbow with 90 degree elbow flexion, brings shoulder in 90 degrees flexion and 10 degree horizontal adduction and ER - with index of other hand, tendon can be palpated just inferior to posterior acromial angle (follow spine of scapula to posterior corner, position two fingers right below that corner; middle finger = infraspinatus, index finger = teres minor)
RROM cervical rotation
patient position: seated - PT uses both hands to provide resistance. One hand is placed over ipsilateral temporal area and opposite hand over contralateral occipital area - patient is asked to look over their shoulder (turning toward hand over temporal region)
RROM cervical extension
patient position: seated - PT uses hand hand to apply resistance against the occiput - if patient is asked to push with movement as if wanting to look up, upper cervical muscles (typically very strong) are test - if patient is asked to do movement of retraction without looking up, it will test lower cervical/upper thoracic region (typically weaker)
RROM cervical flexion
patient position: seated - PT uses one hand to apply resistance against forehead of patient - PT provides stabilization with other hand over thoracic spine - make sure patient brings chin down while pushing with forehead, not pure head protraction
RROM cervical side-bending
patient position: seated - PT uses one hand to apply resistance against lateral aspect of the skull (above ear) and patient brings ear toward shoulder - PT provides stabilization with other hand over opposite shoulder
first rib depression
patient position: supine - place web space with thumb point up or dorsal aspects of proximal phalanges while in a fist on superior aspect of first rib - take up slack by passively side-bending toward side PT working on - ask patient to take deep breath, and upon exhalation, apply downward pressure - apply graded mobilizations or sustained stretch
Quadrant Test (foraminal compression test and Spurling test B)
patient position: seated - neck is passively guided to ~45 degrees of rotation to involved side, then passively guided into diagonal movement toward involved side, combining sidebending and extension of cervical spine - this position maximally loads the posterior facets, therefore it is a provocative test indicating irritation/inflammation of posterior facets positive: provocation/increase of radicular symptoms (pain, numbness, tingling) down upper extremity
Spurling test "Test A" (seated)
patient position: seated - neck is passively side-bent towards symptomatic side, and overpressure (about 7kg) is applied to patient's head positive: provocation/increase of radicular symptoms (pain, numbness, tingling) down upper extremity
neck compression test (seated)
patient position: seated - patient's neck is first placed in slightly flexed position - PT cups both hands over the patient's head and applies gentle and progressive neck compression downward (5-10 seconds) positive: provocation/increase of radicular symptoms (pain, numbness, tingling) down upper extremity
neck distraction test (seated)
patient position: seated (can also be done in standing) - PT cups both hands under mastoid process and applies gentle and progressive neck distraction upward and hold for a few seconds (5-10 seconds) - only of value if patient has symptoms while sitting down positive: reduction/elimination of radicular symptoms (pain, numbness, tingling) down upper extremity
Allen maneuver (hyperabduction test)
patient position: seated (could be standing) - PT palpates radial pulse - PT places one hand behind patient's shoulder (over posterior scapula to prevent trunk rotation) - patient asked to turn head away from tested side - PT passively brings patient's arm to 135 degree shoulder abduction, and pulls arm back slightly behind scapular pain (with hand taking pulse) - testing position maintained for up to 30 seconds -- stop if reproduction of pain POSITIVE: reproduction of symptoms designed to assess compression between pectoralis minor and underlying ribs
Costoclavicular syndrome test
patient position: seated (could be standing) - PT palpates radial pulse - patient asked to assume exaggerated military position: elevation shoulder blades, retract and lower as low as possible - testing position maintained for up to 30 seconds -- stop if reproduction of pain POSITIVE: reproduction of symptoms designed to assess compression between clavicle and first rib
Adson Test
patient position: seated (could be standing) - PT palpates radial pulse - patient asked to turn head towards affected side, then extend head - PT laterally rotates and extends patient's shoulder while palpating radial pulse - patient asked to take deep breath - testing position maintained while patient holds breath for up to 30 seconds -- stop holding breath if reproduction of pain POSITIVE: reproduction of symptoms designed to assess compression between anterior and middle scalene
proximal radioulnar joint -- anterior glide of radius on ulna
patient position: seated in a chair next to table - patient's forearm is supported by table with elbow at about 70 degrees of flexion and forearm slightly supinated (about 35 degrees) - PT reaches across patient and places hand of arm closest to patient under proximal forearm region and use lumbrical grip to grasp and stabilize the ulna - index and long fingers of the other hand are placed just posterior to head and proximal radius - anteriorly directed force is applied to proximal radius while stabilizing the ulna
proximal radioulnar joint -- posterior glide of radius on ulna
patient position: seated in a chair next to table - patient's forearm is supported by table with elbow at about 70 degrees of flexion and forearm slightly supinated (about 35 degrees) - PT reaches across patient and places hand of arm closest to patient under proximal forearm region and use lumbrical grip to grasp and stabilize the ulna - thenar eminence of other hand is placed just anterior to head and proximal radius - posteriorly directed force is applied to proximal radius while stabilizing the ulna
Hoffman Test
patient position: seated with PT holding hand in manner as observing movement of thumb as distal end of third digit is quickly "flicked" normally this should result in no thumb motion movement of thumb in adduction/flexion is indicative of central nervous disorder specificity is better, therefore better at ruling in condition with positive
palpation of supraspinatus tendon
patient position: sitting - PT stands behind patient - PT holds patient at elbow with 90 degree elbow flexion, passively brings shoulder in combined position of maximum extension, IR, and adduction (arm behind back) - with index of other hand, tendon can be palpated just anterior and below ACJ
palpation of long head of biceps tendon
patient position: sitting - PT stands behind patient - PT holds patient at elbow with 90 degree elbow flexion, shoulder at 20 degrees IR with arm at side of body - with index of other hand, tendon can be palpated in deltopectoral triangle (just lateral to coracoid process)
palpation of subscapularis tendon
patient position: sitting - PT stands behind patient - PT holds patient at elbow with 90 degree elbow flexion, shoulder at neutral position with arm at side of body - with index of other hand, tendon can be palpated in deltopectoral triangle (just lateral to coracoid process)
AROM of cervical spine
patient position: sitting and/or standing (position that symptoms occur) assess each movement for amount of motion, distribution of movement, smoothness, pain/symptoms, location, time of symptoms
tests for lateral elbow tendinopathy
patient position: sitting or standing 1. with elbow flexed at 90 degrees, forearm pronated, wrist in neutral, PT supports under volar aspect of distal forearm and resist wrist extension (resistance at radial side of hand to elicit action of ECRB) 2. with elbow flexed at 90 degrees, forearm pronated, wrist in neutral, PT supports under volar aspect of distal forearm and resist extension of long finger (resistance at proximal phalanx to elicit action of ED) 3. with elbow flexed at 90 degrees and forearm in neutral, PT stabilizes the medial aspect of the elbow and resist forearm supination 4. while supporting behind the elbow, examiner passively stretches the wrist/fingers extensor with a combination of elbow extension, forearm pronation, and wrist flexion
soft tissue technique of upper trapezius
patient position: supine - use grasping technique along anterior border and work entire length up to occipital region - use gentle oscillations or maintain pressure - alternatively, parallel mobilization along anterior border
tests for medial elbow tendinopathy
patient position: sitting or standing 1. with elbow flexed at 90 degrees, forearm supinated, wrist in neutral, PT supports under dorsal aspect of distal forearm and resist wrist flexion 2. with elbow flexed at 90 degrees and forearm in neutral, PT stabilizes the lateral aspect of the elbow and resist forearm pronation 3. while supporting behind the elbow, examiner passively stretches the wrist/fingers flexors with a combination of elbow extension, forearm supination, and wrist extension
Roos test
patient position: standing - patient instructed to abduct both shoulders to 90 degrees and externally rotate both to 90 degrees -- elbows bent to 90 degrees flexion - patient closes and opens hands slowly, repetitively for up to 3 minutes POSITIVE: inability to hold test position for duration of test and/or ischemic pain, heaviness, profound weakness of arm, and numbness/tingling of hand
active compression (O'Brien) test
patient position: standing STEP 1: - patient actively brings arm to 90 degrees of shoulder flexion, then perform small amount of horizontal adduction, then rotate arm/shoulder by point thumb to floor - therapist provides resistance at distal forearm pushing toward floor -- produce pain? STEP 2: - redo the same test, but with thumb pointing up toward ceiling IF PAIN CHANGES BETWEEN TWO TEST POSITIONS (and is less with thumb up), test might indicate SLAP lesion (places tension on long head of biceps) -- if pain does not change, it is likely ACJ pathology
lift off test
patient position: standing (or sitting) - PT of patient brings patient's hand (dorsal) on patient's small of back, then patient is asked to lift hand off away from back MAKE SURE PATIENT IR, NOT JUST EXTENDS SHOULDER inability to do this suggests a significant tear of subscapularis
belly press test
patient position: standing (or sitting) - PT passively brings patient's hand (palmar) on patient's belly, and passively brings patient's elbow forward to achieve maximum shoulder IR, then patient holds position - if they can hold position, they are asked to press their hand on their belly while keeping elbow anterior to hand inability to hold elbow anterior to the hand in either part of the test suggests suggesting significant tear of subscapularis
external rotation lag test at 90 degrees of abduction
patient position: standing (or sitting) - PT passively brings patient's shoulder in a combination of 90 degrees abduction and end range of ER, and patient holds position inability to hold end range position is positive test suggesting significant tear of posterior portion of rotator cuff (likely infraspinatus and/or teres minor)
external rotation lag test along the side
patient position: standing (or sitting) - PT passively brings patient's shoulder to end range of ER, and patient holds position inability to hold end range position is positive test suggesting significant tear of posterior portion of rotator cuff (likely infraspinatus and/or teres minor)
drop arm test
patient position: standing (or sitting) - PT passively brings patient's arm to 90 degrees of abduction (palm down) -- patient holds position for few seconds while PT slowly removes support of arm - IF patient able to hold position, patient slowly lowers arm back down to side inability to hold arm at 90 degrees or slowly lower arm back down suggests significant tear of rotator cuff (likely supraspinatus tendon)
test for pronator teres syndrome
patient position: standing or seated with elbow flexed at 90 degree and forearm neutral PT stabilizes lateral aspect of the elbow and resist forearm pronation -- continue to resist pronation while passively extending the elbow positive test: tingling or paresthesia in median nerve distribution
resisted supination ER test
patient position: supine - PT brings shoulder in 90 degree of abduction and neutral rotation -- elbow in 90 degree of flexion and forearm toward ceiling - PT asks patient to perform forearm supination and elbow flexion, while passively ER shoulder and resisting supination POSITIVE: reproduction of patient's pain SPECIAL TEST OF SLAP LESION/LABRAL TEAR -- not super necessary to do if both bicep load tests are positive
neck distraction test (supine)
patient position: supine - PT grasps under patient's chin and occiput, slightly flexes patient's neck to position of comfort, and gradually applies distraction force up to 14 kg and hold for a few seconds (5-10 seconds) -- alternate option: one hand under occiput, other hand on forehead - only of value if patient has symptoms while lying down positive: reduction/elimination of radicular symptoms (pain, numbness, tingling) down upper extremity
muscular flexibility testing -- upper trapezius
patient position: supine - PT holds head under occiput with hand opposite to muscle being tested - cervical spine positioned in slight (10 degrees) ipsilateral rotation - PT uses other hand to stabilize ipsilateral shoulder down - cervical spine slowly brought into contralateral side bending - hand behind occiput provides gentle amount of traction
muscular flexibility testing -- sternocleidomastoid
patient position: supine - PT holds head under occiput with hand opposite to muscle being tested - cervical spine positioned in ~40 degrees ipsilateral rotation - PT uses other hand to stabilize ipsilateral shoulder down - cervical spine slowly brought into contralateral side bending - hand behind occiput provides gentle amount of traction
muscular flexibility testing -- levator scapulae
patient position: supine - PT holds head under occiput with hand opposite to muscle being tested - cervical spine positioned in ~60 degrees ipsilateral rotation - PT uses other hand to stabilize ipsilateral shoulder down - head is slowly brought upward toward the ceiling - hand behind occiput provides gentle amount of traction
muscular flexibility testing -- scalenes
patient position: supine - PT holds head under occiput with hand opposite to muscle test - cervical spine in neutral rotation and neutral flexion/extension - PT uses other hand to stabilize ipsilateral shoulder down - cervical spine is slowly brought into contralateral side bending - hand behind occiput provides gentle amount of traction
RROM deep neck flexors
patient position: supine - patient lifts head off the table -- more patient leads with chin, less they use deep neck flexors
soft tissue technique for scalenes
patient position: supine - use parallel mobilization starting with middle scalenes - begin proximally behind SCM about C3 level and course distally towards 1st rib - bias fingertips anteriorly or posteriorly to address anterior or posterior scalenes
soft tissue technique for SCM
patient position: supine - using grip technique hold anterior and posterior borders moving from proximal to distal to assess mobility, use gentle oscillations or maintain pressure - alternatively, parallel mobilization on anterior, then posterior borders
PROM of cervical spine
patient position: supine assess each movement for amount of motion, distribution of movement, smoothness, pain/symptoms, location, time of symptoms
biceps-pronated load test
patient position: supine (could be standing) - PT passively bring shoulder in 90 degrees of abduction and end range ER -- elbow is in 90 degree of flexion and forearm is pronated (hand away from patient) - PT asks patient to perform elbow flexion, which therapist resists without allowing movement POSITIVE: reproduction of pain SPECIAL TEST OF SLAP LESION/LABRAL TEAR (provides more stretch than supinated)
biceps load test
patient position: supine (could be standing) - PT passively bring shoulder in 90 degrees of abduction and end range ER -- elbow is in 90 degree of flexion and forearm is supinated (hand facing patient) - PT asks patient to perform elbow flexion, which therapist resists without allowing movement POSITIVE: reproduction of pain SPECIAL TEST OF SLAP LESION/LABRAL TEAR (replicates peel back)
assessment of pectoralis major tightness
patient position: supine in hook lying (knee bent) - patient is asked to place hands behind the head with fingers interlaced, slowly let elbows move away from midline in relaxed manner - with normally flexibility, elbows should be able to rest on table with arms parallel to table surface if limited, measure distance between table and elbow
assessment for pectoralis minor tightness
patient position: supine in hook lying (knee bent) with arms relaxed at side of body - PT observes orientation of superior aspect of acromion = ideally face horizontal direction -- the more the superior aspect faces toward the ceiling, the shorter the pectoralis minor OR measure distance between table and posterior edge of acromion (difficult to provide "normal" due to variation of patient size)
upper limb neurodynamic test 3 (ulnar nerve)
patient position: supine with cervical spine in neutral position 1. patient's shoulder is abducted slightly and resting on table, elbow at 90 degrees flexion; forearm, wrist and fingers in neutral position 2. PT uses a stride position and places the left arm under patient's scapula, and reach with fingers to grasps patient's top of shoulder so shoulder is in "neutral" position 3. shoulder is abducted to 90 degrees, then externally rotated to 90 degrees 4. forearm is pronated 5. wrist and fingers are 6. elbow progressively brought into flexion until symptom reproduction (angle of elbow flexion is noted) 7. patient brings ear toward tested side, which should immediately decrease symptoms and allowed greater extension
upper limb neurodynamic test 1 (median nerve)
patient position: supine with neutral cervical spine 1. patient's shoulder is abducted slightly and resting on table, elbow at 90 degrees flexion; forearm, wrist and fingers in neutral position 2. PT uses one hand over top of shoulder to stabilize (more depression = more provocative) 3. shoulder is abducted to 90 degrees 4. wrist and fingers are brought into extension, and thumb into abduction 5. forearm is supinated and shoulder is brought into 90 degrees external rotation 6. elbow progressively brought into extension until symptom reproduction (angle of elbow flexion is noted) 7. patient brings ear toward tested side, which should immediately decrease symptoms and allowed greater extension
transverse ligament test (anterior shear test)
patient position: supine with neutral neck posture (head supported on pillow) 1. PT cradles occiput with both hands and both index fingers cradling posterior arch of C1 2. head and C1 are lifted (translated) in an anterior direction, which creates shear force at C1/C2 (translate C1 anterior to C2) -- intact ligament should have NO MOVEMENT positive: provocation of neurological symptoms and signs (includes distal paresthesia) specificity is better, therefore better at ruling in condition with positive
posterior (dorsal) glide of GHJ
patient position: supine with shoulder abducted to 90 degrees and positioned just past the edge of the table -- elbow higher than shoulder - scapula is stabilized by table - PT's outside hand is holding the patient's elbow and provides slight distraction - other hand positioned on anterior aspect of humerus with fifth digit at edge of tip of acromion - therapist leans towards patient so shoulder is over sternum force applied posteriorly and slightly lateral to follow plane of glenoid
inferior glide with arm at 90 degrees of abduction of GHJ
patient position: supine with shoulder at 90 degrees in plane of scapula - PT hand supporting patient's arm above elbow applies a slight longitudinal distraction force - other hand applies a downward mobilizing force on the superior aspect of humerus just lateral to the acromion - using a stride stance, the hip behind the mobilizing hand can be used to apply the force on posterior aspect of mobilizing hand
distraction with shoulder in 90 degrees of flexion for GHJ
patient position: supine with shoulder at 90 degrees of flexion - PT faces patient and use both hands at proximal end of humerus to impart force perpendicular to long axis of humerus
inferior glide of GHJ
patient position: supine with shoulder in rest position - PT fixates the scapula by providing a posteriorly directed force on anterior aspect of the shoulder - longitudinal traction force applied through the humerus by griping just proximal to patient's elbow with caudal hand
distraction of glenohumeral joint
patient position: supine with shoulder in rest position - PT hand furthest from the patient is used to stabilize patient's scapula by blocking lateral border of scapula - other hand is positioned at proximal medial aspect of humerus to distract the GHJ
anterior (ventral) glide of GHJ
patient position: supine with shoulder in resting position - PT's hand closest to patient stabilizes the scapula by applying a posteriorly directed force on the anterior surface of the shoulder (medial enough to prevent blocking humeral head) - other hand grips humeral head below acromion with fingers around the posterior aspect and thumb on anterior aspect mobilizing force applied anteriorly and slightly medially to follow plane of glenoid fossa
humeroulnar joint -- distraction
patient position: supine with shoulder slightly abducted - PT seated next to table, facing the patient - patient's upper arm is resting on the table with olecranon process just beyond the edge of the table - PT outside hand stabilizes the distal end of the humerus while palpating joint space next to olecranon process - with patient's distal forearm supported on PT's shoulder and the blow in resting position, PT uses inside hand to apply a force perpendicular to long axis of the forearm
radiohumeral joint -- posterior glide
patient position: supine with shoulder slightly abducted and elbow flexed to 90 degrees - PT sits at edge of table with back facing the patient - patient's arm is slightly abducted while maintaining posterior aspect of upper arm in contact with the table - PT passively extends elbow so posterior aspect of forearm is now resting on PT's thigh - elbow should be almost fully extended and forearm in near full supination - PT's hand closest to patient's shoulder stabilizes distal end of upper arm with palm of hand and tip of 5th digit used to palpate the radiohumeral joint line - thenar eminence of other hand is placed just anterior to head and proximal radius - posteriorly directed force is applied to proximal radius while stabilizing humerus
radiohumeral joint -- distraction
patient position: supine with shoulder slightly abducted and elbow flexed to 90 degrees - PT sits at edge of table with back facing the patient - patient's arm is slightly abducted while maintaining posterior aspect of upper arm in contact with the table - PT passively extends elbow so posterior aspect of forearm is now resting on PT's thigh - elbow should be almost fully extended and forearm in near full supination - PT's hand closest to patient's shoulder stabilizes distal end of upper arm with palm of hand while using the index finger to palpate the radiohumeral joint line - PT's other hand is used to grip distal end of radius (just proximal to styloid process) in a manner similar to gripping a golf club
radiohumeral joint -- anterior glide
patient position: supine with shoulder slightly abducted and elbow flexed to 90 degrees - PT sits at edge of table with back facing the patient - patient's arm is slightly abducted while maintaining posterior aspect of upper arm in contact with the table - PT passively extends elbow so posterior aspect of forearm is now resting on PT's thigh - elbow should be almost fully extended and forearm in near full supination - PT's hand closest to patient's shoulder stabilizes distal end of upper arm with palm of hand while using the index finger to palpate the radiohumeral joint line - index and long fingers of other hand are placed just posterior to head and proximal radius - anteriorly directed fore applied to proximal radius while stabilizing the humerus
ligamentous laxity test
patient position: supine with upper arm supported on table and elbow flexed at approximately 20 degrees (can also be completed in prone) ulnar (medial) collateral ligament: apply a valgus force to the elbow radial (lateral) collateral ligament: apply a varus force to the elbow
upper limb neurodynamic test 2 (median nerve)
patient position: supine, diagonally across table with shoulder over edge of the table 1. PT holds patient's wrist, and other arm cradles and supports patient's forearm and PT holds patient's flexed elbow (pistol grip -- three fingers holding hand, index finger holding back thumb) 2. PT uses anterior aspect of thigh over top of shoulder to stabilize in "neutral" position, which shoulder is held in ~10 degrees of abduction 3. elbow is extended 4. entire arm/forearm is externally rotated 5. wrist and fingers are extended, and thumb abducted 6. if there are no symptoms, the shoulder is slowly abducted until symptom reproduction OR ~40 degrees (angle of shoulder abduction is noted) 7. patient brings ear toward tested side, which should immediately decrease symptoms and allowed more shoulder abduction
upper limb neurodynamic test 2 (radial nerve)
patient position: supine, diagonally across table with shoulder over edge of the table 1. PT uses anterior aspect of thigh over top of shoulder to stabilize shoulder in "neutral" position, which shoulder is held in ~10 degrees of abduction 2. elbow is extended 3. entire arm/forearm is internally rotated 4. wrist is flexed (angle of wrist flexion is noted) 5. if there are no symptoms, the shoulder is slowly abducted until symptom reproduction OR ~40 degrees (angle of shoulder abduction is noted) 6. patient brings ear toward tested side, which should immediately decrease symptoms and allowed more shoulder abduction
P.O.L.I.C.E
patient post-acute injury/sprain, combined with education and potential EPAs Protection: control of activity Optimal Loading: ROM in pain-free range -- no stretching (especially with muscle injury) Ice: EPAs, grade I/II mobilization Compression: wrap or sleeve Elevation
name of ultrasound crystal
piezoelectric
soft tissue mobilization: pectoralis minor
position: supine 1) approach perpendicular to fibers under pec major with fingertips going up along rib cage - vary abduction angle passively or perform lower trunk rotation to opposite side 2. go through pec major belly from the tob
anode polarity: positive or negative
positive (want an A+)
hypermobility is commonly found after...
post-injury: short term (ankle sprain) or long-term acquired: excessive ER in baseball players congenital
"classic" pain location of GHJ posterior laxity/instability
posterior shoulder pain (typically no anterior pain)
Primary Prevention
prevent disease from occurring: diet, exercise, etc.
specificity of electrode placement ALONG muscle fibers
specific
Specificity
specific enough to rule out what you are looking for
indications for distraction with shoulder in 90 degrees of flexion for GHJ
specifically stretch posterior capsule to improve IR and horizontal adduction
how does stimulation control acute edema?
stimulation may block: - binding of histamine - release of calcium - binding of calcium NO EFFECT ON EXISTING EDEMA
indiciations for anterior (ventral) glide of GHJ
stretching of anterior capsule to improve ER and extension
resistance before pain (or no pain)
suggest a "chronic" condition suitable for stretching if motion is limited
alar ligament ("cranial side tilt") test
technically tests for dens fracture patient position: supine with neutral neck posture (head supported on pillow) 1. PT cradles occiput with hand while lightly contacting each side of lateral aspect of C2 spinous process with tips/pads of 3rd digit of each hand 2. testing performed by gently introducing cranial side-tilt first to one side, then the other 3. normally, spinous process will instantaneously move opposite to side-tilting direction of cranium - with ligamentous laxity or tear, rotational response of atlas may be delayed or absent Repeat test in cranio-cervical flexion and extension -- TEST MUST BE PROVOCATIVE IN ALL 3 POSITIONS TO SUSPECT INJURY specificity is better, therefore better at ruling in condition with positive
cross friction massage for tendon (length)
tendon should be under tension, moving surrounding tissue around the tendon
fishing during electrical stimulation
while stimulated, more the proximal or distal electrode and move to stimulate nearby areas
C6 myotome testing
wrist extension: tested with arm along side, elbow at 90 degrees flexion, forearm pronated -- resistance applied on dorsal aspect of hand, stabilized under volar aspect of distal forearm brachioradialis: tested with arm along side, elbow at 90 degrees flexion, neutral forearm -- resistance applied to distal forearm, stabilized behind elbow patient position: standing/sitting
