Tests and Measures Lecture Exam

T1 dermatome

abductor digiti minimi

functional ROM

ability or inability to perform a task, multi-planar movement, difficult to specifically measure, qualitative

functional strength assessment

ability to perform task, representative of daily functions, can modify to be patient specific, allows for compensation

healthcare system and pain

absence of practice standard, lack of accountability (pain meds for 10 years and not working), poor coordination across treatment settings

contraindications of MMT

acute dislocation or unhealed fracture (likely immobilized), immediately following surgical procedure, active myositis ossifcans

physiological responses for pain assessment

acute pain which habituates with time (respiration, sweating, muscle tension) not specific to pain experience not correlated with chronic pain do not look sick

contraindications to ROM

always check with MD if joint movement contraindicated, ROM assessment likely too acute dislocation or unhealed fracture, recent surgcial procedure, infection, deep vein thrombosis

camber

angle of the wheels in relation to being straihgt up and down

hanger angle

angle where the footrest bars meet the seat of the wheelchair smaller = more knee flexion but easier to turn

goniometry

angle, measure measures the angles created by the rotary motion of shafts of bones

one-joint muscle resistance

apply at end of range

multi-joint muscle resistance

apply at mid range where length tension more favorable

behavioral/observational pain assessment

appropriate in times of absence of self report, some patients cannot report pain, may not accurately represent pain intensity

outcome measures considerations

appropriateness for test application for health condition, precision of test, interpretability of test, acceptability of test, time and cost of administering test is it reliable, valid, sensitive, and specific? are you able to determine if you made a significant change?

ROM meaning

arc of motion that occurs at a joint, begin 0-180 start measuring ROM from anatomical position = 0

ROM

assess joint motion, integral to function, use of goniometer and inclinometers

Oswestry Disability Index (ODI)

assess symptoms and severity of lower back pain in terms of disablement and the degree to which back or leg pain impacts functional activities body region specific, self report measure

muscle length

assess the length of a given muscle across 2 or more joints, related to functional mobility

Urogenital Distress Inventory

assesses the impact that pelvic floor disorders have on health related quality of life condition specific, self report measure

axis

axis of rotation throughout movement expose landmarks, palpate for accurate identification be at eye level when reading goniometer

what does AROM tell you?

baseline strength, could be limited by pain does not tell whole story must combine with other tests if painful, limited or awkward need further testing

types of pain assessments

behavior/observational, physiological, self-report

C5 dermatome

biceps and brachialis

current pain model

biological factors, psychological factors, social factors

hard end feel

bone contacting bone, elbow extension

factors that affect ROM

bony structures, excessive adipose, decreased skin flexibility/scarring, swelling, tight capsule, decreased ligament length, tight or short muscle tissue, training effects (dancer with excessive ROM)

general/global measures

can be used with all individuals, provide overall measure of health

ROM infants

changes with age, born with physiological flexion tone from utero positioning (stays flexed and ER), bones mostly cartilage and immature in shape active ROM within activity PROM eyeball no goni use french angles test at end when more comfortable, important to be consistent with measuring in same position, must work quickly, tailor measurement to functional progress goals

healthcare profession and pain

clinicians attitudes, beliefs and behaviors (more complicated patients and require more attention), inadequate and inaccurate clinical knowledge, if PT has experience treating chronic pain, if you like the patient, empathy, response cost, compensation status

history

collecting info related to why seeking help of PT patient interview: home life, social support, goals, prior level of function, onset of problem

strength in peds

considerable change over time, natural with growth and development (hard to tell if stronger from growing or from PT), observation of movement and posture (MMT very difficult)

self-report pain assessment

considered gold standard, most valid measure pain intensity at rest and with activity (what aggravates it) fast, quantifiable, valid, sensitive to treatments, but is unidimensional and ignores complexity of pain and does not fully capture biopsychosocial model of pain

inter-rater reliability

consistency between 2 PTs

intra-rater reliability

consistency from the same PT multiple times

keys to hand-held dynamometry

consistent set up, consistent instructions (goal = max effort, ease into test and ease off), consistent effort (encouragement! PUSH PUSH PUSH)

reliability

consistent, repeatable results

firm - capsular end feel

extension of MCP

C6 dermatome

extensor carpi radialis longus and brevis

L5 dermatome

extensor hallicus longus

ideal lateral plumb line

external auditory meatus, acromion, lumbar vertebral bodies, greater tro, slightly ant to knee axis, slightly ant to lateral malleolus, calcaneocuboid joint

poor posture (postural dysfunction)

faulty alignment (increased strain on supporting structures and decreased efficiency of body over its base of support)

faulty posture and no pain

faulty posture + good flexibility mild deviation + tightness (mobility may be the more significant factor) chronic positioning of the spine/body in position that is unnatural or out of neutral position increased load or stress on tissues (elongated vs shortened tissues, stretch weakness: elongated beyond physiological neutral, muscle spindle inhibition, altered length tension)

tips for reading goniometer

find your zero, read at eye level, don't pull goniometer away from body when reading, make sure that it's right side up or not upside down, recheck landmarks

dorsal interossei

finger abduction

palmar interossei

finger adduction

C8 dermatome

flexor digitorum profundus (most distal muscle)

firm - ligamentous end feel

forearm supination

purpose of doing outcome measurements

functional performance, determine treatment technique, insurance purposes, track progress, communicate with disciplinary team many outcome measures and must select correct one and then interpret it

S1 dermatome

gastroc and soleus

ROM process

get patient into proper position, document and modifications, visualize and palpate, allow for full, unobstructed joint motion stabilize proximal segment to prevent compensation and helps isolate joint measure: palpate, re-align, read, record confirm they can get to 0

isometric and isokinetic electromechanical dynamometry (BIODEX)

gold standard for assessing strength, device with moveable elver arm, angular velocity maintained at a constant speed, can test a range of angular velocities as well as isometric strength at given joint angle, patient has to work against moveable arm, measures torque generated by patient

muscle length assessment

greatest extensibility of a muscle tendon unit (how far it can be lengthened), maximal distance between proximal and distal attachment, indirectly measures max PORM of joints crossed by a given muscle purpose to assess hypo or hyper mobility is due to length of inactive antagonist or other structures (helps choose most effective treatment technique)

osteokinematics

gross movement of the shafts of bony segments rather then the movement of joint surfaces movement of one bone to another

forward head posture

head forward of shoulders, upper back increases kyphosis, cranial extension to keep eyes up neck extensors shortened and strengthen neck flexors lengthened and weakened

flat back posture

head forward slightly extended, upper thoracic increased flexion, lower thoracic flattens out (loses kyphosis) post pelvic tilt tight hamstring or weak hip flexors

kyphotic/lordosis posture

head forward, C-spine hyperextended, rounded shoulders, increased thoracic kyphosis and increase lumbar lordosis, ant tilt, hips flexed, weak rectus abdominus or overactive lumbar extensors

sway back posture

head forward, C-spine slight extension, increased thoracic flexion, flattened lumbar thomas test

barrier to assessment and management of pain

health care system, health care profession, patient and family, legal and societal

dorsiflexion peds

high dorsiflexion when born but plantarflexion increase as age, prone often best 70 degrees infant 50 degrees 4months 40 degrees 2 years 30 degrees 13 years

firm - muscular end feel

hip flexion, tight/pulling

L2 dermatome

iliopsoas

patient and family barriers and pain

impairment of communication: language, cognitive ability and cultural, reluctance to report, fear of addiction of meds, lack of insurance/increased cost

axle position

in line with GH forward increase tippiness, back decrease tippiness

seat depth

in seated position measure distance along thigh from back of hip to knee and subtract 1-2 inches to allow space between back of knee and wheelchair seat to prevent skin irritation

hand-held dynamometry

make test instrument perpendicular to limb segment during test, allow 2-3 seconds of build up to maximum strength and hold isometric strength for 3-5 seconds, tester matches resistance consistent process = consistent results

arm rest height

measure distance from butt ot elbow in 90 degree flexion and add 1 inch plus cushion height to promote upright posture

leg length discrepancy (LLD)

measured ASIS to medial malleolus in supine under 1cm not uncommon in growing children, can contrubute to scoliosis block measure = functional measure in standing

ideal ant/post plumb line

midways between heels, between lower extremities, midline of pelvis, spine, sternum and skull

developmental testing peds

milestones to measure where child is at developmentally testing of a child's functional abilities and skills as compared to other children of the same age assess activities and participation, eligibility for services, development of goals and plan of care, prognosis, progress over time

responsiveness

minimal detectable change: minimal amount of change that ensures difference isn't due to error

one-joint muscles

muscle length testing = PROM in opposite direction of muscle action if tight: decreased PROM with firm resistance, might be palpable, pain in region, patient reports it's tight if too lax, passive tension in capsule and ligaments maintain norml joint ROM but will lengthened and lead to increased ROM

myotome

muscle or group of muscles supplied by a specific spinal nerve

how to determine the role of posture in proper body mechanics

must assess bony alignment and muscle balance (weak/tight muscles) goal: adequate ROM and strength but not excessive one of the first things tested (after subjective) because patient will change posture if they know you're watching

postural assessment

normal spinal curves (cervical lordosis, thoracic kyphosis, lubar lordosis) ASIS same horizontal plane and ASIS + pubic symphysis same vertical plane

gross MMT

not muscle specific, screening, identify deficits when multi-joint involvement, good place to start

trunk MMT in ASIA

not significant, watch belly button

muscle tone spectrum spinal cord injury

not strength, cannot MMT, tone = spasticity low tone = down syndrome, peds patients, placid paralysis abnormalities = impair function

french angles scarf sign

1-3mo unable to touch opp shoulder 4-6mo able to touch opp shoulder 7-12 mo able to reach beyond opp shoulder

adductor angle french angle

1-3mo: 40-80 4-6mo: 70-110 7-9mo: 100-140 10-12mo: 130-150 tone decreases over time in first year, more flexible

popliteal angle french angles

1-3mo: 80-100 4-6mo: 90-120 7-9mo: 110-160 10-12mo: 150-170 tone decreases over time in first year, more flexible

heel to ear

1-3mo: 80-100 4-6mo: 90-130 7-9mo: 120-150 10-12mo: 140-170 tone decreases over time in first year, more flexible

grading method for MMT

5 = full ROM, can't break after max resistance 4+ = full ROM with mod/max resistance 4 = full ROM and moderate 3+ = full ROM with min resistance 3 = full ROM no resistance (screen test) 3- = half ROM with gravity 2+ = grav elim + resistance 2 = grav elim full ROM 1 = trace 0 = no evidence

dorsiflexion french angles

60-70 degrees within first 12 months

hamstring lengths peds

90/90, pop angle, hamstring length test, SLR

do you test AROM or PROM first?

AROM

2 methods of PROM

AROM + overpressure (endfeel) or PROM entire ROM + overpressure at end

dermatome

Area of skin supplied by a single spinal nerve

diaphragm

C3-C5 other respiratory muscles = intercostals, pec minor, scalenes, SCM

pectoralis major clavicular head

C5-C7

pectoralis major sternal head

C8-T1

process of receiving wheelchair

MD refer for wheelchair assessment, PT eval, assistive technology professional eval

collecting initial data

PMH, prior interventions, lifestyle, patient identified problems, observations, patient interview, medications, other diagnoses

ROM vs muscle length

ROM = patient positioned so passive muscle doesn't limit ROM, muscle is on slack at all joints muscle length = intentionally building tension or increasing length across 2 joints

flexibility

ROM in a joint and the length of muscles that cross a joint

upper cross syndrome

Rounded shoulders and a forward head posture (over development of pecs) Lengthened/inhibited muscles - Rhomboids, Lower and middle trapezius, serratus anterior, teres minor, longus coli and longus capitus Hypertonic/facilitated muscles - Levator Scapulae, Pectoralis major, upper trapezius, sternocleidomastoid, scalenes, suboccipitals

assisted cough

This technique is used when the patient's abdominal muscles cannot generate an effective cough. (i.e. spinal cord injury) must teach caregivers how

ASIA exam

define and describe the extent and severity of a patient's spinal cord injury and help determine future rehabilitation and recovery needs (neurologic level) Grade A = complete lack of motor and sensory function below the level of injury, including anal area (unable to control bowel movement / feel it (distal end of spinal cord) Grade B-D = incomplete, B = some sensation below injury, C = 50% can move against gravity, D = more than 50% strong enough to move against gravity Grade E = all neurologic function has returned

validity

degree to which a measurement measures what it's supposed to, accuracy

Disabilities of Arm, Shoulder, Hand (DASH)

designed to evaluate disorders and measure disability of the upper extremities, and monitor change or function over time body region specific, self-report measure given before/during/after treatment to monitor progress quick, easy lower the score the better the function (no difficulty)

Lower Extremity Functional Scale (LEFS)

designed to evaluate disorders and measures disability of the lower extremity and monitor change or function over time body region specific, self-report measure higher the score better the function

reason for pain assessment

diagnostic, severity, determine therapy interventions, evaluate progress/effectiveness of therapy

review of systems

differential diagnosis: symptoms related to other health concerns? screen all major body systems determine if appropriate for PT determine if referrals are necessary

apraxia

difficult with motor planning to perform tasks or movements when asked uses an item for something else then what its purpose is

individual specific measures

does individual's overall health status impact function?

condition specific measures

does the condition limit patient functionally?

standard procedures of ASIA

done in supine, AROM and PROM, demonstrate test, palpate muscle, document findings, weak muscles will have less endurance

purpose of tests and measure throughout episode of care

evaluate/assess/re-assess, document change, determine progress toward identified goals, demonstrate change for patient "buy-in" test, retest, repeat

Y balance test

evaluates dynamic balance and functional symmetry in order to determine a person's risk for injury to return to sport readiness (functional strength) single leg balance assessed while reaching in 3 directions nonvestibular and vestibular balance, functional mobility, strength performance based measure, higher level functioning test

important elements of MMT with patient

explain testing strength, maximize effort, notify tester of pain or discomfort, patient should not hold their breath (Valsalva could increase BP) assess contralateral side to compare "normal"

seat width

in seated position, measure widest distance hip to hip and add 1-2 inches to allow space between arm rest and sides of hips, prevents skin irritation

sources of error within MMT

inconsistent resistance, not correcting compensations, pain, inter-rater variability

discharge

indicate achievement of the outcomes that are the end points of care and thereby ensure timely and appropriate discharge did PT do what was intended? insurance needs to see progress to get paid

PROM precautions

infectious process inflammatory process strong pain medication osteoporosis hypermobile joint painful hemophilia hematoma soft tissue injury anticoagulation

precautions of MMT

infectious process, inflammatory process, strong pain meds, marked osteoporosis, hypermobile joints, painful conditions, hemophilia, hematomas, soft tissue injury, patients who lack general strength/energy to undergo strength eval, history of CVD, monitor vital signs as able, isometric efforts can stress the vascular system significantly, ensure patient does not hold their breath (Valsalva)

setting goals

intended impact on functioning, need to be measurable, functional and time limited

body region specific measures

is body function or structure limiting patient functionally?

mat evaluation

joint ROM adequate for seated posture, ROM and strength adequate for mode of drive control, body measurements for wheelchair prescriptions determine what barriers there are to achieving a functional, comfortable and upright seated posture

soft tissue end feel

knee flexion, elbow flexion

requirement for MMT

knowledge of anatomy, good observation skills (watch for compensations), knowledge of technique (be consistent, alternative test positions, documentation, slow gradual resistance)

ataxia

lack of muscle coordination unsteady staggering gait

scoliosis

lateral curves in infants = always atypical, red flag

sequence of assessing muscle length

lengthen muscle at either proximal or distal joint, hold the position of that joint, lengthen muscle at second joint (must be passive!!!), measure PROM at second joint, written as single number not a range

PT examination

obtaining history, performing systems review, and selecting and administering certain tests and measures to gather data about the patient

abnormal end feels

occurs sooner or later in ROM than usual, or end-feel that is not expected soft: edema, synovitis firm: increased muscle tonus, tissue shortening hard: osteoarthritis, loose body, fracture, empty: no end feel because pain prevents reaching end of ROM, muscle protecting

two joint and multi joint muscles

often do not have the length for full PROM at all joints "passive insufficiency"

ASIA scoring

only consider from neurologic level, no +/- like MMT, less differentiable 0 = total paralysis 1 = palpable 2 = full ROM in grav elim 3 = full ROM against grav 4 = full ROM against grav with moderate position 5 = full ROM against grav and full resistance 5* = full ROM against grav and sufficient to be considered normal NT = not testable

specific MMT

optimally isolated strength of single muscle or small group, allows identification of specific muscle weakness

MMT

originated in 1912 during polio epidemic

stationary arm

parallel to longitudinal axis of segment that is not moving, sometimes a vertical or horizontal line

5 year rule

patient must remain in same wheelchair for 5 years unless have change in medical condition

patient specific functional scale

patient reported outcomes measure used to evaluate functional ability to complete specific activities 0-10 (unable to perform to able to perform) individual specific patient lists activities that bothers them and allows patient to identify their own problems and what they want to work on

self report measures

patient's perception of their impaired body function that is limiting their activities or function

MMT sequence

perform ROM first, intro/explanation (purpose/consent/movement desired), move patient into test position (expose landmarks/muscles), stabilize proximal segment, screen test (AROM) to determine resistance/test position, record grade

screen test

perform motion through full AVAILABLE ROM against gravity and then add resistance if partial ROM given, then place is gravity eliminated must grade on their available ROM

justifications

physical abilities through Mat assessment wheelchair propulsion test, timed propulsion, count push strokes, quality of propulsion, document pain, pulse ox, postural assessment, environment

center of gravity

position of rear wheels in relation to seat of wheelchair because it affects the stability and manual propulsion of wheelchair

moving arm

positioned and maintained parallel to longitudinal axis of moving segment

contraindications to ROM but partial passive and/or AROM allowed

post surgical protocol, visual observation reveals opening of an incision with ROM, patient pain

MMT Definition

procedure for evaluation of function and strength of individual muscles/muscle groups based on effective performance of a movement in relation to forces of gravity and manual resistance, little more subjective

performance based measures

provide data to the PT about level of impairment in body structure or functions

L3 dermatome

quadriceps

sources of error of ROM

reading wrong scale/number, timing of measurement, patient motivation, overpressure for PROM, compensation

tests and measures unique to children

reference values are age dependent, changes due to growth, developmental levels (compare to average chronic age) 0-18 very different ranges, size, prematurity, cognitive developments, communication abilities, social/emotional development, parent involvement

legal and societal barriers and pain

regulation of controlled substances (easy access), societal judgement regarding chronic pain, insurance issues

posture

relative arrangement of parts of the body, position in which you hold your body, often thought as static positioning, standing/sitting/laying down

psychometrics

reliability: consistent time after time validity: degree of utility, do what is intended responsiveness: able to detect at level that is clinically important

hand grip dynamometry

reliable and valid assessment of hand strength, objective index of general UE function, maximal voluntary force, norms available strength dependent on synergistic action of flexor and extensor muscles hand dominance, fatigue, time of day, age, nutritional status, available motion, pain

test-retest reliability

repeatability, stability of measurement

causes of postural dysfunction

repetitive activities, sports, work, age, medical conditions

the break test

resistance applied in opposite direction of line of pull of muscle, progressively apply resistance to allow full muscle recruitment, stop when patient breaks

importance of improving ROM

restore ROM to restore function

planes and axes of motion

sagittal: M/L frontal: A/P transverse: vertical

what can limit PROM?

scar tissue, boney structure, pain, fat, swelling

PT Exam: Tests and Measures

select tests and measures based on information gathered earlier clinical reasoning to establish diagnosis, prognosis, plan of care must obtain the measurements

contraindications to ROM but only PROM allowed

severe quad contusion, acutely inflammed rheumatoid arthritic joint

pain memory

short term memory of pain tends to be more accurate, ask for average pain in 24 hours or 7 days, long term memory not reliable,

wheelchair propulsion mechanics

shoulder 70 abduction, start extended and int rotated, end flexed and ext rotated

tricep substitution

shoulder ER, quick bicep contraction/relaxation, triceps spasticity

documentation of ROM

side of body, joint, motion measured, type of motion (AROM, PROM), angle range subjective limitations: pain, apprehension, spasm, crepitus, end feel any deviation from recommended test position document if patient does not reach neutral starting position

documentation of MMT

side, muscle, grade include limitation (pain) or compensation describe deviation from standard test position

stabilization of MMT

stabilize proximal attachment to provide fixed, stable point from which muscle can pull goal is to limit possibility of substitutions (gravity, other muscles, passive tension)

DME wheelchair

standard wheelchair in hospitals

goniometer

stationary arm = proximal, distal arm = distal

goals of MMT

subjective assessment of muscle strength, development of therapeutic exercises, reproduction of pain requires application of manual resistance, palpation and visual observation of surface anatomy

tenodesis

surgical suturing of the end of a tendon to a bone

AROM precautions

surgical tendon/ligament repair significant soft tissue injury laceration/surgical incision through muscles

hip extension peds

thomas test staheli better reliability in children with CP

L4 dermatome

tibialis anterior

C7 dermatome

triceps

ROM process intro

use lay terms patient can understand, introduce self and role, explain purpose of the test, have goniometer nearby, move patient into test position, describe/demonstrate movement desired, confirm with patient

specific ROM

use tools to measures (goniometer), objective/measurable

application of resistance in MMT

use wide contact area, gradual build up, use consistent lever arms, avoid crossing another joint, apply resistance near distal end of segment, watch own body mechanics

9 hole peg test

used to assess finger dexterity and upper extremity function scores based on time to complete placement of pegs one by one into holes on board from a container and remove them quickly as possible (timed test) body region specific, performance based measure

girth or circumference

used to determine joint swelling (indicates severity of injury or inflammation) or for muscle girth to quantify atrophy or hypertrophy

LE alignment as age in peds

varus then straight then valgus then straighten cartilage changes of lifespan and body adjusts, transitioning to weight bearing and then reshape birth 15 degrees varus 12 months 5 degrees varus 18 months 0 degrees (straight) 24 months 5 degrees valgus 3-4 years 10-15 valus 4-6 years 7 valgus 8-10 years 0 (straight)

gross ROM

visual observation of movement in anatomical planes, screening, might not need goniometer

patient identified problem list

what the patient sees that they can or cannot do, description of functional limitations and disabilities hypothesis of what is wrong with your patient and will guide clinical decision making about what to test or measure

purpose of dynamometers

when MMT isn't sensitive, precise or specific enough quick, simple, non-invasive, portable, more precise, used to document change

who is MMT appropriate?

when need to identify muscle unit involvement or muscular imbalances, patients with weakness or paralysis, CNS dysfunction (may have abnormal sensation or tone and be less accurate)

seat back height

while seated measure from butt to bottom of scapula and add or subtract depending on how much postural support is needed so the back of seat doesn't interfere with shoulder movements

backrest width

while seated measure width of chest at top of backrest and add 3/4 inch for optimal pushing

floor to seat height

while seated, measure distance from fold of back of knees to heels and add 2 inches to allow room for footrests

femoral torsion pedas

will decrease as age, prone preferred birth 30-40 degrees 3-4 years 35 degrees adult 12 degrees

tibial torsions peds

will decrease with age and then increase again 2 years: 11 degrees 3 years: 6-8 degrees 5 years: 9-10 degrees 7 years: 10-11 degrees adolescent to adult: 13-22 degrees