Data Collections Lecture - Quiz / Final

What deviations of gait are seen when someone is in pain?

-Individual will minimize time in weightbearing on the affected side, hence decreased stance time -Shortened stride length on the unaffected side due to decreased swing phase -May have lateral trunk shift towards the affected side during stance -May abduct UE's or reduce arm swing following initial contact to decrease weight bearing on the affected side -Heel strike may be avoided entirely to eliminate jarring of the limb

What are three common compensations seen when one lower extremity is short?

-One can "extend" their short limb by walking on their toes -One could drop the pelvis on the short side, effectively "lengthening" the extremity -One could do nothing, resulting in an increase in the vertical rise and fall of the center of gravity during each step

What are the two types of gait patterns displayed from weakness of the hip abductors?

-Uncompensated gluteus medius gait (Trendelenburg gait) -Compensated gluteus medius gait

Muscle Grades: Gravity minimized position (no added resistance)

0/5: no movement, no palpable or observable muscle contraction 1/5: no movement but a flicker of muscle contraction is palpable or observable 2-/5: less than full ROM in gravity minimized position 2/5: full ROM in gravity minimized position

List and describe each subphase of gait:

1. Initial Contact (Heel strike): moment heel touches the ground 2. Loading Response (Foot flat): Weight rapidly transferred onto limb, First period of double limb support- shock absorption 3. Midstance (Midstance): Body progresses over stable limb 4. Terminal Stance (Heel Off): Progression over stance limb continues, Body moves ahead of limb, Weight transferred onto forefoot 5. Pre-Swing (Toe Off): Rapid unloading of limb as weight is transferred to opposite limb, second period of double limb support 6. Initial Swing (Acceleration): foot comes off the floor, thigh begins to advance 7. Mid-Swing (Mid-Swing): Foot clears the floor-Knee extends -Thigh continues to advance 8. Terminal Swing (Deceleration): Knee fully extended-Limb comes back towards the ground

What is the loose packed position for the talocrural joint (ankle)?

10 °plantarflexion, midway between maximum inversion and eversion

Muscle Grades: against gravity, no added resistance

2+/5: less than half ROM, AG 3-/5: greater than half ROM, AG 3/5: Full ROM, AG

What is the loose packed position for the knee joint?

25 °flexion

Muscle Grades: against gravity and manual resistance

3+/5: Full ROM against gravity and minimal resistance 4-/5: Full ROM against gravity and mild to mod resistance 4/5: Full ROM against gravity and moderate resistance 4+/5: Full ROM against gravity and mod to max resistance 5/5: Full ROM against gravity and maximal resistance (Unable to break patient)

What is the loose packed position for the hip joint?

30 °flexion, 30 °abduction, and slight external rotation

What is the loose packed position for the glenohumeral joint?

55 ° -70 °abduction, 30 °horizontal adduction, rotated so that the forearm is in the transverse plane

What is the loose packed position for the ulnohumeral joint?

70 °elbow flexion, 10 °forearm supination

Describe an abnormal soft end feel. What does it indicate?

A boggy sensation that indicates the presence of synovitis or soft tissue edema.

Describe a normal firm (soft tissue stretch) end feel. Give an example of this.

A firm or springy sensation that has some give when muscle is stretched; for example, passive ankle dorsiflexion performed with the knee in extension is stopped due to tension in the gastrocnemius muscle.

Describe a capsular stretch end feel. Give an example of this.

A hard arrest to movement with some give when the joint capsule or ligaments are stretched. The feel is similar to stretching a piece of leather; for example, passive shoulder external rotation.

Describe an abnormal spasm end feel, what may this indicate?

A hard sudden stop to passive movement that is often accompanied by pain, is indicative of an acute or subacute arthritis, the presence of a severe active lesion, or fracture. If pain is absent a spasm end feel may indicate a lesion of the central nervous system with resultant increased muscular tonus.

Describe a normal hard (bony) end feel? Give an example of this.

A painless, abrupt, hard stop to movement when bone contacts bone; for example, passive elbow extension, the olecranon process contacts the olecranon fossa.

Describe an abnormal springy block end feel? Give an example of what may cause this:

A rebound is seen or felt and indicates the presence of an internal derangement; for example, the knee with a torn meniscus.

Describe an abnormal firm end feel. What does it indicate?

A springy sensation or a hard arrest to movement with some give, indicating muscular, capsular, or ligamentous shortening.

Describe gluteus maximus gait:

AKA: Rocking Horse Gait Occurs when gluteus maximus muscle is weak, resulting in continual hip extension during the stance phase. The trunk quickly shifts posterior to compensate. The excessive forward, backward motion resembles a rocking horse.

Define and give norms when applicable: Stride

AKA: gait cycle the linear distance between two consecutive initial contacts of right and left leg (heel contact) -Normal adult male - 1.46 m -Normal adult female - 1.28 m

What type of ROM will you ask your patient to do first when measuring in clinic? Why?

AROM. Because if they have full ROM, there's no reason to do PROM. If they don't have full ROM, then you will do passive ti ascertain why they have limitations.

What is the close-packed position for the glenohumeral joint (shoulder)?

Abduction and external rotation

Define Joint play/accessory movements:

Accessory movements are movements in the joint and surrounding tissues that are necessary for normal ROM but that cannot be actively performed by the patient. Joint play describes the motions that occur between the joint surfaces and also the distensibility or "give" in the joint capsule, which allows the bones to move. The movements are necessary for normal joint functioning through the ROM and can be demonstrated passively, but they cannot be performed actively by the patient.

Describe an abnormal hard end feel. Give an example.

An abrupt hard stop to movement, when bone contacts bone, or a bony grating sensation, when rough articular surfaces move past one another, for example, in a joint that contains loose bodies, degenerative joint disease, dislocation, or a fracture.

Describe the Hip Flexor Gait:

At pre-swing on the affected side, there is a sudden backward movement of the trunk and pelvis as a unit that continues throughout swing Pelvis may forcibly tilt posteriorly in an attempt to thrust the limb forward Increased time spent in stance on the unaffected side to allow the affected side to complete the swing phase

Why is end-feel important?

Because it lets you know if there is a pathological problem within a joint.

Deep Tendon Reflexes: a. How are they graded? b. What locations are these commonly performed?

Bicep, Hamstring, Patella, Ankle 0: No response 1+: Present, but depressed, low normal 2+: Average, normal 3+: Increased, brisker than average but not abnormal 4+: Very brisk, hyperactive with clonus, abnormal

What gait pathologies do you usually see when someone has a hip joint flexion contracture?

Bilateral -Increased anterior pelvic tilt, lumbar lordosis -Step length decreased bilaterally -Low back pain due to increased compensatory motion in lumbar spine -High energy consuming gait pattern Unilateral -Shortened stance phase on the affected side -Tendency to anteriorly tilt trunk to increase knee stability

Define and give norms when applicable: Rate of speed of normal gait or cadence

Cadence - number of steps per unit of time Normal adult male: 111 steps /min Normal adult female: 117 steps/min

What are two things you can do to determine if ROM is WNL?

Compare to uninvolved side or compare to a chart of normal values.

What is the close-packed position for the radiohumeral joint?

Elbow flexed 90 ° , forearm supinated 5 °

What is the close-packed position for the ulnohumeral joint (elbow)?

Extension

What is the close-packed position for the radiocarpal joint (wrist)?

Extension with radial deviation

Precautions for MMT

Following neurosurgery Surgery of eye, abdomen, or spinal disc Where fatigue or overwork may worsen the condition

What is the close-packed position for the interphalangeal joint?

Full extension

What is the close-packed position for the knee joint?

Full extension and external rotation of the tibia

What is the loose packed position for the radiohumeral joint?

Full extension, full supination

What is the close-packed position for the hip joint?

Full extension, internal rotation and abduction

What is the close-packed position for the subtalor joint?

Full supination

Describe the Parkinson's Gait:

Gait is shuffling or characterized by short, rapid steps. Patient may lean forward and walk progressively faster, seemingly unable to stop himself (festination).

What gait pathologies do you usually see with a gastroc/soleus contracture?

Gastrocsoleus Contracture (heel cord tightness) -Tibia unable to dorsiflex during stance -Knee joint unable to flex during stance -Knee may be driven in to genu recurvatum -Excess trunk forward lean required to maintain forward progression

Describe the capsular patterns of motion for shoulder:

Glenohumeral: external rotation, abduction (only through 90-120 °range), internal rotation Sternoclavicular/acromioclavicular: pain at extreme range of motion notably horizontal adduction and full elevation

What are the abnormal end feels?

Hard Soft Firm Springy block Empty Spasm

What are the normal end feels?

Hard (Bony) Soft (Soft tissue apposition) Firm (Soft tissue stretch) (Capsular stretch)

What are the high energy phase of gait?

High energy phase (STANCE) 1. Leg is decelerated at time of heel strike 2. Shock is absorbed at time of heel strike 3. Torso balanced at midstance 4. Motion is initiated at push off

What type of gait does someone with Cerebral Palsy usually have?

Hip Abduction Contracture -wider stance and gait -Circumducted gait

Describe an abnormal empty end feel, give an example of this:

If considerable pain is present, there is no sensation felt before the extreme of passive ROM as the patient requests the movement be stopped, this indicates pathology such as an extra-articular abscess, a neoplasm, acute bursitis, joint inflammation, or a fracture.

Contraindications for MMT

If it can disrupt the healing process or result in injury or deterioration of the patient's condition inflammation in the region Inflammatory neuron disease (GB, MS) Severe cardiac or raspatory disease Severe pain

What are the contraindications for goniometry? Give examples.

If muscle contraction (for AROM only) or motion of the part (AROM or PROM) could disrupt the healing process or result in injury or deterioration of the condition. Examples include: •Region of suspected subluxation, dislocation or fracture •s/p surgery or injury if it interrupts the healing process •bone spurs or excessive growth of calcification in muscle suspected or present

Define and give norms when applicable: Step

Initial contact of one leg to initial contact of the opposite leg

What gait pathologies do you usually see in a knee joint flexion contracture?

Involved limb is shorter, and is especially noticeable during stance Unable to completely extend the limb during gait Increase in energy consumption due to greater quadriceps activity during stance

What gait pathologies do you usually see in a knee join extension contracture?

Leg is functionally too long Premature or excessive heel rise on the unaffected side during stance to allow the affected limb to swing through Hip hiking on the affected side during swing Circumduction of the affected side during swing

Interventions for Low MMT scores

Less than 3: NMES, gravity minimized positions, AAROM movements, eccentrically contract muscle 3: motions against gravity with no resistance first Greater than 3: add resistance

What are the low energy phase of gait?

Low energy phase (SWING) 1.Hip flexion initiated 2.Dorsiflexors work in midswing 3.Decelerating swing with hamstrings

Define the make test and the break test. Which type of testing is more common in the clinic?

Make test: in which the resistance must not "break" the muscle contraction so that the patient cannot hold the position. Break test: (more common) in which the therapist gradually decreases the resistance as the limb segment is felt to fall toward the muscle's outer range. If the strength is considered to be a grade 5 or normal, the make test is used, and no effort is made to break the subject's hold.

What is the close-packed position for the talocrural joint?

Maximum dorsiflexion

What is the loose packed position for the subtalar joint?

Midway between extremes of inversion and eversion

What is the loose packed position for the radiocarpal joint (wrist)?

Midway between flexion-extension (so that a straight line passes through the radius and third metacarpal) with slight ulnar deviation.

Describe am Uncompensated Gluteus Medius Gait (Trendelenburg gait pattern):

Occurs when the gluteus medius is weak on one side. A weak gluteus medius on the right results in the left side of the pelvis dropping significantly when the left lower extremity leaves the ground to begin the swing phase. The person shifts their trunk towards the affected side to compensate.

Describe Compensated Gluteus Medius Gait:

Occurs with significant decrease in hip abductor strength. Pelvis on the unaffected side may also drop. Shoulder on the affected side dips significantly, accompanied by a lateral trunk flexion over the affected hip. Trunk rotation may be exaggerated to bring the unaffected hip forward.

Analyze the difference between procedures used to measure length of one joint muscles versus two joint and multi joint muscles.

One Joint: To assess and measure the length of a muscle that crosses one joint, the joint crossed by the muscle is positioned so that the muscle is lengthened across the joint. Example: To test hip adductors, adduct the leg as much as possible. Two Joint Muscle: To assess and measure the length of a two-joint muscle, position one of the joints crossed by the muscle so as to lengthen the muscle across the joint. Then move the second joint through a PROM until the muscle is placed on full stretch and prevents further joint motion. Example: to assess and measure the length of the two joint triceps muscle, place the shoulder in full elevation to stretch the triceps across the shoulder joint. Then flex the elbow to place triceps on full stretch. Multi-joint Muscle: To assess and measure the length of a multi-joint muscle, position all but one of the joints crossed by the muscle so that the muscle is lengthened across the joints. Then move the one remaining joint crossed by the muscle through a PROM, until the muscle is on full stretch and prevents further motion at the joint. Assess and measure the final position of the joint. Example: To assess and measure the length of the multi-joint finger flexor muscles, place the elbow and fingers in full extension to stretch the muscles across these joints. Extend the wrist to place the flexors on full stretch.

What are five common compensations seen when one lower extremity is long?

One could "shorten" the limb by displaying increased flexion of the hip and/or knee during stance phase. One could hyperflex the hip and/or knee during swing phase Circumduction of LE at the hip to functionally shorten the longer leg. Hip hike to clear longer limb in swing phase. One could do nothing and stub their toes or trip a lot

Identify the cause and result of: Antalgic gait

Pain when walking. Results in short, fast step length on affected side to reduce time spent on it.

What happens if you have a bilateral Glueteus Medius gait?

Patient develops as lurch and walk with exaggerated sway.

Describe a Hemiparetic Gait:

Patient usually circumducts affected leg or pushes it ahead of them.

Define and give norms when applicable: Stance time

Reference limb is in contact with the ground -60% of gait cycle

What do you document with MMT?

Side (R/L) Joint Motion MMT Grade Presence of Pain (no need to note if there is no pain)

What are the 2 phases and subphases of gait?

Single Support (Swing) and Double Support (Stance)

What is the loose packed position for the interphalangeal joint?

Slight flexion

What are some common characteristics of people seen with Upper Motor Neuron Legions (Nuero)?

Spasticity Extraneous movements Uncoordinated movements Balance deficits Sensory disturbance / Proprioceptive loss

Describe a "scissoring" gait:

Spasticity in hip adductor muscles resulting in the swing phase leg crossing midline to hit stance leg when walking.

Compare and contrast documentation methods used for range of motion assessment (SFTR, numerical chart).

The SFTR Method: The letters S, F, and T represent the plane of motion (sagittal, frontal, and transverse, respectively) of the joint ROM assessed; To record ROM, the letter identifying the plane of motion or rotational motion is noted. The letter is followed by three numbers that represent the start position, 0 °with normal movement, and the ROM present on either side of the start position. Example: Shoulder left S:60-0-180 °right S:60-0-80 ° Numerical Chart: the ROM is recorded by writing the number of degrees the joint has moved away from 0 ° —for example, Shoulder Flexion= 160 °or 0 °-160 °

Define and give norms when applicable: Step length

The linear distance between two consecutive initial contacts of right and left leg

Describe the capsular patterns of motion for hip:

The order of restriction may vary: flexion, abduction, and internal rotation

Identify the cause and result of: Waddling gait

The presents with shoulders behind the hips when standing with little to no reciprocal pelvis or trunk rotation. To compensate, entire side of the body must swing forward to progress the leg in a waddling motion. Commonly seen in people with muscular dystrophy.

When you measure ROM what should you compare the patient's involved side's measurements to? When would you not do this?

Their uninvolved side. When there are also severe problems with the "uninvolved" side.

Describe the quadriceps gait:

This occurs when quadriceps muscle is weak, resulting in the inability to extend the knee during the stance phase of gait. The body compensates with forward flexion of the trunk and strong plantar flexion of the ankle, resulting in hyperflexion of the knee.

Describe the capsular patterns of motion for knee:

Tibiofemoral joint: flexion, extension

Define and give norms when applicable: Swing time

Time that the reference limb is not in contact with the ground -40% of gait cycle

Explain why it is important to keep the hand relaxed during measurements ofwrist flexion and wrist extension.

To avoid passive insufficiency.

Explain the purpose of MMT:

To evaluate the purpose and strength of muscles and muscle groups.

What are you measuring with MMT?

Torque which allows you to ascertain strength.

Compare the standard terminology of gait with the Rancho Los Amigos terminology.

Traditional Stance Heel strike Foot Flat Midstance Heel-off Toe-off Swing Phase Acceleration Midswing Deceleration Ranchos Los Amigos Stance Phase Initial Contact Loading Response Midtsance Terminal stance Preswing Swing phase Initial swing Midswing Terminal Swing

List the motions being screened in the general scan of the upper and lower extremities.

Upper Scapular abduction Lateral (upward) rotation Shoulder elevation and external rotation Elbow flexion Forearm supination Wrist radial deviation Finger extension Lower Hip flexion Abduction External rotation Knee flexion Ankle dorsiflexion Toe extension Hip adduction Hip internal rotation Knee extension Ankle plantarflexion Toe flexion.

List some two-joint muscles that are present in the upper and lower extremity

Upper: Biceps and triceps Lower: Semimembranosus, Semitendinosus, Biceps femoris, rectus femoris, gastroc

Identify the cause and result of: Hemiplegic gait

Usually result of CVA. The person shifts the body to the uninvolved side to be able to circumduct the involved leg during the swing phase. Circumduction is necessary to compensate for the weak or paralyzed dorsiflexor muscles. The uninvolved leg lands flat-footed or toe first instead of a normal heel strike.

Describe the Gastrocsoleus gait (sore foot limp):

When gastrocnemius or soleus is weak, the ankle displays decreased ability to plantar flex or heel rise at push off. The body compensates by displaying a shortened step length on the affected side.

Precautions for Goniometry: list some examples:

When movement may aggravate the condition. PIMOHHHASFI •Painful conditions •Inflammatory process in or around the joint •Taking pain meds or muscle relaxers •Region of significant osteoporosis •Hypermobile joint •Hemophilia •Region of hematoma •Joints with bony ankylosis •s/p injury with soft tissue disruption (tendon, muscle, ligament) •Region of newly united fracture •After prolonged immobilization

Describe a normal soft (soft tissue apposition) end feel? Give an example of this.

When two body surfaces come together a soft compression of tissue is felt; for example, in passive knee flexion, the soft tissue on the posterior aspects of the calf and thigh come together.

Describe Ataxic Gait:

Wide base of support with jerky and unsteady movements of upper and lower extremities. Difficulty with walking in a straight line and tend to stagger. Drop foot.

Define and give norms when applicable: Width of normal step / base of support (BOS)

Width-distance between midpoint of heel on one foot and same point on other foot

What's the difference between WNL and WFL?

Within Normal Limits: based on the average motion typically seen at that joint. It does not mean that someone is abnormal if they go beyond that value. Within Functional Limits: WFL is the average ROM needed to perform functional tasks.

Define and give norms when applicable: Walking velocity

measure of the body's movement in a given direction (Velocity = Distance/time) Normal adult male: 86 m/min Normal adult female: 77 m/min

Describe Steppage Gait (Foot drop):

occurs when dorsiflexors are weak or paralyzed. Results in the ability to clear the toes during the swing phase. The body compensates by lifting the knees higher to allow the foot drop to clear the floor. Instead of heel strike, there is toe strike.

Describe the capsular patterns of motion for talocrural:

plantarflexion, dorsiflexion

Describe Dorsiflexor Gait (Foot Slap):

the foot slaps onto the ground during heel strike due to weak dorsiflexors that cannot bear the weight of the body during heel strike.

Define and give norms when applicable: Double support

time both feet are on the ground 20% of gait cycle, two periods per cycle

Understand non-pathological factors that could alter the ROM of the joints from the established norms.

• Reading the wrong side of the scale on the goniometer • Having expectations of what the reading "should be" and allowing this to influence the recorded result. • A change in the patient's motivation to perform. • Taking successive ROM measurements at different times of the day. • Measurement procedure error

List non-pathological factors that could alter the ROM of the joints from the established norms.

• Reading the wrong side of the scale on the goniometer • Having expectations of what the reading "should be" and allowing this to influence the recorded result. • A change in the patient's motivation to perform. • Taking successive ROM measurements at different times of the day. • Measurement procedure error

Define non-capsular pattern of restriction:

•A limitation of movement not in the capsular pattern. Due to sprains, adhesions, internal derangement or extra-articular lesions (i.e. bursitis)

Define capsular pattern of restriction:

•A proportional limitation of joint motions that are characteristic to each joint due to a total joint reaction.

List the eight steps of the goniometry procedure:

•Explanation and instruction •The PT will test unaffected side then affected side. •Position (note in chart if alternate positioning is used) Typically want to position against gravity. •Expose area to be measured. Make sure motion is not being blocked by clothing or other devices or pillows. •Stabilize proximal joint segment to help avoid substitute motions. •Align goniometer •Palpate bony landmarks or align arms parallel to longitudinal axis of long bones •Set axis •Set stationary arm •Set movable arm •Assess AROM (if permitted) •Measure end position. •Document AROM or PROM

What measurements do you document (7 things)? Give an example:

•Side: R/L •Joint (i.e. knee) •Direction you are measuring (i.e. flexion) • Type of motion •A/PROM (active or passive) •position (usually only if alternate position used) •presence or absence of pain •Example: R knee flexion AROM=120 deg, no pain; R knee flexion PROM=125 deg, with pain

Why do we measure PROM? (3 reasons)

•To determine amount of movement possible at a joint if active motion is restricted or unable to be assessed •To discern what may be limiting joint movement: End feel •To discern movements that cause or increase pain

Define substituion:

•unwanted motions due to pain, weakness, poor instruction or stabilization by PTA, or soft tissue restriction.