Exam 1 Flashcards
(237 cards)
1
Q
What are the types of clinical reasoning?
A
- Algorithms
- Forward reasoning
- Interactive reasoning
- Conditional reasoning
2
Q
What does HOAC stand for and what is it used for?
A
- Hypothesis oriented algorithm for Clinicians ll
* Method for hypothesis development and provides a good algorithm to use for reflection of clinical practice
3
Q
What occurs with Forward Reasoning?
A
- Have a pre-existing expectation and looking for information that fits
- Uses past experiences
- “If then” pattern recognition
- If x is green then x is a frog
- If x is a frog then x croaks and eats flies
- Need some experience and needs to be careful to make quick judgments or you may miss something
4
Q
What occurs with Backward Reasoning?
A
- Starts with a hypothesis and works backward
- If x croaks and eats flies then x is a frog
- If x is a frog then x is a green
5
Q
What occurs with interactive reasoning?
A
- Teaching, patient focused
- Getting to know the patient and involving them in the problem solving process
- Can be difficult for a novice
6
Q
What occurs with conditional reasoning?
A
- Reflection time
- Good or bad- can invite criticism and make self aware to mistakes that were made
- Exhausting
- Difficult for a novice
- Hallmark of an expert clinician
7
Q
What does the Nagi Model look at?
A
- Pathology
- Impairment
- Functional Limitation
- Disability
8
Q
What does the International Classification of function (ICF) look at?
A
**Ability slant to the Nagi Model
- Body structure and function
- Activity
- Participation
- Contextual factors
9
Q
What does the ICF look at?
A
*focuses on human functioning and provides a unified, standard language and framework that captures how people with a health condition function in their daily life rather than focusing on their diagnosis or the presence or absence of disease.
10
Q
What are the objectives of palpation?
A
- Detect abnormal tissue texture and location
- Detect asymmetries of position
- Detect sensitivity to palpation/pressure
- Detect changes in findings to note improvements/regression of symptoms
11
Q
What is one of the most sensitive parts of the body?
A
The hand
12
Q
What are the phases of palpatory sense?
A
- Reception- proprioception and mechanoreceptors of the hand receive stimulation from the tissues palpated
- Transmission- information transmitted through peripheral and central nervous system to the brain
- Interpretation- this inflammation is analyzed and interpreted
13
Q
What enhances interpretation?
A
Experience!!
14
Q
What parts of the hand are used for specific purposes in palpation?
A
- Thumb and fingertips- pressure probes for differences in depth
- Finger pads- Fine discrimination of textural differences, skin, contour temperature
- Palm of the hand- Stereognostic sense of contour and shape
15
Q
How do you test stereognosis?
A
The patient identifies common objects placed in hands without visual cues
16
Q
What is stereognosis?
A
*The ability to perceive and recognize the form of an object using cues from texture, size, spatial properties
17
Q
What are the principles of palpation?
A
- Move slow
- Avoid excessive pressure- layer your palpation and don’t start deep
- Concentrate/focus
18
Q
What is ACROM?
A
Active range of motion- the arc of motion attained by a subject during unassisted voluntary joint motion
19
Q
What does the AROM allow the examiner to do?
A
- Screen for abnormal movements (quality amongst quantity)
- Assess patients willingness to move
- Assess patients ROM and coordination
20
Q
What does AROM give an idea of?
A
Gives an indication of contractile tissue status
21
Q
What is PROM?
A
Passive range of motion- the arc of motion attained by an examiner without assistance from the subject
22
Q
What does PROM allow the examiner to do?
A
- Detect pain
- Give an indication of true joint mobility
- Assess the tissue that is limiting the motion (end feel)
23
Q
What are 5 end feels and a description of their limitation?
A
- Hard- Bone
- Soft- Soft tissue approximation (muscle)
- Firm- Capsular, ligament, muscle stretch
- Boggy- Edema, synovitis
- Empty- Pain
24
Q
What does PROM provide the examiner information about?
A
- Integrity of joint surfaces
* Extensibility of joint capsule and associated ligaments
25
What is a capsular pattern?
Pathological conditions involving the entire joint capsule cause a particular pattern of restrictions involving all or most of the passive motions of the joint
26
What are the factors affecting ROM?
* Age
* Gender
* Body Mass (adipose tissue or muscle mass)
27
What can goniometry determine?
* A joint position (resting/End Range)
* Total amount of motion available at a joint
* Muscle length
28
What is goniometry used for?
*Used to measure and document the amount of active and passive joint motion
29
What is goniometric validity?
*The degree to which an instrument measures what it is purported to measure: the extent to which it fulfills it's purpose
30
What does most research support when considering goniometric validity?
* Face- the instrument generally appears to measure what it's supposed to measure
* Content- whether or not an instrument adequately measures and represents the domain of content (the substance) of the variable of interest
* Criterion related- Justifies the validity of the instrument by comparing measurements made with the instrument to a well established gold standard of measurement (ex. radiography)
31
What is goniometric reliability?
*the amount of consistency between successive measurements of the same variable on the same subject under same conditions
32
What does goniometric reliability vary upon?
Varies based on the body part being measured
33
How is the reliability for the ROM of the extremities?
Good to excellent reliability
| *Upper > Lower
34
What type of measurements have higher goniometric reliability measurements?
Fixed position measurements have more reliability than motion measurements
35
What is an intrarater and an interrater and which is better for reliability? Also how much deviation is ok in each?
* Intrarater= one examiner (better choice)
- 4-5 degrees deviation by one examiner
* Interrater= two examiners
- 5-7 degrees deviation between examiners
36
How much degree difference is necessary to show true changes?
6-12 degrees
37
How do you improve your reliability?
CONSISTENCY!
* well defined positions
* well defined anatomical landmarks for alignment
* same device to take successive measurements
* same examiner taking successive measurements
* use the device that is suitable in size to the joint being measured (ex. larger for shoulder, hip, knee, elbow, and smaller for wrist, fingers, ankle
38
What are ROM measurement tools?
* Universal goniometer
* Gravity dependent goniometer- pendulum/bubble inclinometer, single/double inclinometer
* Region specific ROM device- CROM/BROM
* Tape measure
* visual estimation
39
What are the characteristics of the Universal Goniometer?
* Most common instrument used to measure joint motion (Clinical > Research)
* Plastic/Metal
* Many different sizes- arms vary from 1-14 inches in length
* Flexible vs rigid
* Built in bubble levels
40
What is the anatomy of a goniometer?
* Stationary Arm- usually placed on the bone proximal to the joint being tested
* Movement Arm- placed distally to the joint being tested
* Fulcrum- placed over the axis (changes during movement)
41
What are the characteristics of an inclinometer?
* Gravity dependent goniometers-
- uses gravity on pointer (pendulum) and fluid levels (bubble) to measure motion
- 360 degree protractor
* Single inclinometer Method
- Good for obtaining total ROM
- Doesn't eliminate compensations (so may need to use 2)
* Digital inclinometer- Android Play Store: Clinometer
42
When and why do you use the double inclinometer Method?
* Better when trying to isolate movement to a specific location (only lumbar ROM minus thoracic, minus hip flexion)
* Elimates compensations
* A little more difficult to perform
43
What are a CROM/BROM and what are they used for?
*Joint specific measurement device
CROM=Cervical
BROM= 'back'/lumbar
*Can be more reliable due to consistency (inter and intra)
44
What is the tape measure typically used for?
* Skin distraction
* Chin to chest
* Finger tip to floor
45
Why do some examiners use visual estimation?
* Some choose to use this over goniometric measurements but NOT recommend: Subjective vs. Objective
* Useful in the learning process and can help reduce errors due to incorrect reading
46
What is the optimal testing position for a patient? what are alternative positions?
OPTIMAL
* Place the joint in starting position of 0 degrees
* Permit complete ROM (against gravity/gravity assist)
* Provide stabilization for the proximal joint segment
ALTERNATIVE
*Needed when the optimal testing positions cannot be attained because of patient limitations
47
What are normal patient testing positions?
* Supine
* Prone
* Sitting
* Standing
48
What is important when testing several joints/motions and why?
*Important to have a planned examination sequence so you avoid having a painful patient move into multiple positions and flare-up
49
Where should you stabilize when assessing ROM?
*Stabilize the patients body and proximal joint so motion can be isolated and a "true measurement" can be read
50
When would you want combined motions to occur when assessing ROM?
*Functional tasks such as shoulder IR/ER, Flex/ABD (GH vs total motion)
51
When documenting ROM what are measurements needed to take and what are they?
* End Position- point in which ROM ended (ex. 145 degree knee flexion)
* Actual ROM- Points measured from (Ex. 0-50 degrees of elbow flexion or 20-70 degrees of elbow flexion)
* Total ROM- The number of degrees actually measured (both of the above examples are 50 degrees total ROM)
52
What is WNL and what does it constitute?
"Within Normal Limits" and constitutes normal pain-free ROM during active or passive motion
53
What are hypo/hypermobile?
* Hypomobile ROM: an elbow that doesn't acheive full extension. Ex. (theta) 0-20-50
* Hypermobile ROM: an elbow that starts in 20 deg hyperextension and ends at 140 deg flexion. Ex. 20-0-140
54
How are muscle length testing measured?
*Measured indirectly by determining the maximal passive motion of the joints crossed by the muscle
55
How do you perform Manual muscle tests and how should they be applied?
* Manual resistance applied to a limb or other body part to objectify strength
* Should be applied slowly, building up, never sudden or uneven
* Applied in the direction of the 'line of pull' of the muscle
* It's important to stabilize proximal segments to avoid substitutions/compensations
* *Very subjective test
56
What are characteristics of Manual Muscle testing?
* can be applied to a general motion (wrist extension)
* Can be more muscle specific (ECRL/ECU)
* When able, compare to uninvolved side
57
What are the grades and descriptions for manual muscle testing?
```
0 = no activity = absent
1 = Trace motion, muscle contracts, no motion = trace
2- = Can't complete full ROM in gravity eliminated position = Poor-
2 = Full ROM, gravity eliminated = Poor
2+ = Full ROM gravity eliminated, less than 1/2 ROM against gravity = Poor+
3- = Full ROM gravity eliminated, more than 1/2 ROM against gravity = Fair-
3 = Full ROM, against gravity = Fair
3+ = Full ROM, against gravity, min resistance = Fair+
4 = Full ROM, against gravity, mod resistance = Good
5 = Full ROM, against gravity, max resistance = Normal
```
58
What is the most commonly used Manual Muscle test and what does it entail?
* Break Test
* The patient is asked to hold body part at mid-point in ROM and to not allow the examiner to "break" the hold by the manual resistance
59
What influences manual muscle testing?
* Positioning- length of the muscle being tested and one vs. two joint muscles
* Proper stabilization
* Where the resistance force is being applied- short vs. long lever arm
* Pain- maybe not just muscle weakness
60
What does pre positioning the muscle influence in MMT?
large influence on strength and can be positioned by patient or therapist
61
What does the length tension curve with MMT show?
* Within about 10% the resting length of the muscle, the tension the muscle exerts is maximum
* At lengths above or below this optimum length the tension decreases
62
Where is resistance usually applied in one and two joint muscles and why?
One joint= applied at end ROM bc it allows for consistency
Two joint = applied at or near mid-range
*Providing resistance at consistent test positions can yield good reliability as well
63
How is most stabilization completed during MMT?
manually by the PT
64
What are characteristics of long lever arm resistance?
* The longer the lever arm the greater the challenge for the muscle being tested
* Longer lever arms may be indicative of more functional demands
65
Where should resistance be applied for a long lever arm in MMT?
*Near the distal end of the segment to which the muscle attaches, but be cautious of excessive strain on the joints caught in the middle
66
What are some noteworthy factors when doing MMT?
* Pain- can be a limiting factor
* Fatigue- testing before vs after exercise
* Sensory loss- if a patient can't feel the resistance you may not have a consistent/accurate assessment
* Hand dominance
* Therapist communication- consistent instruction needed!
* The patient- do they want to show off or seem more impaired than they really are?
67
How would you test and document a patient who had limited knee flexion to 20 degrees?
You would test them in their ROM of 20 degrees and if they can hold a max resistance than they get a 5 MMT
68
What will patients do when they need more strength because they are weak?
They will substitute, whether it's conscious or unconsciously done
69
When is MMT more reliable and valid?
In the presence of profound weakness (neurological condition)
70
What are some limitations to MMT?
* lack of objectivity
* Reliability varies considerably
* lacks sensitivity
71
How do you test using a dynamometer?
* set to second handle position from the inside
* Patient is sitting with their arm resting at side and elbow flexed to 90 degrees, wrist btwn 0-30 deg extension and 0-15 deg ulnar deviation
* Therapist tells patient to squeeze as hard as they can and then records the average of 3 successive trials
72
What are anthropometric measurements and when are they used?
* comparative measurements of the body used in nutritional assessments
* used with infants/children growth and development
* Adults- height, weight, BMI, percent of body fat
73
What are the BMI categories?
Underweight= < 18.5
Normal Weight= 18.5 - 24.9
Overweight= 25 - 29.9
Obesity= BMI of 30 or greater
74
When would a therapist screen both extremities at the same time?
* Speed up the process
* Usually not be stabilized proximally
* Not a "true" assessment
75
If weakness or loss of motion is found when bilaterally screening extremities what should you do?
* Weakness = re-test unilaterally with stabilization to get a more accurate representation of the weakenss
* Loss of motion = re-test motion with same method of quantification
76
Why do we care about posture?
* ROM
* Function
* Breathing
* Pain
* Weakness
* Organ function
* vision
* independence/ mobility for life
77
What positions do we assess posture?
* Statically- standing, sitting, lying down
* Dynamic- Walking, running, jumping
* Should be done from different angles (lateral, front, back)
78
How should a patient be when assessing their posture and what do we look for?
* Must be adequately undressed- first without shoes then with bc they can effect posture
* They should be examined in habitual or relaxed posture
* Look for asymmetry (normal btwn sides)
* Look for muscle wasting, soft tissue swelling, bony englargment
79
What is normal posture and what does it align with?
* The position where minimal stress is applied to each joint
* Straight line passing through:
- earlobe/EAM
- Bodies of cervical vertebra
- Tip of the shoulder
- Midway through the thorax
- Bodies of the lumbar vertebra
- Slightly posterior to hip joint
- Slightly anterior to the axis of the knee joint
- Just anterior to lateral malleolus
80
What are the characteristics of good posture in an anterior view?
* Head is straight
* Tip of nose in line with manubrium and umbilicus
* Upper trap neck line and bulk should be equal, slopes approximately equal
* Shoulders level- dominant side slightly lower
* Clavicles and AC joints level and equal
* Arms equidistant from the waist
* Palms facing the body
* Iliac crests level
* ASIS level
* Patellae point straight ahead
* Knees are straight
* Heads of fibulae are level
* Arches are present in the feet and on the two sides
* Feet angle out equally
81
What questions should you ask when assessing posture anteriorly?
* Is the head tilted- torticollis?
* Is there facial asymmetry?
* Which side is the patients dominant side?
* Any protrusion or depression of ribs?
* Do the hips look level?
* Do they have pronated/supinated feet?
82
What constitutes "good" posture in a posterior view?
* Head is in midline
* Shoulders are level
* Scapular spines and inferior angles are level- the base of spine is at T3/4 and inferior angles at T7
* Medial borders of scapula are equidistant from the spine- 3/4 finger width from spinous processes
* Spine is straight- (posterior line of reference is spine of C7 through the gluteal cleft)
* Ribs are symmetrical on both sides
* Arms are equidistant from the body
* PSIS are level
* Gluteal folds are level
* Knee joints are level
* Both achilles tendons descend straight to calcanei
* Heels are straight
83
What questions would you ask when assessing posture posteriorly?
* Does the head look straight?
* How do the shoulder level compare to the front, is there contour of the upper traps?
* Do the scapula look symmetrical?
* Does the spinal column look straight- scoliosis?
* Is the pelvis level?
* How do the PSIS relate to the ASIS?
* Are the knee creases equal?
* Are the achilles tendons symmetrical?
* What's happening at the rear foot?
84
What type of muscle activation and activity are need for posture muscular activity?
* Muscle activation= isometric
| * Activity= Endurance
85
In a clinic how do they train posture?
*Train core muscles, bracing, 3 sets of 10
But this isn't endurance training so a person needs to get into the position and do activities to increase endurance and increase posture
86
What are some lateral view faulty alignments?
* Hyperlordosis
* Kyphosis
* Kypholordosis
* Flat Back
* Round Back
* Dowager's Hump
87
What are some symptoms/problems with Hyperlordosis?
* Pelvic anterior tilt
* Hip flexion
* Abdominals and hamstrings elongated and weak
* Erector spinae and hip flexors short and strong
88
what are some symptoms/problems with kyphosis/kypholordosis?
* *Increased thoracic curvature that can be accompanied by lumbar lordosis
* Rhomboids are elongated and weak
* Serratus anterior, pec major/minor, teres are short and strong
89
What are some symptoms/problems with Sway Back?
* Spine bends back sharply at the lumbosacral angle which causes entire pelvis to shift forward and puts hips into extension
* Abs and hip flexors are elongated and weak
* The glutes are shortened and strong
90
what are some symptoms/problems with Flat back?
* Decreased pelvic inclination to 20 deg and mobile lumbar spine
* flexors are elongated and weak
* Extensors are short and strong
91
What are some symptoms/problems with Dowager's Hump?
* Often seen in older patient's- especially women
* 1-3 thoracic vertebrae
* Mainly caused by osteoporosis- anterior wedging of the vertebral bodies
* Results in a flexed head and protruding abdomen- maintain center of gravity
* Structural issue bc vertebral bodies are no longer square but wedge shaped
92
What are some anterior view faulty alignments?
* Torticollis
* Lateral Pelvic tilt
* Hip anteversion/retroversion
* Coxa vara/valga
* Genu varum/valgum
* Bowing of tibia
* Foot pronation/supination
93
What are some symptoms/problems with torticollis?
* Can be congenital or acquired, mostly acquired and due to inactivity. In utero if this happens then the muscles don't elongate or develop
* "Scoliosis of the cervical spine"
* Contracted SCM so treatment is to stretch the SCM
94
What are some posterior view faulty alignments?
* Scoliosis
* Do the forward flexion test
* Rearfoot varus/valgus
95
What do you do for the forward flexion test and what does it test for?
* Tests for scoliosis
- ask the patient to flex forward at the hips while both knees are straight and feet together
- is there asymmetry (rib hump)
- Pathological kyphosis
- Lumbar spine straightens/flexes normally
- Any restrictions to forward bending
96
What are symptoms/problems with scoliosis?
*Functional vs. Structural
Functional= caused by postural problems, nerve root irritation, compensation from LLD, contracture (non- progressive)
Structural= bony deformity (congenital or acquired), excessive weakness
-lacks normal flexibility, asymmetrical SB
-Does not disappear on flexion
-Progressive
-Idiopathic accounts for 75-85% of all cases
*Named superior first
*Wedging of the vertebral bodies
*Other changes (shoulder height and scapular position)
97
What are symptoms/problems from a Rib Hump?
* Fixed rotational prominence on the convex side
* Seen when patient flexes forward
* Spine rotates to one side and ribs push out posterior and appear higher
* Narrowing of the thoracic rib cage occurs
* Vital capacity is considerably lowered if the lateral curvature exceeds 60 deg- malposition of organs within the rib cage also occurs
98
What are symptoms/problems with Upper Crossed Syndrome?
* Results from forward head posture
* Loss of lower cervical lordosis
* Extension of upper cervical spine
* Increased kyphosis of cervical thoracic junction
* Internal rotation of shoulder girdles
* Tight pectoralis Major/minor, upper trap, levator scapula, SCM
* Weak deep neck flexors, lower and middle trap, serratus anterior, rhomboids
99
What are some symptoms/problems with Pigeon Chest (pectus carinatum)?
* Sternum projects forward and downward causing protrusion of the sternum and ribs
* Increased in AP diameter
* Congenital deformity
* Restricts ventilation volume
100
What are some symptoms/problems with Funnel Chest?
* Sternum is pushed posterior by overgrowth of the ribs
* AP diameter is decreased
* Congenital deformity
* Heart my be displaced
* Hollow depression on inspiration
101
What are some symptoms/problems with Barrel Chest?
* Sternum projects upward
* Large rib cage, round torso
* Increased AP diameter
* Emphysema patients often have this
102
What is scapular tilting?
When the inferior angle of the scapula pops out due to tightness of pectoralis minor
103
What is scapular winging?
When the weak serratus anterior or palsy/nerve damage to it causes the whole border of the scapula to wing out
104
What muscles are tight during scapular adduction?
rhomboids
105
What muscles are tight during scapular abduction?
Serratus Anterior
106
How can a lower extremity effect posture?
* Leg length difference (LLD)
* Knee hyperextension
* Knee varus/valgus
* Foot pronation/supination
107
What is the difference between a true and apparent LLD?
```
True= There is a bone imbalance
Apparent= Muscle imbalance which causes the appearance of a LLD
```
108
What occurs at the knees, foot, and hip during genu varus and valgus?
Genu Varus- Knees are out, foot is supinated and hips are in ER/retroversion
Genu Valgus- Knees are in, pronated foot, hips in IR
109
What alignments should there be in a sitting posture?
* Ear over acromion
* Slight cervical lordosis
* Retracted scapula in proper position
* Slight thoracic kyphosis
* Slight anterior tilt with lumbar lordosis
110
What should you consider when in sitting posture?
* Femur support
* Lumbar support
* Vision alignment
* Height of seat
* Feet Position
111
What is the capsular pattern of the glenohumeral joint?
*ER > AB > IR
112
What is the capsular pattern of the SC joint?
* Pain at extremes of ROM
| * Horizontal Adduction and full elevation
113
What is the closed pack position of the SC joint?
*Full elevation
114
What is the closed pack position of the AC joint?
*90 degrees of Abduction
115
What is the capsular pattern of the AC joint?
*Pain at extremes of ROM
116
What is the location of the ST joint?
* Sagittal Plane- tipped 10 dg forward
* Transverse Plane- 30 dg anterior to frontal plane
* Frontal Plane- Essentially parallel to vertebral column
117
How many muscles attach to the scapula?
17!!
118
How much upward/downward rotation, protraction/retraction, and elevation/depression are at the scapula?
* Upward/downward rotation = 60 dg
* Protraction/retraction = 15 cm
* Elevation/Depression = 12 cm
119
What does scapulohumeral rhythm allow?
*Allows muscles to maintain good length-tension relationship to minimize active insufficiency
120
When does the 2:1 ratio of scapulohumeral rhythm occur?
* Typically after 30 dg of shoulder elevation
| - 0-30 dg is mostly scapular setting
121
What is the summary of clavicular movement during upward rotation?
* As the scapula upwardly rotates the distal end of the clavicle elevates to 30 dg.
* The costoclavicular and coracoclavicular ligaments become taught and cause a posterior rotation of the clavicle
- Rotates 45 dg to get the final 60 dg of scapular ROM
122
What is the summary of the AC joint movement?
Mainly functions as a pivot point
* 4.3 dg IR
* 14.6 dg upward rotation
* 6.7 dg posterior tilting
123
What is the scapular movement from 0-30 dg?
* Minimal to no scapular movement
* Scapula is setting
* Axis at spine of scapula near vertebral border
124
What is the scapular movement from 30-60 dg?
* Fossa rotates upward with GH joint
| * Axis moves towards the glenoid fossa and is at the AC joint by 90-100 dg of elevation
125
What are the borders of the Axilla?
* Anterior: Pec major and minor, subclavius
* Posterior: Subscapularis, teres major, and latissiumus
* Medial: Serratus anterior, ribs 2-6, intercostals
* Lateral: Bicipital groove, coracobrachialis, short head of biceps
126
What are the contents of the Axilla?
* Lymph nodes
* Brachial Plexus
* Axillary vessels (Vein and artery)
127
What manual muscle tests of the scapula should be performed sitting?
* Scapular Abduction and Upward Rotation
| * Scapular Elevation
128
What manual muscle tests of the scapula should be performed in prone?
* Scapular adduction
* Scapular depression and adduction
* Scapular depression and downward rotation
* Scapular depression
129
what can be palpated on the Bony anterior aspect of the neck?
* C1 transverse process
* Hyoid Bone
* Thyroid cartilage
* First Cricoid Ring
* Carotid Tubercle
130
How do you palpate the Hyoid bone?
* Ask the patient to swallow while hand is cupped around anterior portion of neck, palpate just below chin
* Level with C3
131
How do you palpate the Thyroid Cartilage?
* Inferior to the hyoid, notch will be palpable then feel above and below
* Upper portion "Adams Apple" level with C4
* Lower portion is level with C5
132
How do you palpate the First Cricoid Ring?
* Immediately inferior to thyroid cartilage
* Use light pressure, don't gag
* Level with C6
133
How do you palpate the Carotid Tubercle?
* Laterally about 1 inch from First Cricoid Ring
* Anterior tubercle of C6 transverse process
* Palpable deep under muscles
- can come in laterally to contact TP and the move anterior while staying under the musculature
* Palpate separately!
- Both at the same time could restrict blood flow of both carotid arteries that run adjacent to the tubercles
134
How do you palpate the SCM?
* In supine as patient turn their head to opposite side that is being palpated (can have them attempt to raise head from table to make if more prominent)
* Trace the muscle from it's origin to insertion
* Palpate both sides to compare
135
How do you palpate the thyroid gland?
* Below Adams Apple
* Overlies the trachea in a H pattern
* Normal Gland is smooth and indistinct
136
How do you palpate the Parotid gland?
* Partially covers angle of mandible
* Not distinctly palpable, if normal the angle will feel sharp/bony
* If abnormal, will feel boggy/soft
137
How do you palpate the supraclavicular Fossa?
* Superior to clavicle and lateral to suprasternal notch
- Normal is a smooth indentation
- Englargement/swelling coud be from edema secondary to trauma, lumps may be due to enlarged lymph glands
- Abnormal cervical rib may be felt here
- Platysa crosses but does not fill
- Cupola (dome) of the lung extends into fossa and sometimes injured by puncture wounds or clavicle fracture
138
How do you palpate the spinous processes of cervical vertebrae?
* Posterior to midline of cervical spine
* No muscles cross midline so it's indented
- Tissue buldges lateral to spinous processes are deep paraspinals and superficial trapezius
- Start at base of skull
- First palpable spinous process is C2
- Note normal lordosis
- C7 and T1 are larger
- Normally in line but slight anatomical variations due exist
- Not necessarily "rotated"
139
How do you palpate the cervical facet joints?
* Move fingers laterally approx 1 inch
* Feel for the facets between the cervical vertebrae
- Small domes- layer your palpation to make sure you are "Down to the bone"
* Patient needs to be relaxed
* Palpate these bilaterally down to C7 and T1
140
What is the AROM in the Upper cervical spine?
* C0/1 and C1/2
- Flexion: 0-10/15 dg
- Extension: 0- <30 dg
- Coupled SB/Rotation
- Non-coupled SB/Rotation
141
What is the AROM in the lower cervical spine?
* C2/3 to C7/T1
- Flexion: 0-35/45 dg
- Extension: 0- <30 dg
- Side bending
- Rotation
- Coupled SB/rotation
- Non-coupled SB/rotation
142
Between C1/C2 What percentage of cervical rotation occurs and what is the degree?
* 50% of cervical rotation occurs here
| * 35-45 dg occurs here
143
What are the norms of combined cervical ROM with goniometer?
```
Flexion: 0-40 dg
Extension: 0-50 dg
Lateral Flexion: 0-22 dg SD 7-8 dg
Rotation: L 49 dg, R 51 dg
70-90 dg
```
144
What two things do the craniocervical flexion test assess?
- Uses a stabilizer (pressure cuff) placed under neck about to occiput to assess deep cervical flexors
* *The strategy to perform upper cervical flexion
* *Isometric endurance of deep cervical flexors
145
What does the Neck flexor endurance test do?
* Uses observation of neck folds and placement of therapists hand under the occiput to assess cervical endurance
* Involves superficial cervical muscles but still assessing control of deep cervical flexors
146
In the craniocervical flexion test Stage one, how is it performed?
Stage one: Analysis of performance
* Patient supine, hook-lying with pressure biofeedback under neck just about to the occiput pumped to 20 mmHg
* Patient requested to "Say Yes" so they slide the back of the head up the bed with a head-nod action to elevate the pressure from 20 to 22 mmHg
* Hold 2-3 seconds then relax to starting position
* Repeated through 2 mmHg increment to 30 mmHg
* Tester analyses the motion and palpates the activity of SCM or anterior scalenes (minimal activity until last 1-2 stages)
147
What are signs of abnormal patterns/poor activation of DNF when doing the craniocervical flexion test in stage one?
* Range of head rotation does not increased with increments
* Movement strategy is more head retraction
* Patient lifts the head in attempts to reach target pressures
* Movement is performed too quickly (speed)
* Palpable activity of superficial flexors or hyoid muscles in 1st 3 stages.
* Pressure dial does not return to starting position (Greater than 20 mmHg)
148
What is the baseline assessment for the craniocervical flexion test in stage one?
*the stage of the test (increment) that the patient can acheive for the 2-3 seconds with correct movement without palpable activity
149
What occurs during Stage 2 of the craniocervical flexion test?
Stage 2: Isometric Endurance
* Patient performs head nod into first target pressure (22 mmHg) and holds for 10 seconds
* If the patient can perform at least 3 repetitions of 10 second holds without substitutions, it's progressed to the next target pressure
* Therapist monitors movement strategy and pressure
150
What are the signs of reduced endurance during stage 2 of the craniocervical flexion test?
* Patient cannot hold the pressure steady
- Decreases even though they seem to be holding the head in the flexed position
* Over recruitment of superficial flexors
* Pressure level is held but with a jerky action
- Suggests an alternate muscle is being used to hold the pressure (weakness of deep cervical flexors)
151
What is the baseline for stage 2 in the craniocervical flexion test?
The pressure level that the patient can hold steady for the repeated 10-second holds with minimal superficial muscle activity and absence of any other substitution strategies
152
How is the Neck flexor endurance test performed?
* In supine hook-lying with hands on stomach
* Patient performs a "chin tuck" or upper cervical flexion and raises head from table approximately 1 inch
* Therapist starts a timer while he places his hands under occiput and observes anterior neck skin folds
- Preferred way is to use a skin crayon to draw a line across the folds
153
When would you terminate the neck flexor endurance test?
Terminate the test if:
* Edges of the lines drawn no longer touched for more than 1 second
* Subjects head touched the raters hand for more than 1 second
154
What are the norms for the neck flexor endurance test?
Norms:
* Patients without neck pain = 38.95 seconds
* Patient with neck pain = 24.1 seconds
155
What does the somatosensory system do?
* Receives information from the environment
| * Testing how well the individual receives the necessary information
156
What are the purposes of the sensory exam?
* Identify a pattern of loss
* Identify which sensations are affected
* identify the degree to which sensations are limited
157
What do our exam results of a sensory exam affect?
* Interventions
- With modality issues a person can't tell if they're being burned or not
* Goal setting
* Patient/family education
* Discharge Planning
- What things do we need to tell them to do when they're at home so they're safe and healthy?
158
What patterns of sensory loss are tested for?
* CNS/other systems
* Glove-stocking or body segment
* Peripheral nerve
* Dermatomal
159
What is motor testing for?
* Assessing the efferent response to a stimuli
* Stimuli used:
- Isometric resistance to movement: myotomes
- Deep tendon reflexes
* Myotomes
- Representative muscle of a single nerve root
160
What are the components of sensory testing?
* Cranial nerve testing
* Sensory testing
- Peripheral nerve distribution
- Spinal nerve (dermatome) distribution
* Myotome testing
* Reflexes
- Cranial nerve reflexes: Jaw reflex
- Upper motor neuron reflex testing: Hoffman's, Babinski, Clonus
- Deep tendon reflex testing: UE and LE
161
What is the purpose of a quick screen cranial nerve test?
*Determine if a full cranial nerve screen is necessary
162
What is a dermatome?
* Area of skin supplied by a single spinal nerve segment
| * Ex. C4 is top of shoulders, C5 is deltoid area
163
How do you test for a peripheral nerve?
*Test sensation in areas in which the nerve roots reside
164
How do you test a spinal nerve root?
*Test area corresponding to that nerve root
165
What can cause spinal nerve impingement?
* Disc protrusion
* Foramen closing/narrowing
* Tumor or growth
166
What is affected with a C5 nerve root impingement?
*Motor: Deltoid and biceps weakness
*Reflex: Biceps
Sensation: Lateral upper arm/deltoid
167
What is affected with a C6 nerve root impingement?
Motor: Biceps and Wrist extensors
Reflex: Brachioradialis
Sensation: lateral forearm and thumb
168
What is affected with a C7 nerve root impingement?
Motor: Wrist flexors
Reflex: Triceps
Sensation: Middle 3 fingers and part of palm
169
What is affected with a C8 nerve root impingement?
Motor: Finger flexors
Reflex: No DTR associated
Sensation: medial side of forearm and pinky finger
170
What is affected with a T1 nerve root impingement?
Motor: Interossei
Reflex: No DTR associated
Sensation: Medial upper arm
171
What is affected with a L4 nerve root impingement?
Motor: Tibialis Anterior
Reflex: Patellar tendon
Sensation: Medial Portion of the foot and towards the big toe medial surface
172
What is affected with a L5 Nerve root impingement?
motor: Extensor digitorum longus (check for extension of big toe)
Reflex: No DTR associated
Sensation: Over the top of the foot
173
What is affected with a S1 nerve root impingement?
Motor: Peroneus Longus
Reflex: Achilles Tendon
Sensation: Lateral aspect of foot and up the back of the leg a little
174
What are you looking for with axillary nerve peripheral nerve distribution (PND)?
Spinal Nerve Root: C5, C6
Sensation: Lower deltoid area (badge)
Looking for Motor weakness: Teres minor, deltoid
175
What are you looking for with Musculocutaneous PND?
*Injuries rare
Spinal nerve roots: C5-7
Sensation: lateral forearm
Motor: Coracobrachialis, biceps, brachialis
176
What are you looking for with Radial nerve PND?
Spinal nerve roots: C5-T1
Sensation: Back of arm, hand
Motor: elbow extension, wrist and finger extension, supination
177
What are you looking for with median nerve PND?
Spinal Nerve roots: C6-T1
Sensation: Volar surface digits of 1,2,3 and 1/2 of 4
Motor: Pronation, wrist flexion, long finger flexors
178
What are you looking for with Ulnar nerve PND?
Spinal nerve roots: C8-T1
Sensation: Volar/dorsal surface of digits 4,5
Motor: Little finger abduction, interossei, wrist flexion, finger flexion 4,5
*Injury at elbow is more common
179
What are you looking for with Femoral nerve PND?
Spinal nerve roots: L2-L4
Sensation: Anterior thigh and medial lower leg/foot
Motor: Hip flexion, knee extension
180
What are you looking for with Tibial nerve PND?
Spinal Nerve roots: L4-S3
Sensation: Posterior/Lateral leg, sole, heel
Motor: Ankle plantarflexion, inversion, toe flexion
181
What are you looking for with Common Peroneal Nerve PND?
Spinal Nerve roots: L4-S2
Sensation: Lateral leg (Superficial peroneal nerve), Lateral aspect of knee and skin between big toe and 2nd toe (deep peroneal nerve)
Motor: Superficial= eversion, Deep= dorsiflexion, toe extension
*Injury = Foot Drop
182
What does a stocking/glove pattern of sensory loss might mean?
* Diabetic neuropathy
* Cortical Lesion
*Doesn't follow dermatome or peripheral nerve pattern
183
In which direction do you go when mapping the borders of sensory loss?
*You map distal to proximal
184
What tests can be done to test for which sensations are impaired?
* Hot/cold
* Proprioception
* Light touch
* vibration
* sharp/dull
185
What are the types of sensation?
* light touch
* Pressure
* Sharp/dull pain
* Deep bone vibration
* Temperature
* Point localization
* Proprioception
* Kinesthesia
* Tactile localization
* Two point discrimination
186
What are the degrees of sensory deficits?
* Absent
* Intact
* Impaired = partial loss/increased sensitivity
187
How do you do a sensory examination?
* Non-impaired followed by impaired
* Superficial to deep
* Distal to proximal (most for neural evaluation, esp. UMN)
* Randomly with variation in timing
188
How do you improve reliability in a sensory exam?
* Use of consistent guidelines
* Administration of tests by trained, skillful examiner
* Subsequent retests by same individuals
* Ensure patient's understanding of test and ability to communicate
* never use your fingers bc of temperature sensation
189
What are the purposes of a motor exam?
* Identify the pattern of strength loss
| * Identify the degree to which strength is limited
190
What are the procedures during muscle testing?
* Isometric hold of the muscle groups supplied by a particular myotome (nerve root) or peripheral nerve
* Use myotome key muscles testing if suspect nerve root compression or SCI
* Use peripheral nerve muscle testing if a peripheral nerve lesion is suspected
191
What is the myotome for C5?
* Shoulder abduction
| * Elbow flexion
192
What is the myotome for C6?
* Elbow flexion
| * Wrist extension
193
What is the myotome for C7?
* Elbow extension
* Wrist flexion
* finger extension
194
What is the myotome for C8?
* Finger abduction/adduction
* DIP flexion of middle finger, finger flexion/wrist flexion
* Thumb ABD
195
What is the myotome for T1?
* ABD and ADD of fingers
| * ABD of little finger
196
What is the myotome for C4?
*Shoulder elevation/shrug
197
What is the myotome for L2?
*Hip flexion
198
What is the myotome for L3?
*Knee extension
199
What is the myotome for L4?
*Ankle dorsiflexion
200
What is the myotome for L5?
*Great toe extension
201
What is the myotome for S1?
* Ankle plantar flexion
| * Eversion
202
What is the myotome for S2?
*Knee flexion
203
What are Deep Tendon Reflexes?
* Reflex arc from the muscle spindle to the spinal cord (Ia phasic) and output back to the same muscle (agonist muscle fibers)
* Loss or diminished conductivity in the DTR is abnormal
* Do it 3 times to make sure the recovery time is good
204
What are the UE DTRs?
* C5 = biceps
* C6 = Brachioradialis
* C7 = Triceps
205
What are the LE DTRs?
* L3-L4 = Quadriceps
* L5- S1 = Hamstrings
* S1-S2 = Achilles
206
What is Hoffman's reflex and what is a positive test?
* Technique: Hold the middle finger, flick the distal end
| * + Test: IP joint of thumb on same hand flexes
207
What is the Babinski Reflex and what is a positive test?
* Technique: Stroke the bottom of the foot from a lateral (heel) to medial (toe) direction
* + Test: First toe extends and the other four toes fan outward
- Indicates a presence of an abnormal reflex
208
What can affect peripheral nerve distribution?
* Sever, crush, or damage nerve
* Impingement
* Bell's Palsy
* Peripheral vestibular disorders
209
What can affect dermatomal distribution?
* SCI
* Tumor at the nerve roots
* Trauma nerve roots
* Impingement nerve roots
210
What can affect Body segment distribution?
* Metabolic disturbances (diabetes, alcoholism, hypothyroidism)
* Lyme's disease
* Burns
* Toxins
* Nutritional Deficits
* CVA
* TBI
* MS
211
When documenting the degree or severity of involvement in a motor/sensory exam what should be included?
* Absent
* Impaired
* Hypersensitive
* % accuracy
* Delayed
* Patient subjective report
212
When documenting the body area affected what should be included?
* Right/Left
* UE/LE
* Trunk
* Face
213
When documenting the modality tested what should be included?
* Light touch
* Sharp/dull
* Proprioception
* Tactile localization
* Temperature
* Deep pressure
* Myotome
* Vibration
214
What are the 3 joints of the elbow?
* Humeral Ulnar
* Humeral Radial
* Proximal Radioulnar
215
What direction is the axis of movement of the humeroulnar joint?
*It is a hinge joint and moves downward and medial and responsible for the carrying angle
216
What is the resting position of the humeroulnar joint?
*70 dg flexion and 10 dg supination (from neutral)
217
What is the closed pack position and capsular pattern of the humeroulnar joint?
* Closed pack position: Full extension and supination
| * Capsular pattern: flexion, extension (% of flexion lost is less than extension)
218
What are the bony landmarks of the humeroulnar joint?
*Trochlea of the humerus and trochlear notch of the ulna
219
What kind of joint is the humeroradial joint and what are the bony landmarks?
* It's a uniaxial synovial hinge joint
| * Bony Landmarks: Capitulum of the humerus and the head of radius
220
What is the resting position, closed pack position, and capsular pattern of the humeroradial joint?
* Resting Position: Full extension and supination
* Closed pack position: Elbow flexed to 90 dg supinated to 5 dg (radial head closest to capitulum)
* Capsular Pattern: Flexion, extension
221
What kind of joint is the proximal radioulnar joint and what are the bony landmarks?
* Uniaxial Pivot Joint
| * Bony Landmarks: Head of radius on the radial notch of ulna
222
What is the resting position, closed pack position, and capsular pattern of the proximal radioulnar joint?
* Resting Position: 70 dg elbow flexion, 35 dg supination
* Closed pack position: 5 dg supination
* Capsular Pattern: Equal limitation of supination and pronation
223
What is carrying angle?
* Angle of intersection between a line connecting the midpoints in the humerus and the proximal ulna long axis of the humerus and long axis of the ulna
* Should be symmetrical bilaterally
* Necessary to have forearm clear the body when carrying an object in the hand
224
What is the normal, valgus, and varus carrying angles?
* Normal: males = 5-10 dg, females = 10-15 dg
* Cubital Valgus: angle greater than 15 dg
* Cubital Varus: angle is less than 5 dg
225
What is the triangle sign?
* Relationship of medial and lateral epicondyle and the olecranon
- view both flexion and extension of the elbow
- Flexion: these three points will form an equilateral triangle
- Extension: these three points should be in a straight line
226
What can a protective posture suggest?
* Sign of pain, may have swelling in the elbow joint
| * can be an olecranon bursitis
227
What muscles originate on the lateral supracondylar ridge?
*From superior to inferior it's Brachioradialis, ECRL, ECRB (which is actually on the epicondyle)
228
How do you confirm if you are palpating the head of the humerus?
*You ask the patient to pronate and supinate so you feel the head spin under your fingers
229
What is the cubital tunnel made up of?
*Medial epicondyle, olecranon process, and tendinous arch of the flexor carpi ulnaris
230
How do you palpate the ECRL and ECRB?
*Clench fist and/or resist extension and radial deviation
231
How do you palpate the Extensor digitorum communis?
*Extend fingers
232
How do you palpate the Extensor Carpi Ulnaris?
*Extend and ulnarly deviate
233
How do you palpate the Extensor digiti mini?
*Extend pinky
234
What are the borders of the cubital fossa?
* Medial Border: Pronator Teres
* Lateral Border: Brachioradialis
* Superior Border: Imaginary line btwn epicondyles
235
What are the contents of the cubital fossa?
* Biceps Brachii Tendon
* Brachial Artery
* Median Nerve
236
How do you test for Hypermobility?
* Beighton's Test
* Quick and straightforward
* By itself a high score does not mean there is hypermobility syndrome, need other symptoms and signs
* A low score should be considered with caution; numerous sites are not "counted" in the score
237
What are the scoring system in the Beighton's test?
* 1 point if palms on ground and legs straight
* 1 point for each elbow that bends backwards
* 1 Point for each knee that bends backwards
* 1 point for each thumb that touches forearm
* 1 point for each little finger that bends >90 dg
*Total score: 9
