Flashcards in Final Deck (218)
What is gait?
The manner in which a person walks
What is a step?
From the heel strike of one foot to the next heel strike of the contralateral (opposite) foot
What is step length?
The distance between steps
What is a stride?
From the heel strike of one foot to the next heel strike of the ipsilateral (same) heel strike. (lasts 1 sec)
What is speed?
The rate of linear forward motion of the body
What is cadence?
The number of steps taken per unit of time. Steps/min
What is the general cadence for adult men
What is the general cadence for adult women
What is the general cadence for start of jogging/running
How do you increase gait speed?
By increasing stride length, & cadence
What is a step width?
The linear distance between midpoint of heel of one foot and the same point on the other foot completing the step.
What is the general step width?
Usually 3 and half inches, but can vary from 1-5 inches
The step width is ____ in elderly and infants
What are the phases of the gait cycle?
Initial contact, loading response, mid-stance, terminal stance, pre-swing, initial swing, mid-swing, and terminal swing
What percent is the stance phase of the total gait cycle?
What percent is the swing phase of the total gait cycle?
What is initial contact in the phases of gait?
The moment when the foot contacts the ground
What is loading response in the phases of gait?
Weight rapidly transferred onto outstretched limb
What is mid stance in the phases of gait?
Body progresses over a single, stable limb
What is terminal stance in the phases of gait?
Body moves ahead of limb and weight is transferred to forefoot. Rapid unloading of limb occurs as weight is transferred to contralateral(opposite) limb
What is pre-swing in the phases of gait?
Rapid unloading of limb occurs as weight is transferred to contralateral limb
What is initial swing in the phases of gait?
Thigh begins to advance as foot comes off the floor
What is mid swing in the phases of gait?
Thigh continues to advance as the knee begins to extend
What is terminal swing in the phases of gait?
Knee extends as the limb prepares for the contact with the ground.
What is happening in the other limb when the reference limb is going through initial contact and loading response?
What is happening in the other limb when the reference limb is going through mid-stance?
Initial swing and 1st part of mid swing
What is happening in the other limb when the reference limb is going through terminal stance?
2nd part of mid swing and terminal swing
What is happening in the other limb when the reference limb is going through pre- swing?
Initial contact and loading response
What is happening in the other limb when the reference limb is going through initial swing and 1st part of mid-swing?
What is happening in the other limb when the reference limb is going through 2nd part of mid-swing and terminal swing?
Loading response(2nd phase) begins with ____ and ends with __
Begins with foot contact and ends with opposite limb toe off
Mid stance(3rd phase) begins with ___ and ends with ___
Begins with opposite limb toe off and ends with ipsilateral heel rise
Terminal stance(4th phase) begins with ___ and ends with ____
Begins with ipsilateral heel rise and ends with opposite limb foot contact
Pre swing starts(5th phase) with __ and ends with ___
Starts with opposite foot contact and ends with ipsilateral toe off
Initial swing (6th phase) starts with ___ and ends with ____
Starts with ipsilateral toe off and ends when the medial malleoli are aligned
Mid swing (7th phase) begins with ___ and ends with ____
Begins with the medial malleoli aligned and ends when the ipsilateral tibia is perpendicular to the ground
Terminal swing (8th phase) begins with ___ and ends with ___
Begins with the tibia perpendicular to the floor and ends when the ipsilateral foot strikes the floor
Where should the PT be positioned during gait training?
Behind the patient and to the side that is being treated. Place one hand with a supinated grip and the other hand in front of the shoulder
What assistive devices should be used with 3-point gait?
Crutches or walker
Assisted devices to use for a patient that has one leg affected and full weight bearing on the other leg is ___
Crutches or a front wheeled walker
Where in the 5 elements of patient management does the subjective exam fall?
Examination and evaluation
What is the primary objective of the initial PT visit called?
Phase 1 differential diagnosis
What question is asked in the Phase 1 differential diagnosis?
Does this patient belong in my clinic?
Will the subjective exam ever need to come back in play?
What is the typical subjective exam flow?
1. Review Baseline Information/Chart Review
2. Establish Rapport
3. Gather General Information
4.Analyze Information/ Hypothesis Generation
5. Gather Specific Information
6. Plan Objective Exam
80% of info needed to make a diagnosis is contained in the ___
What happens in the Review Baseline Information/Chart Review of the subjective exam flow?
• Provides needed information, like:
- General Health Status
- Imaging findings
- Operative reports
- Past medical history and/or treatments
What part of the subjective flow may be the examination?
Review Baseline Information/Chart Review
What happens in the Establish Rapport of the subjective exam flow?
• Welcoming introductions
• Establish effective communication and
• Explanation of perspective
• Clarification of patient expectations
• Sequence of first session – exam process and patients role
What happens in the gather general information step of the subjective exam flow?
• Patient profile (age, gender...)
• Chief complaint
• Body chart
• Present Episode
• Past History
• Aggravating/Easing Factors
• Relationship between regions
• 24-hour behavior
• Patient Goals
• Patient Expectations
The ___ fills out the body chart
Problem area characteristics of of the body chart
• Location of each area of pain / symptoms
• Quality / Type of symptoms
• Depth of symptoms
• Frequency / Constancy of symptoms
• Relationships between areas of symptoms
• Clearing relevant areas
What are the two pain rating scales?
- Numerical Pain Rating Scale (NPRS): o a scale of 1-10
- Visual Analog Scale (VAS) for pain
Which pain rating scale is used the most?
What are radicular symptoms?
direct stimulation of a nerve root results
in a sharp, lancinating pain, well-localized to the dermatome.
What is a visceral referral symptom?
kidney, pancreas, cardiac, etc. - can mimic or masquerade as musculoskeletal pain.
What is a somatic referral symptom?
symptoms that arise from referral of a
musculoskeletal structure (i.e. facet jt.)
What is a trigger point symptom?
hypersensitive spot typically in skeletal muscle that can be associated with a taut band
What happens in the gather specific information step of the subjective exam flow?
• Date of onset
• Mode of onset (injury, any precipitating factors?)
• Gradual onset
• Sudden onset
• Immediate or delayed symptoms after injury?
• Pain and Swelling
• Are symptoms getting better, worse, or status quo?
• Any treatment to date? Effects?
• 24-hour behavior
What are the two factors of the behavior of symptoms that are very important?
- Aggravating and easing factors
What is a systems review?
Where we are asking questions that relate to the different systems of a given patient
What does a systems review do?
It helps us identify red flags
What are red flags?
Signs and/or symptoms that may warrant immediate communication with the referring provider or may warrant a referral/consultation to another healthcare practitioner
The present of a single red flag is usually ____ and must be ___
Not much of a concern, and must be put into context with the rest of the patient's presentation(age, gender, med history...)
What is a category 1 red flag?
Factors that require immediate medical attention
What is a category 2 red flag?
Factors that require subjective questioning and precautionary examination and treatment procedures
What is a category 3 red flag?
Factors that require further physical testing and differential analysis
What is a yellow flag?
Factors that increase the risk of developing, or perpetuating long-term disability and work loss
A yellow flag may warrant ___
May warrant a referral/consultation to a mental health practitioner
Examples of a yellow flag
• Fear avoidant behavior
• Pain catastrophizing
• Loss of pleasure in doing things, feeling hopeless
• High levels of anxiety
• Suicidal ideation
What do we do to further refine our hypothesis of a patient?
What does SINSS stand for?
What is severity?
The intensity of the patients symptoms as they relate to a functional activity
How is severity rated?
• Minimal = Minimal to no pain (0-3/10), symptoms do not limit or hinder activity
• Moderate = Pain reduces activity levels to 40-70% of normal, pain
rated at 4-7/10
• High = Pain symptoms severely reduce or stop activities; ADLs are
are avoided or severely limited, pain rated at 8-10/10
What is irritability?
Time for symptoms to come on and go away
How is irritability rated?
• Low = Tolerates repetitive or sustained activities, can cont. activity after the onset of pain, pain eases in short amount of time
• Moderate = Tolerates brief activities or positions < 10 min, cont. light activities after the onset of pain, pain eases in similar time as onset (may be longer)
• High = Activity not tolerated – are avoided, unable to continue activity after the onset of pain, symptoms takes a long time to ease (>30 minutes)
What are the two types of nature of a pain?
• Musculoskeletal vs. Non-Musculoskeletal
The type of pain often relays information to the clinician regarding the _____
type of tissue involved
The nature of pain is a reflection of ____
differential diagnosis and systems review
What is the stage?
Time frame since the onset of symptoms
What are the stages of pain?
• Acute pain: Recent onset (0-6 weeks)
• Sub-acute pain: Pain may be due to later stages of tissue healing or early stages of developing chronic symptoms (6-12 weeks).
• Chronic pain: Longer duration – usually past expected recovery time
(> 3 months)
What is stability?
The progression of the patients pain (or symptoms) over time
What are the ways to classify the stability of a patient's pain?
Is the patients pain:
• Getting better
• Staying the same
• Getting worse
If a patient has a high severity & irritability we may ____
Limit the SINSS, so as to not make them worse
If a patient has a low irritability we may ____
Not limit the exam, so as to reproduce the symptomsNot limit the exam, so as to reproduce the symptoms
Other things SINSS helps us understand
- Contraindications to the examination?
- Vigor of exam?
- Which structures will I examine?
- Will I do a neurological exam?
- Which examination techniques will I perform?
What are the reasons to screen a patient?
• Sicker patient/client base: more comorbidities
• Quicker: earlier mobility/discharge of hospital pts same day
• Disease progression
• Patient/client disclosure
• Presence of one or more yellow (caution) or red (warning) flags
• Direct Access: people coming off the street
What is direct access?
The right of the public to obtain examination, evaluation and intervention from a licensed PT w/out previous examination by or referral from a physician, gatekeeper or other practitioner
What is primary care?
“…integrated, accessible healthcare by clinicians
who are accountable for addressing a large
majority of personal health care needs,
developing sustained partnerships with
What is a diagnosis?
Recognition of disease/disorder usually via a collection of relevant signs and symptoms
What is a differential diagnosis?
Systematic method to identify the cause
(MSK or non-MSK) of a patient’s symptoms
What is a prognosis?
Predicted optimal level of improvement in function taking in consideration of comorbidities, motivation, psychosocial
factors, patient values/goals
What are constitutional signs?
are general signs/symptoms that are present when illness is present
What are the means of communication?
Verbal cues convey ___ of the message
Vocal cues are __ of communication
Facial cues are __of communication
What is effective communication?
Message sent = message received.
New information makes sense to a person by
comparing it to what is already in their minds
Sources of communication error
• Psychological (listener)
• Speech (speaker)
• Speak slowly
• Speak deliberately
• Keep questions short
• Ask one question at a time
• Begin with open-ended and non-leading questions
• PAUSE – wait for and LISTEN TO response
• Confirm understanding with restatement or
What are open ended questions?
Questions that allows the patient elaborate on their answers
Definition of encoding barriers?
The process of selecting and organizing symbols to represent a message requires skill and knowledge.
What are the obstacles that can interfere with an effective message?
- Lack of Sensitivity to Receiver
- Lack of Basic Communication Skills
- Insufficient Knowledge of the Subject.
- Information Overload
- . Emotional Interference
Transmitting barriers are...
Things that get in the way of message transmission are sometimes called
Types transmitting barriers
- Physical Distractions
- Conflicting Messages
- Channel Barriers
- Long Communication Chain
Decoding Barriers. The communication cycle may break down at the receiving end for some of these
- Lack of Interest
- Lack of Knowledge
- Lack of Communication Skills
- Emotional Distractions
- Physical Distractions
Responding Barriers—The communication cycle may be broken if feedback is unsuccessful:
- No Provision for Feedback
- Inadequate Feedback
What are the 4 categories of non-verbal communication?
What is physical non- verbal communication?
This is the personal type of communication. It includes facial expressions, tone of voice, sense of touch, sense of smell, and body motions.
What is aesthetic non- verbal communication?
This is the type of communication that takes place through creative expressions: playing instrumental music, dancing, painting and sculpturing
What is signs non- verbal communication?
This is the mechanical type of communication, which includes the use of signal flags, the
21-gun salute, horns, and sirens
What is symbolic non- verbal communication?
This is the type of communication that makes use of religious, status, or ego-building symbols.
What are the static features of non- verbal communication?
Static feature: Distance is characterized by...
The distance one stands from another frequently conveys a non-verbal message. In
some cultures it is a sign of attraction, while in others it may reflect status or the intensity of the exchange.
Static feature: orientation is characterized by...
People may present themselves in various ways: face-to-face, side-to-side, or even back-to-back. For example, cooperating people are likely to sit side-by-side while competitors
frequently face one another
Static feature: posture is characterized by...
Are we slouched or erect? Are our legs crossed or our arms
folded ? Such postures convey a degree of formality and the degree of relaxation in the
Static feature: physical contact is characterized by...
Shaking hands, touching, holding, embracing, pushing, or patting on the back
all convey messages. They reflect an element of intimacy or a feeling of (or lack of) attraction.
What are the dynamic features of non- verbal communication?
- Facial expressions
Dynamic feature: facial expressions is characterized by...
A smile, frown, raised eyebrow, yawn, and sneer all convey information. Facial expressions continually change during interaction and are monitored constantly by the recipient. There is evidence that the meaning of these expressions may be similar across cultures.
Dynamic feature: gestures is characterized by...
One of the most frequently observed, but least understood, cues is a hand movement. Most people use hand movements regularly when talking. While some gestures (e.g., a clenched
fist) have universal meanings, most of the others are individually learned and idiosyncratic.
Dynamic feature: looking is characterized by...
A major feature of social communication is eye contact. It can convey emotion, signal
when to talk or finish, or aversion. The frequency of contact may suggest either interest or boredom.
Definition of non-verbal communication according to Tortoriello, Blott, and DeWine
". . . the exchange of messages primarily through non-linguistic means, including: kinesics (body language), facial expressions and eye contact, tactile communication, space and territory, environment, paralanguage (vocal but non-linguistic cues), and the use of silence and time."
Empathic communication is described by Coulehan et al as...
language that aides the process of healing by bolstering patient’s strengths, validating their perspective, and teaching them how to grow to be more self-reliant
What are the habits in the 4- habit model?
- Invest in the beginning
- Elicit the patient's perspective
- Demonstrate empathy
- Invest in the end
Characteristics of : Invest in the beginning
- Create rapport quickly
- Elicit patient concerns
- Plan the visit with the patient
Characteristics of : Elicit the
- Ask for patient ideas
- Elicit specific requests
- Explore the impact on the
Characteristics of: Demonstrate
- Be open to patient’s emotions
- Make at least one empathic
- Convey empathy nonverbally
- Be aware of your own
Characteristics of: Invest in the
- Deliver diagnostic information
- Provide education
- Involve patient in making
- Complete the visit
Where does the objective exam fall in the 5 elements of patient management?
Evaluation and examination
The subjective exam is equal to what kind of hypothesis?
The objective exam is equal to what kind of hypothesis?
What are the goals of the objective exam?
• Look for patterns of movement & restrictions
• Reproduce symptoms or produce comparable sign(s)
• Systematic approach to confirm or rule out your working hypothesis and differentials
Things to consider during an objective exam?
• Get baseline symptoms
• Look for two sets of data:
- What the patient feels (*subjective asterisks*)
- Key comparable signs (*objective asterisks*)
• Do painful movements & tests last if possible
What is the layout of an objective exam?
1. Collect / Test / Measure Objective Data
2. Analyze Data / Establish Working Diagnosis
3. Determine Prognosis
4. Formulate a Plan of Treatment
What are the 3 components of motion testing?
• Active ROM (Physiologic) motion testing
• Passive ROM (Physiologic) motion testing
• Joint Play (Accessory) motion testing
What are the 3 essential assessment for diagnosis?
• Quality of the movement
- Movement pattern, asymmetry, end-feel
• Quantity of movement
• Symptom response
Definition of AROM
The patient's ability to actively move on their own
_____ are applied to normal ROM to reproduce symptoms when necessary
During PROM, examiner takes joint through ROM with patient ____
Each movement in PROM is compared with ___
opposite side (preferred) or accepted norms
PROM is used when...?
AROM is altered or painful
Motion testing helps us determine whether to move to ___ or move to __
• Pain is the dominant factor in patient’s disorder
• Range to first onset of pain (and just beyond)
• Assess for stiffness/ hypomobility
• Apply overpressure to assess end-feel and symptom
What does PROM help understand?
Helps understand if there's any limitations in the ROM (hypomobility) or if the patient has an excessive amount of ROM (hypermobility)
What are the 2 instruments for measuring ROM?
- Bubble inclinometer
What are the ROM general procedures?
• Assess range of motion bilaterally (unaffected side first)
• Recommend two repetitions for each movement
• First repetition: Visually assess movement quality,
quantity, and symptom response
• Second Repetition: Joint measurement as needed
What are the ROM specific procedures?
Patient in base position
• Locate pertinent bony landmarks
• Place goniometer axis of motion at the approximate axis of joint motion
• Align stationary and moving arms along the appropriate body parts and in line with identified bony landmarks
• Move the joint through it’s active or passive ROM
• Read the goniometer at appropriate ranges of motion
Things to record when documenting a ROM measurement
- The type of ROM: AROM or PROM
- Right or left extremity
- The joint and the direction of motion
- The quantity of motion achieved
- Symptom changes
Things to keep ROM measurement in check
• Goniometer measurement error +/- 5 degrees
• Reliability varies widely
• Intra-rater generally better than inter-rater reliability
• Reliability can be enhanced
When is reliability enhanced?
- When we use a standardized test position
- When we use the correct goniometer size
- When the same person evaluates each measurement
What is accessory joint mobility/motion?
The ability to passively move a joint through arthrokinematic (accessory) motion that make up a gross osteokinematic (physiologic) motion
How is accessory joint motion assessed?
Passively by the examiner, but cannot be performed actively by the patient
What is osteokinematics?
Directions the bones move when motion occurs. AKA: “physiologic motions”
Osteokinematics is characterized by ___ motion during ___ movement
Visible motion during voluntary movement
Osteokinematics is typically described as ..
movement around a specific joint axis and within a particular joint plane
What are physiologic motions?
Movement in one of the 3 cardinal planes occurs at right
angles to the joint axis
What are the physiologic joint motions?
- Flexion and Extension
- Abduction and Adduction
- Internal and External Rotation, - Horizontal ABD/ADD
What are the joint planes?
- Frontal (Coronal)
- Transverse (Horizontal)
What are the joint axes?
- Longitudinal (Vertical)
What is arthrokinematics?
motion between the joint surfaces during
AKA: “ accessory motions or joint play”
Arthrokinematics is described as motion that should occur _____
within the joint to allow normal
range of motion (osteokinematic) to occur
Arthrokinematics is characterized as being ___ and ____
Invisible and involuntary
What are types of accessory motions?
- Slide (glide)
Accessory motion: Roll
Various points on one surface contact many points on another surface
Accessory motion: Slide (glide)
One point of one surface in contact with many points on another surface
Accessory motion: Spin
One point of one surface in contact with one point on another surface.
What are the two types of Concave-Convex “Rule”
Convex on Concave and Concave on Convex
What is Convex on Concave?
Convex surface moving on fixed concave surface
In Convex on Concave, Roll and Glide accessory motions occur in the _____ directions.
In Convex on Concave, Movement of bone is in ____ direction to movement of joint (glide).
What is Concave on Convex?
Concave surface moving on fixed convex surface
In Concave on Convex, Roll and Glide accessory motions
occur in the_____ direction.
In Concave on Convex, Movement of the bone is in ___ direction as movement of joint surface.
What are the two types of joint positions?
- Open-Packed (Loose)
Characteristics of Open-packed (Loose)
Ligaments and capsule in
position of greatest laxity
• Joint surfaces are maximally
• Minimal congruency between joint surfaces
• Proper position to assess joint play and to mobilize!
Characteristics of Close-packed
• Ligaments and capsule are taut
• Joint surfaces are maximally
• Maximal congruency between joint surfaces
• Position of maximal stability
• POOR position to assess joint play or to mobilize!
What is end- feel?
The sensation you “feel” in the joint as it reaches the end of the range of motion
What does end-feel do?
• Assesses the quality of motion
• Assists in identifying pathology
Normal end- feels: bone to bone
– hard, unyielding sensation; painless
• Example: elbow extension
Normal end- feels: Soft-Tissue approximation
– soft, yielding compression
• Example: muscle contact with elbow or knee flexion
Normal end- feels: Tissue Stretch
– hard or firm (springy) type of movement with a slight give
• Feeling of springy or elastic resistance
• Example: shoulder rotation, knee extension
What is hard capsular abnormal end feel?
Hard or firm end feel, thicker feeling than normal tissue
• Abrupt onset after smooth, friction-free movement
• Seen in chronic conditions
What is soft capsular abnormal end feel?
– Boggy, very soft, mushy end feel typically accompanied joint
• Stiffness early in range and increases until end range
• Seen in acute conditions
Abnormal end feel: Muscle spasm
sudden and hard end feel; dramatic arrest in movement accompanied with pain; usually due to subconscious effort to protect an injured joint or structure
Abnormal end feel: Bone to Bone
hard, unyielding sensation similar to normal bone to bone
• Restriction occurs before normal end range is expected
• Example: osteophyte formation
Abnormal end feel: Springy Block
also a firm end feel, similar to tissue stretch
• Restriction occurs before normal end range is expected
• Usually has a rebound effect indicating internal derangement in the joint (i.e., meniscal tear)
Abnormal end feel: Empty
no mechanical resistance, but considerable pain is produced by movement
What is capsular pattern?
Characteristic pattern of motion restriction when joint capsule is involved (contracted)
What are the two components of muscle testing?
- Muscle length testing (flexibility test)
- Muscle strength testing (manual muscle testing MMT & resisted isometric test)
What is the purpose of muscle length test (flexibility tests)?
To determine if range of muscle length is normal, limited, or excessive
What is the most common form of muscle strength testing?
Manual muscle testing (MMT)
What is the purpose of muscle strength test?
Helps us to find and measure muscle strength to determine the person's ability to voluntarily contract a muscle or muscle group using gravity or applied manual assistance
The manual muscle test helps...
determine the degree of muscle weakness from either disease, injury or atrophy that may have occurred for a patient
Indications for Muscle Strength Testing
• Diagnosis of peripheral nerve injury or nerve root injuries
• Effects of spinal cord injury & potential recovery
• Basis for treatment planning and prognosis
• Provide measure for treatment progress
• Basis for supportive devices/orthoses
MMT General Procedures
1. Position patient
2. Explanation / PROM
3. Screen Test / AROM
5. Apply resistance
Grading of MMT characeristics
• Attempt to express strength objectively
• Consider age, gender differences
• Name and number grades
• Gravity lessened
• Against gravity
In the muscle grading system, a 3- or above allow _____ gravity going through ___ ROM
- vertical motion against gravity
- going through full ROM
In the muscle grading system, a 2+ or below allow _____ gravity going through ___ ROM
Allow supported horizontal motion: gravity is lessened
Factors Reducing Grading Accuracy
• Limited Joint ROM
• Muscle Hypertonicity/Spasticity
• Others: Fatigue, cognition, cultural/social norms
What are the limitations of MMT?
- Hard to determine which muscle is being tested
- Different physical shapes patients
- Inter rater ability
A normal (5) is described as:
Holds test position against strong to maximum resistance.
Good + (4+) is described as
Holds test position against moderate to strong resistance.
A good (4) is described as:
Holds test position with moderate resistance
A good- (4-) is described as:
Holds test position against slight to moderate resistance.
A fair + (3+) is described as:
Full ROM against gravity; able to hold end ROM against slight resistance
A fair (3) is described as:
Full ROM against gravity; able to hold end ROM without added resistance
A fair - (3-) is described as:
FullROM against gravity; unable to hold end ROM (gradual release occurs)
A poor + (2+) is described as:
Completes partial(< ½) ROM against gravity or slight resistance in gravity minimized position
A poor (2) is described as:
Completes full ROM in a gravity minimized position
A poor- (2-) is described as:
Completes partial ROMin a gravity minimized position
A trace (1) is described as:
Slight, palpable contraction; no joint movement
A zero (0) is described as:
No palpable evidence of muscle contraction
For muscle grading from 4- to 5, the patient should be positioned ____
To allow VERTICAL MOTION against gravity
For muscle grading from 2+ to 3+, patients should be positioned _____
To allow VERTICAL MOTION against gravity
For muscle grading from 2 to 2-, patients should be positioned ____
To allow supported HORIZONTAL MOTION; gravity lessened
For muscle grading from 0 to 1, patients should be positioned _____
To allow palpation of muscle with NO MOTION
What movement happens in the frontal plane?
Abduction and adduction
What movement happens in the sagittal plane?
Flexion and extension