Objective Flashcards
(18 cards)
Components
> Observation > Active RoM > Passive RoM > Strength > Sensation > Co-ordination > Reflexes > Function
*Why assess at all?
Figure out what patient sees as problem (participation/activity) and then work out what is causing these problems (impairment) to create problem list + goals that will guide treatment method
Observation - static postures
> Posture in supine/sitting/standing > Look at: - Base of support - Centre of gravity - asymmetries - muscle activity
Observation - Dynamic movement
> Rolling/Lying to sitting/sit to stand/ stand to sit
- muscle function
- effort
- speed
- smoothness
- timing
- directness
- differences from normal
- visual behaviour
- anticipatory movement
Active Range of Movement
> Likely to look at functional movements rather than a single joint (especially relating to PADL’s + DADL’s)
Will depend on patients ability
Looking for
- postural alignment/compensations
- patterns of movement
- quality of movement (smooth/co-ordinated/timed)
- Involuntary movements
- Pain
- Range (estimate or measure if on a single joint)
- Strength
> Any obvious limitations?
- Soft tissue shortening
- Weakness
- Pain
- Altered Sensation
- Altered Muscle tone
Active Range of movement - UL
Patient in sitting
> Shoulder - flexion
- rotation in both planes
- abduction
> Elbow - flexion/extension
> RUJ's - Pronation/supination
> Wrist - flex/extend vs gravity both ways
- ulnar/radially deviate
> Fingers- flex/ extend
- add/abduct
> thumb - opposition
- flex/extend
*Is it strength or cognition affecting doing movement
Active Range of Movement - LL
In sitting
> Hip - flexion
> Knee - extension
> Ankle - dorsi/plantarflexion
> Toes - flex/extend
- abduct
In Supine
> Hip - abduction/adduction
- flexion
- int/ext rotation
> Knee - flexion/extension
> Ankle - dorsi/plantarflexion
> Subtalar/Midtarsal - In/Eversion
> Toes - flex/extend
- abductPassive Range of Movement
> Physiological movements produced by external force during muscle inactivity
Looking for:
- Obvious limitations: RoM + Sensory Awareness
- anxious
- pain
- Resistance (+change with speed and direction) + type of resistance (muscle shortening or tone) - doesn’t have to be at end range
*UL in sitting if poss, supine if needed - don’t take to full range in shoulder if we suspect instability
+ don’t change flexural tone in fingers if provides them with tenodesis grip (SCI)
*LL in sitting (extension in side lying if poss)
+ don’t overstretch a peripheral nerve injury as will interrupt the regeneration
PROM - define tone + states
> State of readiness in muscle at rest or resistance to passive movement
Hypertonicity - High tone
- Spasticity (rigidity = where both groups of muscles = tight)
- caused by changes to CNS
(can be accompanied by dystonia/dyspraxia = unco-ordinated movements)
Hypotonicity - Low tone
- Flaccidity/Weakness (diminished resistance to passive movement
- Changes to either CNS or PNS
PROM - normal tone is created by:
> Mechanical factors:
- Physical inertia of the limb
- Viscoelastic properties
- Thixotropy (keeping fluid within muscles loose)
> Neural factors
- Active contraction
- Reflex contraction
* IE - input to alpha motor neuron from cortex/brainstem/spinal cord/periphery
(input will be excitatory or inhibitory)
CHANGES TO THIS INPUT WILL CREATE CHANGES IN TONE
PROM - cause of high tone vs. low tone
> High tone
- increased excitation or decreased inhibition
- can only be from CNS
> Low tone
- decreased excitation or increased inhibition
- can be either CNS or PNS
Strength testing
> AROM shows level 3 on oxford scale
May induce flexor/extensor patterns whilst testing - patterns we don’t want to encourage
if v. high tone don’t test
Might be better to do isometric rather than isotonic (record range we tested in as oxford is usually isotonic)
+ if person is weak and we keep testing what they can’t do it has negative psychological effect
Outcome measures
> OBS: photos/videos > AROM: goniometry/ hudl app > PROM: goniometry/ hudl > tone: modified ashworth scale > strength: oxford scale
Sensory Testing
- What are we testing
- Receptors
> Tests whole pathway of receptor up to sensory cortex as damage can occur at any point along pathway
Muscle spindles - respond to quick stretch
*testing this in reflexes
*PROM has to be slow to avoid triggering this
Golgi tendon - responds to muscle tension (when stretched it relaxes muscles to allow greater stretch)
*Targeting this with stretching
Pacinian corpuscles + free nerve endings in muscles and joints as well as Ruffini endings and golgi type endings in joints respond to VIBRATION/PRESSURE/PAIN
In skin: merkel discs/meissner corpuscles/ruffini endings/pacinian corpuscles and free nerve endings respond to MECHANICAL PRESSURE/THERMAL/NOCICEPTIVE INPUT
These then connect to peripheral nerves - damage may be at receptor or peripheral nerve
*Aim is to stimulate sensory system during rehab to create neuroplasticity
Sensory tests + pathways
> Proprioception - assessing body knowing where it is in space (Dorsal column - crosses at medulla)
2 point sensation - distinguish between 2 points (Dorsal Column)
Light or deep touch - (Dorsal column)
Stereognosis - ability to distinguish objects by touch (Dorsal column and Spinothalamic tracts)
Sharp/blunt - Lateral spinothalamic (crosses on entry to spinal cord)
- Dermatomal pattern is used for testing when spinal cord and peripheral nerve injuries
- For other CNS problems (e.g CVA or TBI) use Fugl-Meyer or Nottingham sensory assessment
Co-ordination
Looking for cerebellar problems
> Finger to Nose (looking for ataxia)
> Heel to shin
> Rapid movement tests looking for bradykinesia - challenging basal ganglia - parkinsons
- turning hand over on thigh/tap crease of thumb with finger as fast as possible
Reflexes - procedure
> looking to activate muscle spindle (generally upper motor neuron lesions will increase reflex whereas lower motor neuron lesions will decrease reflex)
Patient is relaxed with tendon on slight stretch
brisk tap to tendon + repeat - note if same/different
- Babinski reflex - firm stroke from lateral plantar calcaneus to base of great toe with sharp edge of reflex hammer - great toe will extend whilst others abduct (normal result is flexion of toes) - generally done by doctor
- Positive result shows upper motor neuron lesion - CNS damage
Reflexes - Muscles tested
> Biceps Brachii (C5-6): - arm = flexed + supported - place thumb over biceps tendon insertion + hit thumb with hammer > Triceps (C6-8): - medially rotate + abduct shoulder (below 75 degrees for patient comfort) - hit just superior to olecranon > Brachioradialis (C5-7): - hit mid muscle in supported neutral (looking for elbow flexion + supination movement) > Quadriceps: (L2-4): - patella tendon > Gastrocnemius/Soleus (S1-2): - slight dorsiflexion - patient seated on edge of bed
Functional Assessment
> Rolling > Lying to sitting > Sitting balance > Sit to stand > standing balance > walking - gait > stairs > UL function - Personal and Domestic Activities of Daily Living (PADLs + DADLs)
