1
Q
Biomechanical Frame of Reference (BFOR)
A
- Became prevalent in 1940s
- Addresses musculoskeletal capacity and problems which underlie movement in daily occupational performance
- -ROM, Strength, Endurance
2
Q
BFOR is concerned with…
A
- musculoskeletal capacity
- peripheral nerve involvement/dysfunction
- cardiopulmonary system dysfunction
3
Q
BFOR is best suited for clients with ___
A
Isolated/selective motor control aka an intact nervous central nervous system
4
Q
Assumptions of the BFOR
A
- Occupational performance requires the ability to move the limbs and the endurance to sustain activity/movement until a goal is accomplished.
- Purposeful activities can be used to treat loss of ROM, strength, and endurance
- This is a bottom-up approach
5
Q
Limitations of BFOR
A
- Does not provide a lens for understanding “occupational” problems that do not result from musculoskeletal problems…cannot be used in isolation.
- Sometimes resolving/remediating these musculoskeletal impairments may not result in changes in occupation.
6
Q
Indicators for Assessment Selection (in a top-down assessment)
A
- In thinking of TOP-DOWN ASSESSMENT… you now have completed your occupational performance assessment (ADL), and NOW, need to decide what other assessments are needed…
- After your observations during the interview/ADL assessments you can consider:
Client’s goals: ( i.e., fine coordination, difficulty with buttoning pants, tying shoes, etc.)
Observations… What might be interfering with ADL performance? What are you noticing?
Diagnosis: Will indicate suspected problems (I.e., Guillain-Barre–strength; SCI–strength and sensation); but still “screen” for others.
Setting: your involvement/role, insurance coverage, client’s course…
7
Q
Definition of ROM
A
The arc of motion through which a joint moves
8
Q
Passive ROM
A
Movement by an external force
9
Q
Active ROM
A
Movement by the muscles surrounding a joint
10
Q
Functional ROM
A
Amount of joint range necessary to perform essential ADLs and IADLs
11
Q
PROM vs. AROM
A
Passive tested FIRST, flexibility, looks @ joint structure itself. Active may be influenced by tendon integrity (hands), may supplement MMT for more specific muscle grading (to document small changes)…
With ROM limitations – is it muscular or tendon related? What’s causing the difference between PROM & AROM? Is it a problem of muscle weakness or tendon integrity in the hands?
12
Q
ROM: Rationale for Assessment in OT
A
- Determine a limitation that is interfering with occupation
- Identify specific areas needing intervention:
ROM: which joint is causing functional problem?
Strength: a muscle imbalance leading to deformity?
Ability to benefit from/use assistive devices?
Document changes/effectiveness of intervention – “If you treat it…measure it”
13
Q
ROM: “Normal” Determinants
A
- Structure of the joint (i.e. mechanics – is it a ball and socket joint, etc.)
- Stretch of joint capsule and ligaments
- Muscle tone and tendons (bulkiness)
- Dominance (more flexible in dominant hand)
- Temperature/Climate (warmer temperature = 2 degrees more flexible)
- Circadian Rhythms (rhythms to patterns of stiffness and tone, especially with arthritis)
14
Q
ROM Limitations
A
- Skin contracture due to adhesions or scar tissue
- Soft tissue contractures such as tendon, muscle or ligament shortening
- Diseases of the joint, e.g arthritis
- Fractures – bony obstruction or destruction
- Burns
- Hand trauma
- Displacement of fibrocartilage or presence of other foreign bodies in the joint, e.g. tumor
- Tumors
- LMN (SCI, Guillain-Barre, myasthenia gravis, polio, PNI
- UMN (TBI, CVA
- Iatrogenic disorders (physican-induced such as tardive dyskinesia)
All of these can cause secondary effects (spasticity, muscle weakness, pain, edema, and immobility), which limit ROM
15
Q
ROM – end feel
A
End feel is the feeling that is elicited when the joint is brought through the entire available ROM.
It is normally hard, soft, or firm:
- Hard: bone on bone (olecranon process/fossa) with elbow extension
- Soft: elbow flexion – soft tissue opposition of biceps/supinator and radial wrist flexors
- Firm or springy sensation that has some give, as in shoulder flexion
End-feel is abnormal when movement is stopped by structures other than normal anatomy
16
Q
ROM: Measurement Procedures
A
- Assess less involved side first.
- Assess Proximal to Distal
- Ask the client to move and observe (Perform Functional AROM Scan)
- Therapist passively moves part to its limit of motion (if limitations observed during functional AROM scan)
Stabilize proximally - If no passive limitations: Problem is AROM = muscle strength. (May measure AROM)
17
Q
ROM: Documentation
A
The “Neutral Zero Method” or “180-degree system”:
- All joint motions begin at 0 degree and increase toward 180 degrees.
- Joints in which ending position of one joint motion is starting position of opposite motion (Example: elbow flexion/extension) get one set of measurements
- Joints in which starting position of both joint motions is the same = neutral/zero (Example: wrist flexion/extension) get two sets of measurements
18
Q
Reporting ROM
A
- After ROM assessment has been completed and evaluation form is filled out, take note of any limitations which are “significant” or which interfere with function or are producing deformity/causing pain
- If several joint ranges have similar measurements, group them together, ie: Shoulder and elbow present with normal ROM; wrist flexion is 0-45 after surgery
- Address ROM and relate to function: “Due to severe flexion contractures of the MP (80-90 degrees) and PIP (70-110) and DIP (20-90) joints, the client is unable to extend fingers to grasp objects that are larger than two inches in diameter.”
- Using the words: slight, moderate, severe
Slight: limitations are present, but client is able to function fairly well
Moderate: limitations are present, interfere with function but client can overcome with use of AE
Severe: limitations severely limit function, contractures present, difficult for client to function even with AE (lacks half or more of normal range usually available at joint).
19
Q
Definition of Strength
A
Strength is defined as the tension-producing capacity of a muscle/group of muscles; “demonstrating a degree of muscle power when movement is resisted, as with objects or gravity”
20
Q
Manual Muscle Testing
A
- the method for measuring tension in a muscle/group of muscles
- is based on the following criteria: evidence of muscle contraction, amount of range muscle move part through, and resistance (including gravity)
21
Q
Maximum Voluntary Contraction (MVC)
A
- maximum tension production under voluntary effort
- aka the greatest amount of tension a muscle can generate and hold only for a moment
22
Q
What happens if a muscle (group) contracts beyond 15-20% of MVC?
A
- Blood flow decreases
- Causes shift to anaerobic metabolism
- Limits duration of contraction
- Limitation is signaled by symptoms of muscle fatigue (cramping, burning, tremors due to accumulation of lactic acid)
23
Q
Anaerobic metabolism
A
This occurs when the lungs cannot put enough oxygen into the bloodstream to keep up with the demands from the muscles energy. It generally is used only for short bursts of activity
24
Q
Muscular endurance
A
- normal contraction against low resistance
- closely related to strength
25
Muscular endurance in neurological conditions
In neurological conditions, may have fewer motor units or muscle fibers available (to call upon to ‘fire’) -- working at 50-75% MVC for low-intensity, everyday work
26
Muscular endurance in neuromuscular conditions
Occurs secondary to a neurological condition (like a stroke) and it is a problem of brain-muscle connection—not a problem of the muscle cells themselves
27
Muscular endurance -- denervation
Essentially when the nerve supply of a part is “cut off” by incision, excision (removal by cutting), or local anesthesia (this could be either a motor or sensory issue or both).
28
Intensity
activity and muscle contraction
29
Resistance
body position: lying, sitting, standing
30
Speed
less resistance, more repetition
31
Duration
length of time
32
Frequency
how frequent/often
33
Primary conditions resulting in muscle strength limitations
- Lower motor neuron disorders: peripheral neuropathies, peripheral nerve injuries…
- Spinal cord injury
- Guillain-Barré syndrome
- Cranial nerve dysfunction
- Muscle diseases: muscular dystrophy, myasthenia gravis…
- Neurological conditions:
LMN with paralysis (Can help diagnose)
UMN with selective control only!
34
Secondary conditions resulting in muscle strength limitations
- Burns
- Amputations
- Hand trauma
- Arthritis
- Fractures
- Other orthopedic conditions
35
When is MMT inappropriate?
MMT is inappropriate for patients who lack the ability to contract a single muscle or a muscle group in isolation, such as patients who exhibit patterned movement
36
MMT Precautions
- Inflammation or pain in region
- Dislocation or unhealed fracture
- Recent surgery
- Myositis ossificans
- Bone carcinoma/fragile bone condition
- When resistive movement is contraindicated:
Osteoporosis, subluxation, joint hypermobility, hemophilia or cardiovascular risk/disease, abdominal surgery/hernia, fatigue that exacerbates the patient’s condition
37
MMT may begin with a gross strength screen, which involves:
- Examination of medical record
- Observation of the client entering the clinic and moving about
- Observation of the client performing functional activities…remove an article of clothing, shaking hands, etc.
- Performance of a gross check of bilateral muscle groups (similar to AROM Scan)
38
Indication for gross strength screen:
should I perform a MMT?
39
MMT -- Individual Muscles
- Tests strength of individual muscle
- Indications: SCI/PNI
- it is less commonly used (depends on the setting you work in)
- Elbow example: different positioning and palpation for biceps, brachialis, brachioradialis
- Helps differentiate level of injury (I.e., brachial plexus injury/SCI) related to nerve or nerve root involvement and whether the involvement is partial or complete
40
MMT -- Muscle Groups
- Tests strength of muscle groups with similar function
| - Indications: general strength, orthopedic conditions, arthritis, etc.
41
MMT - Functional
- Test strength to perform certain functions
- Indications: resistance not allowed, assessed through activity
- Example: pick up a mug of coffee
42
Normal strength depends on:
- age
- gender
- lifestyle
- muscle size and type and speed of contraction
- effect of previous training
- joint position during muscle contraction
- time of day, temperature, and fatigue
43
Muscle strength testing -- look for patterns of muscle weakness vs. generalized weakness
- proximal vs. distal
- spinal innervation (myotomes)
- peripheral nerve distributions
- imbalance between agonist/antagonist
44
MMT Reliability
```
- Be mindful regarding factors influencing testing:
Interest and cooperation of patient
Experience and tone of voice of tester
Posture
Fatigue
Ability to understand directions
Therapist’s definition of muscle grades
Test positions
```
- Environment: distraction-free, comfortable temperature, proper lighting
45
MMT: Specific Procedures
1. Determine PROM = “Available range”
-----screening test-----
2. Assess Proximal to Distal
3. Position patient to move (motion) against gravity
(Test all muscles in one position before changing position)
4. Stabilize proximal attachment
5. Ask patient to move and observe
6. If able to move through full available range against gravity: apply resistance with an open hand or lumbrical grip on the distal end of moving part at the end of the available range (except for shoulder flexion and abduction, which are assessed at mid-range)
7. If unable to move through available range: Position with gravity eliminated (decreased).
8. If able to move through full available range in gravity-eliminated: Apply resistance at distal end of moving part
9. If not motion, palpate prime mover
46
Scoring of MMT
** Can only receive a 3 or above if they can move against gravity:
```
Grade 5 (Normal): can maintain end-point against maximum resistance.
Grade 4 (Good): able to complete full range of motion against gravity and can tolerate strong resistance without breaking the test position…”gives” or “yields” to some extent at the end of its range with maximum resistance.
Grade 3+ (Fair +): takes minimal resistance
Grade 3 (Fair): can complete a full range of motion against only the resistance of gravity additional resistance, however mild, causes the motion to break.
```
**Grading for moving through ROM but with gravity eliminated:
Takes minimal resistance = Poor + (2+)
Takes no resistance = Poor (2)
**If no motion whatsoever:
Tension = Trace grade (1) -- can detect visually or by palpation some contractile activity in one or more of the muscles that participate in the movement being tested…or a tendon pops up or becomes tense
No Tension = Zero grade (0)
47
Reporting Muscle Strength
Slight – muscle grade is in G (good) range
Moderate – muscle grade is in the F to F+ range
Severe – muscle grade is below F
48
Relationship between ROM and Muscle Strength
- Passive range determines “available range”
- Active range is usually a reflection of muscle strength
- Manual muscle test indicates muscle strength
Adult Rehab Week 5
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Decks in class (7)
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