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Flashcards in Week 3 Deck (119)
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1

Where does the objective exam fall in the 5 elements of patient management?

Evaluation and examination

2

The subjective exam is equal to what kind of hypothesis?

Hypothesis generation

3

The objective exam is equal to what kind of hypothesis?

Hypothesis refinement

4

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

5

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

6

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

7

What are the 3 components of motion testing?

• Active ROM (Physiologic) motion testing
• Passive ROM (Physiologic) motion testing
• Joint Play (Accessory) motion testing

8

What are the 3 essential assessment for diagnosis?

• Quality of the movement
- Movement pattern, asymmetry, end-feel
• Quantity of movement
• Symptom response

9

Definition of AROM

The patient's ability to actively move on their own

10

_____ are applied to normal ROM to reproduce symptoms when necessary

Progressions

11

During PROM, examiner takes joint through ROM with patient ____

relaxed

12

Each movement in PROM is compared with ___

opposite side (preferred) or accepted norms

13

PROM is used when...?

AROM is altered or painful

14

Motion testing helps us determine whether to move to ___ or move to __

Pain
• Pain is the dominant factor in patient’s disorder
• Range to first onset of pain (and just beyond)

Resistance
• Assess for stiffness/ hypomobility
• Apply overpressure to assess end-feel and symptom
response

15

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)

16

What are the 2 instruments for measuring ROM?

- Goniometer
- Bubble inclinometer

17

What is a goniometer?

Protractor with movable arms
and comes in various sizes. Used for extremities

18

What is a bubble inclinometer?

360° rotating dial with fluid indicator. Commonly used for spinal movement

19

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

20

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

21

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

22

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

23

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

24

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

25

How is accessory joint motion assessed?

Passively by the examiner, but cannot be performed actively by the patient

26

What is osteokinematics?

Directions the bones move when motion occurs. AKA: “physiologic motions”

27

Osteokinematics is characterized by ___ motion during ___ movement

Visible motion during voluntary movement

28

Osteokinematics is typically described as ..

movement around a specific joint axis and within a particular joint plane

29

What are physiologic motions?

Movement in one of the 3 cardinal planes occurs at right
angles to the joint axis

30

What are the physiologic joint motions?

- Flexion and Extension
- Abduction and Adduction
- Internal and External Rotation, - Horizontal ABD/ADD

31

What are the joint planes?

- Sagittal
- Frontal (Coronal)
- Transverse (Horizontal)

32

What are the joint axes?

- Frontal
- Sagittal
- Longitudinal (Vertical)

33

What is arthrokinematics?

motion between the joint surfaces during
movement.
AKA: “ accessory motions or joint play”

34

Arthrokinematics is described as motion that should occur _____

within the joint to allow normal
range of motion (osteokinematic) to occur

35

Arthrokinematics is characterized as being ___ and ____

Invisible and involuntary

36

What are types of accessory motions?

- Roll
- Slide (glide)
- Spin

37

Accessory motion: Roll

Various points on one surface contact many points on another surface

38

Accessory motion: Slide (glide)

One point of one surface in contact with many points on another surface

39

Accessory motion: Spin

One point of one surface in contact with one point on another surface.

40

What are the two types of Concave-Convex “Rule”

Convex on Concave and Concave on Convex

41

What is Convex on Concave?

Convex surface moving on fixed concave surface

42

In Convex on Concave, Roll and Glide accessory motions occur in the _____ directions.

OPPOSITE

43

In Convex on Concave, Movement of bone is in ____ direction to movement of joint (glide).

OPPOSITE

44

What is Concave on Convex?

Concave surface moving on fixed convex surface

45

In Concave on Convex, Roll and Glide accessory motions
occur in the_____ direction.

SAME

46

In Concave on Convex, Movement of the bone is in ___ direction as movement of joint surface.

SAME

47

What are the two types of joint positions?

- Open-Packed (Loose)
- Close-Packed

48

Characteristics of Open-packed (Loose)

• Ligaments and capsule in
position of greatest laxity
• Joint surfaces are maximally
separated
• Minimal congruency between joint surfaces
• Proper position to assess joint play and to mobilize!

49

Characteristics of Close-packed

• Ligaments and capsule are taut
• Joint surfaces are maximally
contacted
• Maximal congruency between joint surfaces
• Position of maximal stability
• POOR position to assess joint play or to mobilize!

50

What is end- feel?

The sensation you “feel” in the joint as it reaches the end of the range of motion

51

What does end-feel do?

• Assesses the quality of motion
• Assists in identifying pathology

52

Normal end- feels: bone to bone

– hard, unyielding sensation; painless
• Example: elbow extension

53

Normal end- feels: Soft-Tissue approximation

– soft, yielding compression
• Example: muscle contact with elbow or knee flexion

54

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

55

Abnormal end-feels: Capsular

– similar to tissue stretch, but occurs early in motion. Two
subdivisions: Hard capsular and Soft capsular

56

What is hard capsular abnormal end feel?

Hard or firm end feel, thicker feeling than normal tissue
stretch
• Abrupt onset after smooth, friction-free movement
• Seen in chronic conditions

57

What is soft capsular abnormal end feel?

– Boggy, very soft, mushy end feel typically accompanied joint
effusion
• Stiffness early in range and increases until end range
• Seen in acute conditions

58

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

59

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

60

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)

61

Abnormal end feel: Empty

no mechanical resistance, but considerable pain is produced by movement

62

What is capsular pattern?

Characteristic pattern of motion restriction when joint capsule is involved (contracted)

63

There are ___ pattern for each joint

Unique

64

Capsular patterns are often ___

inconsistent, but may be helpful

65

Examples of capsular pattern

• Glenohumeral joint – ER limited more than ABD, limited more than IR
• Hip – FLEX limited more than ABD, limited more than IR

66

What is a fulcrum of a goniometer?

The circular part of a goniometer

67

What is the proximal arm of a goniometer

The one that is attached to the fulcrum. This is in reference to where it'll be facing on the body

68

What is the distal arm of the goniometer?

The one not attached to the fulcrum

69

All hip motion end feel are ____ due to ____, with the exception of ___

Firm due to muscle tension, joint capsule or ligaments.
Exception is flexion of the hip

70

Flexion of the hip end feel is ___, due to

Soft due to muscle bulk

71

Normal end feel of hip joint extension

- Firm due to muscle tension, anterior joint capsule, or ligaments

72

Avoid hip joint extension if patient complains of...

low back (lumber) pain in extension

73

Normal end feel of hip abduction

Firm due to medial joint capsule, muscle tension, or ligaments

74

Normal end feel of hip adduction

Firm due to lateral joint capsule, muscle tension, or ligaments

75

Normal end feel of hip internal rotation seated and prone

Firm due to posterior joint capsule, muscle tension, or ligaments

76

Normal end feel of hip external rotation prone

Firm due to posterior joint capsule, muscle tension, or ligaments

77

Normal knee flexion end feel is ...

- Soft due to muscle bulk
- Firm due to tight muscle/capsular tension

78

Normal knee extension end feel is ...

- Firm due to muscle tension, posterior joint capsule and ligaments

79

Normal ankle dorsiflexion end-feel

Firm due to posterior joint capsule, muscle tension or ligaments

80

Normal ankle plantarflexion end-feel

Firm due to anterior joint capsule, muscle tension or ligaments

81

Normal ankle inversion end-feel

Firm due to joint capsule, muscle tension, ligaments

82

Normal ankle eversion end-feel

Firm due to joint capsule, muscle tension, ligaments

83

Normal metatarsophalangeal (MTP) flexion end-feel

Firm due to dorsal joint capsule, muscle tension or ligaments

84

Normal metatarsophalangeal (MTP) extension end-feel

Firm due to plantar joint capsule, muscle tension or ligaments

85

Normal metatarsophalangeal (MTP) abduction end-feel

Firm due to joint capsule, muscle tension, ligaments or web space fascia

86

Normal metatarsophalangeal (MTP) adduction end-feel

Firm due to joint capsule, muscle tension, ligaments or web space fascia

87

Normal interphalangeal (IP) flexion end-feel

Firm due to dorsal joint capsule or ligaments
Soft due to soft tissue bulk

88

Normal interphalangeal (IP) extension end-feel

Firm due to medial joint capsule, muscle tension or ligaments

89

What are the two components of muscle testing?

- Muscle length testing (flexibility test)
- Muscle strength testing (manual muscle testing MMT & resisted isometric test)

90

What is the purpose of muscle length test (flexibility tests)?

To determine if range of muscle length is normal, limited, or excessive

91

What is the most common form of muscle strength testing?

Manual muscle testing (MMT)

92

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

93

The manual muscle test helps...

determine the degree of muscle weakness from either disease, injury or atrophy that may have occurred for a patient

94

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

95

MMT General Procedures

1. Position patient
2. Explanation / PROM
3. Screen Test / AROM
4. Palpate
5. Apply resistance
6. Grade

96

Grading of MMT characeristics

• Attempt to express strength objectively
• Consider age, gender differences
• Name and number grades
• Gravity lessened
• Against gravity

97

In the muscle grading system, a 3- or above allow _____ gravity going through ___ ROM

- vertical motion against gravity
- going through full ROM

98

In the muscle grading system, a 2+ or below allow _____ gravity going through ___ ROM

Allow supported horizontal motion: gravity is lessened

99

Factors Reducing Grading Accuracy

• Pain
• Limited Joint ROM
• Muscle Hypertonicity/Spasticity
• Others: Fatigue, cognition, cultural/social norms

100

What are the limitations of MMT?

- Hard to determine which muscle is being tested
- Different physical shapes patients
- Inter rater ability

101

A normal (5) is described as:

Holds test position against strong to maximum resistance.

102

Good + (4+) is described as

Holds test position against moderate to strong resistance.

103

A good (4) is described as:

Holds test position with moderate resistance

104

A good- (4-) is described as:

Holds test position against slight to moderate resistance.

105

A fair + (3+) is described as:

FullROM against gravity; able to hold end ROM against slight resistance

106

A fair (3) is described as:

FullROM against gravity; able to hold end ROM without added resistance

107

A fair - (3-) is described as:

FullROM against gravity; unable to hold end ROM (gradual release occurs)

108

A poor + (2+) is described as:

Completes partial(< ½) ROM against gravity or slight resistance in gravity minimized position

109

A poor (2) is described as:

Completes full ROM in a gravity minimized position

110

A poor- (2-) is described as:

Completes partial ROMin a gravity minimized position

111

A trace (1) is described as:

Slight, palpable contraction; no joint movement

112

A zero (0) is described as:

No palpable evidence of muscle contraction

113

For muscle grading from 4- to 5, the patient should be positioned ____

To allow VERTICAL MOTION against gravity

114

For muscle grading from 2+ to 3+, patients should be positioned _____

To allow VERTICAL MOTION against gravity

115

For muscle grading from 2 to 2-, patients should be positioned _____

To allow supported HORIZONTAL MOTION; gravity lessened

116

For muscle grading from 0 to 1, patients should be positioned _____

To allow palpation of muscle with NO MOTION

117

What movement happens in the frontal plane?

Abduction and adduction

118

What movement happens in the sagittal plane?

Flexion and extension

119

What movement happens in the transverse plane?

Internal and external rotation