(1) UQ Scanning and Clinical Decision Making Flashcards
Regional Interdependence Definition
Idea that seemingly unrelated impairments (in an area outside of the one being assessed) may be associated with pt’s primary complaint / mediated by central mechanisms
When is a good time to consider Regional Interdependence?
Pt’s presentation is unclear
Response to treatment is less than favorable
Biomedical Model
Diagnosis is required to prescribe treatment
More applicable to infectious diseases than MSK disorders
Vague descriptors used in absence of clear diagnosis (knee pain, disc herniation)
Regional Interdependence (Impairment) Model
Physical (MSK) Impairments: Pain, ROM
Neurophysiologic Impairments: Impact of pain on function
Biopsychosocial Impairments: Impact of depression, fear avoidant behaviors, pt expectations on outcomes
Somatovisceral Impairments: Impact of referred or radicular pain
Impairments Associated w/ Chronic Neck Pain (Ghamkhar Research)
Decreased:
*Neck muscle strength
*Scapulothoracic muscle (traps, rhomboids) strength
*Hip muscle strength
*Trunk flexor/extensor strength
Lateral elbow pain is associated with impairments in what other areas of the body?
Cervical
Shoulder
Wrist/hand
LB pain is associated with impairments in what other areas of the body?
Hip
PFPS is associated with impairments in what other areas of the body?
LB/hip
Foot/ankle
Thoracic HVLAT treatment is proven to improve what in addition to the t-spine area?
Decrease c-spine pain
Increase lower trap strength
Improve outcomes in pts with RC tendinopathy and adhesive capsulitis
When treating the different areas of the spine, what serves as the most proximal point? What are the implications of this?
Center of body mass
T-spine more proximal than c-spine (c-spine is already more mobile than t-spine) - treat t-spine first!
How do we decide when or when not to scan?
No obvious MOI/history related to S&S
Proximal cause for distal symptoms
Non-mechanical “sounding” symptoms (serious, non-MSK conditions)
Components of UQ Scanning Exam
Observation/pt history
Cervical AROM (OP as appropriate)
UE ROM (shoulder, elbow, wrist, hand)
Myotomes (C5-T1)
Dermatomes (C4-T1)
Cervical compression/distraction
NPT (ULTT 1)
Common UQ DTRs
Pathologic reflexes
Palpation (pulses, glands, lymph nodes)
What can we observe for when looking at a pt’s eyes?
Ptosis (compare dilation of pupils)
Bulging eyes (could be related to a thyroid problem)
If a pt responds “Yes” to the presence of a symptom related to a red flag, what else should you consider?
Is the complaint new/different/unusual for the pt
Is there an explanation for it that would minimize concern
Has pt mentioned this to a physician (if so, has it worsened since then)
Review of Systems vs. Systems Review
Review of Systems (ROS): Collects info about each system to determine what warrants physical examining
Systems Review: Hands-on component of exam
When does fatigue become a concern during a general health screen?
When it interferes with one’s ability to carry out daily activities at home, work, school, social setting
Malaise Definition
Uneasiness, feeling that “something isn’t right”
Fever, chill, sweats can all be indicative of what? When is a fever considered “significant?”
infection, cancer, inflammatory disorders
> or = 99.5 degrees for 2 weeks+
What parameters make weight loss/gain significant? What could this be indicative of?
Unexplained loss/gain of 5-10% of BW
depression, cancer, GI disease
What could n/v be attributed to outside of GI problems?
Metabolic, CV, liver dysfunction
Pregnancy
Medications
Increased intracranial pressure, HA, hemorrhage
Dizziness + lightheadedness can be attributed to what?
Neurologic, CV dysfunction
DM, anxiety, psychosis
Paresthesia, numbness, weakness can be attributed to what?
Renal, endocrine disorders
Adverse drug reactions
Progressive neurologic loss
A change in mentation/cognitive ability can be a result of what?
Delirium, dementia
Head injury
Adverse drug reactions
Infection
Red vs. Yellow vs. Blue Flags
Red - potentially life-threatening
Yellow - psychological factors that may impact pt outcomes
Blue - socioeconomic factors (e.g., occupation) that may impact pt outcomes
Yellow Flags (Examples)
Negative coping skills
Anxiety / depression
Kinesiophobia
Dizziness
Abnormal sensory patterns
Progressive weakness
Fainting
Circulatory / skin changes
Blue Flags (Examples)
SES
Social determinants of health
Is it abnormal to observe side-to-side differences in a pt’s UE ROM?
Not always!
Differences inevitable in dominant vs. non-dominant side
C5 Myotome
Shoulder abd
Deltoid
Axillary N.
C6 Myotome
Elbow flex
(biceps brachii, musculocutaneous n.)
Wrist ext
(ECRL, ECRB, ECU, radial n.)
C7 Myotome
Elbow ext
(triceps brachii, radial n.)
Wrist flex
(FCR, FCU, median n. for radialis + ulnar n. for ulnaris)
C8 Myotome
Finger flex
FDS, FDP, lumbricals
Median N. (superficialis), Median + Ulnar N. (profundus, lumbricals)
T1 Myotome
Finger abd
Dorsal interossei
Ulnar N.
Label UE Dermatomes (C4-T1) and corresponding peripheral nerves.
What does pain reproduced with cervical compression suggest?
Disc herniation
Vertebral end plate/body fx
Acute arthritis/jt inflammation
Nerve root irritation (if radicular symptoms produced)
What does pain reproduced with cervical distraction suggest?
Spinal ligament tear
Tear/inflammation of AF
Muscle spasm
Large disc herniation
Dural irritability (if non-radicular arm pain produced)
In the event of a pt experiencing pain w/ cervical distraction, what are we MOST concerned about?
Spinal cord
This could indicate cervical instability which may be life-threatening
Radicular vs. Non-Radicular Arm Pain
Radicular: Symptoms “shoot” below the elbow
Non-Radicular: Symptoms stay above the elbow
What are the indications of a POSITIVE ULTT?
Differences between limbs in elbow ROM
Reproduction of concordant neurologic symptoms in UE w/ movement of distant component
Different symptoms between two extremities
NINDS Grading Scale
DTRs
0 - absent
1 - slight (hyporeflexia)
2 - normal
3 - brisk (still considered norm)
4 - enhanced (hyperreflexia including clonus if present)
A positive Hoffman’s/Babinski/Lhermitte Reflex are all indicative of what?
UMN lesion
Lhermitte specifically demyelination on SC
The Lhermitte Phenomenon is most commonly seen in individuals with ___.
MS
Cervical Myelopathy
Cervical Radiculopathy
Neck trauma
What would prompt you to perform a Cranial Nerve exam?
Concussion (head trauma)
MVA
Observable symptoms (eyes, facial droop, slurred speech)
Cranial Nerves Major Functions
I (Olfactory): Smell
II (Optic): Vision
III (Oculomotor): Eyelid and eyeball movement
IV (Trochlear): Innervates superior oblique / turns eye down and laterally
V (Trigeminal): Chewing / face and mouth touch and pain
VI (Abducens): Turns eye laterally
VII (Facial): Controls most facial expressions / secretion of tears and saliva / taste
VIII (Vestibulocochlear): Hearing / equilibrium sensation
IX (Glossopharyngeal): Taste / senses carotid BP
X (Vagus): Senses aortic BP / slows HR / stimulates digestive organs / taste
XI (Spinal Accessory): Controls traps and SCM / controls swallowing movements
XII (Hypoglossal): Controls tongue movements
UMNs vs. LMNs
Location / Structures
UMN: CNS - cortex / brainstem / corticospinal tracts / SC
LMN: CN nuclei + nerves / anterior horn cell / spinal roots / peripheral nerve
UMNs vs. LMNs
Pathology Examples
UMN: Stroke, TBI, SCI
LMN: Peripheral nerve neuropathy / radiculopathy / polio / Guillan Barré
UMNs vs. LMNs
Tone
UMN: Increased - hypertonia / velocity-dependent
LMN: Decreased or absent - hypotonia / flaccidity / nonvelocity-dependent
UMNs vs. LMNs
Reflexes
UMN: Increased - hyperreflexia / clonus / exagerrated cutaneous and autonomic reflexes / positive Babinski
LMN: Decreased or absent - hyporeflexia / cutaneous reflexes decreased or absent
UMNs vs. LMNs
Involuntary Movements
UMN: Muscle spasms: flexor or extensor
LMN: Fasciculations w/ denervation
UMNs vs. LMNs
UMN: Impaired or absent - dysynergic patterns, mass synergies
LMN: Weak or absent (if nerve integrity interrupted)
UMNs vs. LMNs
Strength
UMN: Weakness / paralysis ipsilateral (stroke) or bilateral (SCI), contra if above decussation in the medula, ipsi if below CST distribution; never focal
LMN: Ipsi weakness / paralysis in limited distribution - segmental / focal / root pattern
UMNs vs. LMNs
Muscle Appearance
UMN: Disuse atrophy - variable, widespread distribution, especially for antigravity muscles
LMN: Neurogenic atrophy
What would indicate to you to assess a patient’s pulses?
Temperature changes
Discoloration of the skin
If you recognize a patient’s pulse is reduced, what would be the next step?
Check each pulse point in a proximal to distal pattern for comparison
What are we assessing in the taking of a patient’s pulse?
HR, potency
Scale:
0 - absent
1 - markedly reduced
2 - slightly reduced
3 - normal
4 - bounding pulse
Thyroid Gland Palpation
Distal and lateral to laryngeal prominence
Looking for asymmetries, pain, tenderness, lump or nodule
Only assess based on symptoms (pain / tenderness/ hx of thyroid issues) and visible asymmetries
Deep Cervical Lymph Node Palpation
Only palpate when indicated based on symptoms (recent sickness / infection) and visible asymmetries
Pattern Recognition vs. Diagnostic Reasoning
Pattern Recognition: Forward reasoning / used by expert clinicians
Diagnostic Reasoning: Formation of dx based on physical disabilities and impairments while considering tissue pathology, pain mechanisms, other contributors / used by novice PTs
Tendon Healing Timelines
Tendinopathy: General tendon problem / 3-7 weeks
Tendinosis: Chronic degeneration of a tendon / 2-6 months
Laceration: Cut in a tendon / 5 weeks - 6 months
Insertional: Injury to area where tendon attaches to bone / 3 months - up to 2 years
Muscle Healing Timelines
Exercise-Induced: 0-3 days
Grade I Strain: Small number of fibers stretched or slightly torn / 0-14 days
Grade II Strain: Significant number of fibers torn / 4 days - 3 months
Grade III Strain: Complete rupture of muscle fibers / 3 weeks - 6 months
Ligament Healing Timelines
Grade I: Mild sprain, over-stretching but no tear / 0-3 days
Grade II: Partial tear / 3 weeks - 6 months
Grade III: Complete tear / 5 weeks - 1 year
Graft: Healthy tissue replacing torn ligament / 2 months - 2 years
Bone / Articular Cartilage Healing Timelines
Bone Fracture: 5 weeks - 3 months
Articular Cartilage Repair: 2 months - 2 years
