1.0) Outcome Procedures

Question 1

MRC procedure

Answer 1

1. Unclothe the part of patient needed to allow palpation and observation of the muscle to be tested. Give clear explanations to the patient and demonstrate.
2. Test good side first. Assume this will be grade 5 test for grade 5 only.
3. For the affected side, check the available range by passive movement

4.Then, starting from grade 0, progressively test the affected side. Stop
progressing through the grades if the patient cannot achieve the next grading. Record the highest grade achieved /5 (e.g. 3/5)

Question 2

0-2

Answer 2

1. Position the patient to eliminate the effect of gravity on the movement. Support limb either manually or using a re-ed board.
2. Check for a contraction visually and by palpation of the muscle belly
3. Use the mid-range (strongest) to assess for grade 1 contraction= flicker

4.For grade 2, check that the movement can be completed through full available with gravity counterbalanced
range.

Question 3

3

Answer 3

1. Position the patient to allow the movement to occur against gravity
2. Check that movement can be completed through full range
3. Isolate the movement to prevent any trick movements- eg tilted pelvis hip adduction

Question 4

4

Answer 4

1. Same as grade 3 but with added resistance
2. Upper limb 0.5kg
3. Lower limb 1kg

Question 5

5

Answer 5

1. Same as grade 4 but with maximal resistance
2. The resistance may be applied by a heavy hand/ankle weight or the therapist

– position yourself at a mechanical advantage and ensure you can resist the movement evenly throughout range.

3. If the muscle group allows for it, the patient’s own body weight may be used as a maximal resistance eg plantar flexors
4. Consider whether the muscle can work effectively as an agonist, antagonist, synergist, fixator, eccentrically, concentrically for short burst and sustained activity.

Question 6

Range of Movement Assessment

Explanation

Answer 6

It is necessary in clinical practice to measure the available range of passive and active movement of the joint to produce a problem list and evaluate the success of treatment

Question 7

Range of Movement Assessment

Methods

Answer 7

Goniometry

Inclinometer

Tape measure

Question 8

To improve reliability of a specific measurement the following guidelines should be followed:

Answer 8

▪️Unclothe the part of the body you want to observe and palpate

▪️Choose a starting position which allows the joint to be positioned at zero (anatomical position) and allows patient to move through the full available range for that joint

▪️Stabilise the proximal joint segment E.g. forearm on a table for wrist movement

▪️Instruct patient to perform the movement slowly and smoothly observe for patient using trick or substitute movements

▪️Observe the movement estimate the joint range before measure

▪️Measure good side first

▪️Measure bad side more than once to improve reliability

▪️Record the measurement accurately

Question 9

What is a Goinometer used for

Answer 9

To assess the range of movement in peripheral joints

It allows a physio to measure the degree is through which a joint moves

It is most commonly used for joint movements in the sagittal and frontal planes

Question 10

How do you improve the reliability of Goniometery

Answer 10

Bony landmarks are used to determine the placement of the axis – placed on joint line and the arms of the goniometer with other honey land marks

Eg knee flexion: instruct bring heel to bum bend knee as far as possible

🔹Start position: 1/2 or supine lying

🔹Axis position: lat fem con

🔹Stationary arm:GT femur

🔹Moving arm: lat malleolus

Question 11

What is zero degrees

Answer 11

Usually the position of the joint in the anatomical position and the starting point but the patient may not be able to achieve this position

Question 12

Goniometer procedure

Answer 12

▪️Select the appropriate size of goniometer

▪️Measure the unaffected side once first, then the affected side twice.

▪️Visually inspect the active range of movement and estimate the available ROM – this will help you to know which scale to read from on the goniometer

▪️Consider whether the joint has moved through the zero point of that ROM (e.g. if the patient was able to move their wrist from a flexed position to an extended position, they will have moved through zero degrees of both wrist flexion and wrist extension).

▪️Position the patient in the appropriate starting position (Table )

▪️Identify the bony landmarks for the axis and arms of the goniometer, mark the axis using a washable pen if the landmark is difficult to visualise.

▪️If the joint has not obviously moved through zero degrees of the range of motion, measure and record the starting position in degrees.

▪️Instruct the patient to carry out the active movement – you can follow the movement with the arms of the goniometer but this is not essential

▪️Measure the position of the joint at end-range by lining up the goniometer with the relevant bony points.

▪️Record the end-range in degrees. For the affected side, take the average (midpoint) of your two readings.

▪️Record the range from starting point to and end point (e.g. 0-90 degrees or (10-120 degrees). This is your range of movement and should be recorded for both sides.

Question 13

What is the difference between extension and hyper extension

Answer 13

Extension = natural follows flexion

Hyperextension =motion opposite flexion beyond 0°it will be a - number

Can occur at elbow and knee:
Knee flexion 0-130° + 10° hyperextension

Question 14

Why would you use an Inclinometer

Answer 14

Measuring neck ROM where goniometer is impossible can also be used to measure shoulder ROM

Question 15

Inclinometer Procedure

Answer 15

Very similar to goniometer with additional considerations

Question 16

Inclinometer Procedure

Peripheral joints:

Answer 16

▪️The Velcro strap is applied around the limb distal to the joint

▪️Attach the goniometer laterally if the movement takes place in the sagittal
plane

▪️Attach the goniometer anteriorly if the movement takes place in the coronal
plane

Question 17

Inclinometer Procedure

Neck movements:

Answer 17

▪️The Velcro strap is applied around the forehead and above the ears

▪️Attach the goniometer laterally for cervical flexion & extension

▪️Attach the goniometer anteriorly for side flexion

Question 18

Inclinometer Procedure

All inclinometry

Answer 18

▪️Align the compass needle with zero by turning the white dial on the device until the indicator lines up with the zero mark

▪️Instruct the patient to carry out the movement and record the final position in degrees

Question 19

Tape measure

Answer 19

For movements that cannot be measured by either goniometry or inclinometer through a tape measure is used to measure ROM

Question 20

What are Special Tests used for

Answer 20

To assess the patient initially and/or to use as an ongoing outcome measure to assess the effectiveness of an intervention

Question 21

Special Tests

Visual Analogue Scale

Answer 21

Simple tool to measure pain.

Patient indicates their pain by marking a line on a 10 cm line one and says no pain other and says worst pain imaginable

1 I——————————2l————— 3l

1: No pain
2: patients perceived pain
3: worst pain imaginable

*Measure in mm from the left= VAS score

Question 22

Numerical Rating Scale

Answer 22

What is your pain 1-10

Question 23

Special Test

Peak Expiratory Flow Rate

Answer 23

Simple, cheap test that measures maximum expiratory flow rate (fastest speed patient can breathe out) using a peak flow meter.

Monitor asthma

Healthy adults normal PEFR is 400- 650 litres/min which varies according to age, height and sex.

Question 24

Procedure peak flow

Answer 24

▪️Explain to the patient the purpose of PEFR and obtain consent.

▪️Attach a clean or disposable mouthpiece

▪️Set the arrow to the zero mark

▪️Position the patient upright - preferably standing up

▪️Ask the patient to take a maximal inspiration then to close their lips around the mouthpiece and to exhale as forcibly as possible

▪️Record score

▪️Repeat the 3 times ensure arrow is reset to the zero mark

▪️Dispose of the mouthpiece (if appropriate), and ensure equipment is clean

▪️Record all 3 readings and indicate the highest value reached (best of three) L/min

▪️Compare the measurement against a recognised chart of normal values

Question 25

What should PEFR readings be viewed in addition to

Answer 25

Ideally should be viewed as a trend alongside other data rather than a single measurement.

Comparison to a patient’s own usual reading will be most helpful clinically.

Question 26

Special Test

Outline the Balance Test

Answer 26

Assess and monitor progression of static standing balance.

All tests to be completed once for 60 seconds on each leg if the patient is safe to do so.

The patient should have bare feet.

Record the time that the test was stopped (will be ≤60 seconds).

Consider patient safety at all times e.g. by positioning the patient within grabbing distance of a plinth and positioning yourself close to the patient.

Question 27

Timed Single-Leg Stance

1. Eyes Open Test

Answer 27

Stand on one leg, place your arms across your chest with your hands touching your shoulders

Don’t let your legs touch each other.

Look straight ahead with your eyes open and focus on an object about 3 feet in front of you.

Question 28

Criteria to stop timing the test:

Answer 28

Legs touched each other

Feet moved on the floor,

Foot touches floor

Arms moved from their start position

Question 29

2. Eyes Closed Test

Answer 29

Stand on one leg, place your arms across your chest with your hands touching your shoulders

Don’t let your legs touch each other

Look straight ahead with your eyes open and focus on an object about 3 feet in front of you

Close your eyes

Question 30

Criteria to stop timing the test:

Answer 30

Legs touched each other

Feet moved on the floor,

Foot touches floor

Arms moved from their start position

Eyes opened

Question 31

Special Test

Outline the Figure of Eight Method

Answer 31

Assessing and quantifying ankle oedema.

Performed once on the unaffected side and twice on the affected side.

The patient is in long sitting with the knees extended (may use a pillow under the knees for comfort) and the ankles in a neutral position.

Question 32

Special Test

Figure of Eight Method- Boney Landmarks

Answer 32

> Tuberosity of the navicular

> Base of 5th metatarsal

> Tip of medial malleolus

> Tip of lateral malleolus

> Tibialis Anterior tendon

Question 33

Special Test

Figure of Eight Method- Procedure

Answer 33

a) Place the zero on the tape measure midway between the Tibialis Anterior tendon and the tip of the lateral malleolus.
b) Take the tape medially across the instep and inferior to the tuberosity of the navicular
c) Bring the tape across under the medial longitudinal arch and laterally to just proximal to the base of the 5th metatarsal.
d) Take the tape measure around the ankle to the distal tip of the medial malleolus and then across the Achilles tendon towards the tip of the lateral malleolus.
e) Take the tape back to the zero point
f) Record the length in millimetres & take the average of 2 readings

Question 34

Special Test

Outline the Timed Up & Go

Answer 34

Measure of functional mobility.

Used particularly with elderly

Identifies patients who are at risk of falling.

Question 35

Special Test

Preparation Timed up and go Test

Answer 35

Chair with a line on the floor 3 metres away.

Patients wear their usual footwear and use their usual walking aid.

One untimed practice attempt followed by one timed attempt (after an appropriate rest period if required).

Question 36

Special Test

Procedure Timed up and go Test

Answer 36

1. Ensure the patient starts with their back against the chair and feet flat on the floor.
2. Say to the patient: “when I say go, I want you to stand up from the chair, walk to the line on the floor at your normal pace, turn and walk back to the chair then sit down”
3. Start timing using a stopwatch when you say “Go”.
4. Stop the timing when the patient’s bottom sits back down on the chair.
5. Record the time in seconds.