Exam 1 Flashcards
Why is the examination process important?
Helps determine the patient’s initial functional level
- also reveals interests and goals
What are the other rationales for the examination process? (3)
- set goals based on the findings in the exam
- re-evaluate functional level
- reset goals for the rehab plan
What is objective data?
What you see
- HR, BP, # of feet a person can walk (signs)
What is subjective data?
What the patient tells you
- I feel tired, im in pain, (symptoms)
What does the documentation consist of?
- Medical records
- Physical chart
- Communication tool w/ other health care providers
- it is legally required
True of False:
If it is not documented, it did not happen.
True
What do you NEED to include in the documentation of a patient?
- history
- outcomes measure questionnaire
- Inspection
- Palpation
- Joint and Muscle Function (ROM, MMT)
- Joint Stability Tests
- Special Tests (MD, PT, OT, KT)
- Neurologic Testing
- Vascular Screening
- Mobility tests
- Ability to perform ADLs
- Standardized testing
True or False:
You shouldn’t examine the right leg if the left leg is injured.
False, you must examine BOTH legs for comparison purposes.
Which limb should you measure first in the examination process and why?
Measure the non-injured limb first because this will decrease apprehension (nerves) and help the patient relax because he/she will know what to expect.
What are the 4 main special considerations for a clinical assessment?
- Keep modesty in mind if patient needs to wear a hospital gown. (patient needs to be comfortable)
- Keep patient covered as much as possible
- Religious and cultural considerations
- Physician’s order for KT (specifically)
True or False:
You always need a physician’s order when doing a clinical assessment.
True
True or False:
Medical records can be computerized or written.
True
When should you and should you not use open ended questions when assessing a patient?
SHOULD: to find more information about them to understand their situation better
SHOULD NOT: time running out, critical pain, bad mood
What does Past Medical History consist of?
- Medical records, Non-actue examinations
- health conditions, known pathologies
- previous injuries/surgeries
- predisposing factors
What do Previous History Questions consists of?
- Is there a history of injury to the body area? On either side?
- describe and compare current injury
- do the current symptoms duplicate the old symptoms? - Are there any possible sources of weakness from a previous injury?
What are the 4 main points of Past Medical Health?
- General medical health (current health status)
- Relevant illness and lab work (review radiology reports)
- Medications (what are they currently taking? CHECK VITALS)
- Smoking/heavy alc use (decrease exercise tolerance, increased risk for CVD, may delay healing time)
What does MOI stand for?
Mechanism of Injury
What is the difference between macrotrauma and microtrauma?
Macro: happens immediately
Micro: happens overtime
What should you document when dealing with pain?
- location
- type
- referred (heart, back, neck, arm)
- radicular
- daily pain patterns
- provocation and alleviation patterns
1. other symptoms
2. treatment to date
3. does the patient want to get better?
4. disability or limitations
What are the goals of the physical examination process? (2)
- physician determines clinical diagnosis
- therapist identifies impairments and functional limitations
When does inspection of the patient begin?
as soon as the patient walks through the doors
What does inspection consist of?
- gait
- posture
- function
- guarding
- splinting
- walking aids
How should you palpate a patient with pain?
bilaterally moving out to towards the pain
What should you look at in a physical examination?
- deformities
- swelling
- skin condition(s)
- signs of infection
What does the joint and muscle function assessment function involve?
- AROM
- PROM
- MMT
- Joint stability tests (stress test, joint play)
What is laxity?
clinical sign of the amount of “give” within a joint
What is instability?
joint’s inability to function under the stresses of functional activity
What is hypomobile?
below normal laxity
What is hypermobile?
above normal laxity
What are special tests?
Specific tests designed to indicate particular injuries or problems. These tests can either decrease or increase symptoms. Reported as positive or negative.
What is dermatone?
area of skin innervated by a spinal nerve root
How is sensory testing performed?
- patients eyes are closed
- use of feeling in the skin (dull or sharp feeling from an object)
True or False:
If one muscle is weak, suspect muscle pathology or peripheral nerve pathology.
True
True or False:
If both muscles are weak, suspect nerve root or peripheral nerve pathology.
True
In reflex testing, an increased response leads to …
higher motor neuron lesion
In reflex testing, a decreased response leads to …
lower motor neuron lesion
In deep tendon reflex (DTR), how should it be performed?
- muscle stretched and relaxed
- patient should look away
- strike tendon with reflex hammer
- Jendrassik maneuver for difficult patients (distract them from area being tested)
What does bed mobility testing consist of?
rolling left and right, scooting, moving, supine to sit, sit to stand
What do transfers testing consist of?
bed to chair
chair to chair
wheel chair to toilet
wheel chair to car
What do gait evaluation testings consist of?
stability, level of dependence, distance, velocity
What are the 3 normal curvatures of the spine?
- lordotic (cervical)
- kyphotic (thoracic)
- lordotic (lumbar)
What are the facet joints?
the connections between the bones of the spine
What are the intervertebral foramen?
the holes where the nerves run through
What is nerve plexus?
a branching or intersecting of efferent and afferent nerve fibers
Where is the lumbar plexus and what does it innervate?
T12-L5
innervated anterior and medial muscles of the
- thigh
- medial leg
- foot
L2-L4
- posterior branches form the femoral nerve, innervates hip flexors and knee extensors
- anterior branches form the obturator nerve, innervates hip adductors
Where is the lateral cutaneous nerve and what does it innervate?
L2-L3
innervates the lateral part of the thigh
Where is the sacral plexus and what does it innervate?
L4-S3
innervates the buttocks, posterior thigh, and entire lower leg
Where is the sciatic nerve and what is special about it?
L4-S3
longest and widest nerve in the body, can feel pain, burning, tingling, and numbness when damaged
What are the following symptoms of a vertebral disc lesion?
- loss of water
- decreased protein
- altering chemical structure
What is a disc herneation?
extrusion of the nucleus pulposus through the annulus fibrosus
True or False:
Spinal stenosis is the narrowing of the spinal canal or intervertebral foramen
True
In which age population is spinal stenosis most common in?
50+
Which pathology is known as the Collared Scotty Dog?
Spondylolysis
What is spondylolysis?
defect in the pars interarticularis (Fx)
- the lower back pain restricts extension
What is spondylotisthesis?
- can be a progression of spondylysis
- decapitated scotty dog
What is a sacroilliac dysfunction?
ilium rotates and subluxates on the sacrum
- mobility at SI joint is 2 mm or less
What are the causes of a SI dysfunction?
injury of pubic symphysis
tight hamstrings
tight hip flexors
What is the clinical evaluation of the thoracic and lumbar spine?
- past med history, back surgeries, gen health, changes in activity, mental health status
- history of present conditions
- location of pain
- onset of pain
- severity of pain
- MOI
- consistency of pain
- bowel or bladder control
- disability with LBP
Outcome questionnaire for LBP interpretation of scores:
0-20%: minimal disability
21-40%: moderate disability
41-60%: severe disability
61-80%: crippled
81-100%: patient is either bed-bound or exaggerating their symptoms
Inspection of the thoracic spine:
- breathing patterns
- bilateral comparison of skin folds
- shape of the chest
Inspection of the lumbar spine:
- lordotic curve
- standing posture
- paraspinal muscle tone
What are the spinal landmarks?
T2- posterior from the jugular notch of the sternum
T3- even w/ medial border of scapular spine
T7- even w/ inferior angle of scapular
L3- posterior to umbillicus
L4- level w/ illiac crests
L5- back dimples
S1-S2- level of the PSIS
Which landmarks of the spine do you use for tape measuring ROM of spine flex and ext?
C7 and S1
What is the Hoover Special Test?
Used to identify if a patient is actually exerting effort during the test. Positive test shows patient is malingering
- performed in supine position
- attempt straight leg raise on involved side
- Positive test indicates patient does not attempt to lift the leg and the examiner does not sense pressure from the uninvolved leg pressing down on the hand
What is Adam’s Special Test for Scoliosis?
Postieror view of the spinal column while the patient flexes the spine; note the presence of a hump over the left thoracic spine, suggesting scoliosis
- standing with hands in front arms straight
- patient bends forward sliding hands down legs
- Positive test indicates an assymetrical hump is observed over the lateral aspect of the thoracolumbar spine
What is the SLR Test?
The uninvolved leg is flexed at the hip until symptoms are experienced. The involved leg is extended approx 10 degrees and ankle is passively dorsiflexed
- performed in supine position
- therapist gently raises leg in air until pain.
- if pain is before 70 degrees, the test is positive for sciatic nerve irritation
- if pain is before 30 degrees, the test is HIGHLY positive
What is the Slump Test?
Designed to place progressively more tension on the nerve and nerve roots by changing positions and then systematically positioning the patient to provoke or alleviate symptoms
- sitting over edge of table
- patient flexes thoracic spine, forward shoulders, flex neck, extend legs, dorsiflex ankle
- if pain begins then relieve the last movement
- pain at anytime is positive for sciatic nerve or other spinal root irritation or irritation of the dural lining of the spinal cord
What is the Quadrant Test?
The patient (standing) moves into extension, followed by side bending and rotation to the same side. The examiner applies pressure to emphasize the position
- if patient is older, may have them sit for balance reasons
- have patient extend spine, side bend, and rotate toward the involved side. Therapist apply pressure downward on shoulders
- Positive if patient complains of any pain on the involved side which indicates nerve root compression
What is Femoral Nerve Test?
The femoral nerve (L2,L3,L4) is placed on stretch by passively flexing the patient’s knee. Nerve root impingement will result in radicular pain the in anterior and or lateral thigh
- patient is in prone position
- therapist passively flexes the knee and extends hip while stabilizing body.
- Positive is complaints of pain in anterior thigh which indicates femoral nerve irritation
What is Sacroiliac Special Test?
SI joint compression test. Spreading the ASIS compresses the SI Joint.
- compression is side-lying and distraction is supine
- compression: examiner applies pressure to spread ASIS…distraction: the examiner applies pressure down through the anterior portion of the ilium
- Positive score if pain is felt
What is Fabere Test?
Also known as Patrick’s Test
- patient is supine with involved leg crossing over the other making a triangle (flexed, abducted, externally rotated)
- place one hand on the knee and the other over the opposite ASIS, press on both at the same time
- if complaints of pain, test is positive for SI joint or hip joint pathology
Pathologies and Related Special Tests of the Thoracic Spine (3):
- can affect respiration
- pathologies can refer to pain in thoracic spine
- cancer, gallbladder, and gastroesophageal conditions
Pathologies and Related Special Tests of the Lumbar Spine (1):
- pathologies that can be mistaken as LBP can be kidney infection, CA, or other pathologies. Kidneys are located just above the pelvis and lumbar spine.
Regarding the spine, what are 3 typical KT treatments?
- Postural Control Education
- Core Stability Exercises
- Biomechanical Education
Mobility testing regarding the spine (11)
- Bed mobility, transfers, gait
- Independent (no help)
- Modified independent (assistive device only)
- Supervision (cueing, set-up)
- Stand-by assist (needs a helper close by)
- Contact guard assistance (helper holds onto gait belt)
- Minimal assist (patient does 75%+)
- Moderate assist (patient does 50-74%)
- Maximal assist (patient does 25-49%)
- Total assist (patient does 24-0%)
- Log roll technqiue
True or False:
There are a total of 7 bones in the pelvis.
True
2 ischium
2 pubic
2 illial bones
sacrum
How many joints are in the hip and what are they?
5 joints
- 2 acetabularfemoral
- 2 SI
- 1 pubic symphysis
What type of joint is the hip?
ball and socket
What is the iliofemoral ligament also known as?
- Y ligament
- Ligament of Bigelow
True or False:
The iliofemoral ligament is supposed to be the strongest ligament in the body
True
What action does the iliofemoral ligament help prevent?
hyperextension of the hip
True or False:
The TFL (tensor fascia latae) is on the posterior side of the leg.
False, it is on the lateral side
What is the site called where the iliotibial band meets the tibia?
Gerdy’s tubercule
What are the motor functions of the femoral nerve?
leg flexion at the hip
leg extension at the knee
What are the motor functions of the obturator nerve?
adduction of the thigh
True or False:
The name of the sciatic nerve changes with each bone it passes by.
True
Pertaining to the pelvis and thigh, what should you get from the patient’s past medical history?
- prior medical conditions
- surgeries
What should be included with the history of the present condition?
- location of symptoms
- onset
- MOI
- aggravating activities
- what alleviates pain
- training techniques
- pre-program hip pain and “hip disability questionnaire”
What is coxa vara known as?
genu valgus
What is coxa valga known as?
genu valgum
What is the angle of inclination in the hip
125 degrees, slightly decreased in women
What is the normal degrees for angle of torsion?
15-20 degrees anteversion
What are anteroverted hips?
(increased angle 21+ degrees) internal femur rotation and toe in gait
What are retroverted hips?
(decreased angle less than 15 degrees) external femur rotation and toe out gait
What can anteversion lead to?
tibial torsion
What should the inspection of the pelvis and thigh consist of looking at?
- limping or iliac crests unequal could be leg length discrepancy (pain with >2cm difference
What is the femoral triangle? (muscles/ligament)
- inguinal ligament
- sartorius muscle
- adductor longus
What is in the femoral triangle? (nerve, vein, artery)
- femoral nerve
- femoral artery
- femoral vein
Where is the inguinal ligament?
between the ASIS and the pubic tubercles
True or False:
If feel unusual bulges along the inguinal ligament, it may be an inguinal hernia.
True
Where is the femoral artery?
Passes under the inguinal ligament and is palpable inferior to the midpoint of the inguinal ligament
True or False:
The femoral nerve and the femoral vein are palpable.
False
A ______ sac overlies the greater trochanter of the hip.
bursa
True or False:
The bursa sac itself is not palpable unless inflamed
True
Where should you palpate for the guided by “point to where it hurts test”
gracillis
adductor longus/magnus/brevis
Palpation points of the anterior structures of the pelvis and thigh:
- pubic bone
- inguinal ligament
- ASIS
- AIIS
- Sartorius
- Rectus femoris
Palpation points of the lateral structures of the pelvis and thigh:
- Iliac crest
- TFL
- Glute med
- IT band
- Greater trochanter
- Trochanteric bursa
Palpation points of the posterior structures of the pelvis and thigh:
- Median sacral crest
- PSIS
- Glute max
- Ischial tuberosity and bursa
- Sciatic nerve
- Hammies
What is the Trendelenburg Test for Glute Med Weakness?
Patient is asked to stand on affected leg. In presence of weak glute med, the pelvis lowers on the opposite side of the affected leg.
- patient is standing
- positive test indicates weak glute med
What is the Thomas Test/Rectus Femoris Contracture Test?
TT: Tests for tight hip flexors. Patient’s left leg is tested. Tightness of left rectus femoris muscle, tightness of iliopsoas muscle group.
RFCT: (a modification of the TT). patient is positioned so the knee of the test leg is off the table. tightness of hip flexors results in the opposite knee and hip flexing.
- TT: lying prone on table
- RFCT: lying supine with knees bent at end of table
- one leg is passively flexed to patient’s chest allow the knee to flex during the movement, the opposite leg rests flat on the table
- Positive test indicates the the lower leg moves into extension and the involved leg rises off the table
What is Ely’s Test?
Ely’s test for hip flexor tightness. Passive flexion of the knee results in hip flexion, causing it to rise off the table
- patient is lying prone
- knee is passively flexed towards patient’s buttocks
- Positive test indicates that the hip on the side being tested flexes causing it to rise from the table.
True or False:
A slipped capital femoral epiphysis is the displacement of the femoral head relative to the femoral neck.
True
In a slipped capital femoral epiphysis, the femoral head __________ in acetabulum.
In a slipped capital femoral epiphysis, the femoral neck __________ anteriorly
remains / displaces
True or False:
slipped capital femoral epiphysis is the most common hip disorder in older adolescents that are overweight.
True
What are 3 degenerative hip changes?
- Arthritis
- Acetabular labrum tears
- Avascular necrosis
What does the “C” sign indicate? (patient uses hand in a C shape around area of pain.)
indicates intra-articular pathology
What is the Hip Scouring (Hip Quadrant) Test?
This procedure moves the hip through its ROM while an axial load is placed on the femur.
- patient is supine
- the examiner passively flexes patient’s knee and applies pressure downward along the shaft of femur to compress the joint surfaces internal and external rotate
- Positive score indicates pain or symptoms felt in the hips
What are 2 causes of labral tears?
- Hip dislocations
- Repeated subluxations
What is piriformis syndrome?
- sciatic nerve passes under or through the piriformis
- tightness spasm or hypertrophy
- pressure on the sciatic nerve
What is the Piriformis Syndrome Test?
- Patient in supine position
- Tester flexes the leg to 90 degrees and then carefully applies pressure moving the knee toward the opposite shoulder.
- Positive test means pain was felt in the buttock and sciatica areas
What are the 3 precautions for a total hip arthroplasty?
- No hip flexion beyond 90 degrees
- No adduction past the midline
- No internal rotation past the midline
What is the goal of the precautions concerning a total hip arthroplasty?
prevent dislocation
Posterior lateral approach notes:
- involves cutting the hip ext rotators and posterior hip capsule with an incision between the glute max and med
- spares the hip abductors but most suceseptible to posterior dislocation
- Individual should avoid
1. hip flex past 90 degrees
2. hip adduct past midline
3. hip int rot past neutral - rules typically followed for the first 8 weeks
Anterior lateral approach notes:
- utilizes a lateral curved incision that cuts through the glute mini, glute max, TFL, vastus lat, and anterior capsule
- spares the posterior elements of the hip but violates the hip abductors
- Individual should avoid:
1. combined hip ext rot and flexion
2. hip adduct past midline
3. hip int rot beyond neutral - decreased dislocation rate
Anterior approach notes:
- utilizes an anterior incision between the TFL and sartious, which affects only the anterior capsule
- the anterior incision does not violate the contractile and connective tissues around the hip, except for the surgical site
- Individual should avoid:
1. hyperextension of the hip
2. extreme hip ext rotation
What does ORIF stand for?
Open reductio internal fixation
True or False:
ORIF will not have the same precautions as a total hip replacement
True
What weight bearings are included with ORIF?
(most likely to be partial weight bearing)
- non weight bearing
- toe touch weight bearing
- touch down weight bearing
- partial weight bearing
- 50% weight bearing
- weight bearing as tolerated
