Exam 1 Flashcards
What are the elements of the patient/client management model?
Examination
Evaluation
Diagnosis
Prognosis
Intervention
Outcomes
What is included in the examination portion of the patient/client management model
History (interview)
Physical Examination (systems review and tests and measures)
What is part of the evaluation part of the patient/client management model ?
-Interpretation of the results to tests and measures with the integration of information collected during the history
-Diagnoses (PT diagnoses)
-Prognosis (optimal level of improvement, establish goals and plan of care)
Intervention is administered based upon _____?
Evaluation
Outcomes of the patient client management model includes what ?
-Did the intervention work?
-Test, Intervene, Re-test
-Improvement in body structures and functions, activities, and participation?
-Goals met or not?
why in the patient client management model is there so many backward arrows?
Being a PT is not linear and it is more “circular”
- circle back to find different plans/methods
What are some examples of demographics taken during patient history part of examination?
- Age
-DOB
-Gender
-Referral source (MD or self)
-Reason for referral
-Occupation
Why is something in documentation marked with an asterisks sign ?
Indicates a problem that you plan to track throughout the plan of care for the patient
What is a chief complaint and where does in belong in the patient client management model?
-In the examination portion
-Patient identified problems (typically marked with an *)
-Essentially the how when and why they are at PT
(PIP, date of injury/diagnoses, mechanism of injury, reason for seeking PT services, SINSS and Body chart)
What is included within the patient history (initial intake) portion of the patient client management model?
-Interview patient (family or caregiver as well)
-Review medical record
-Review intake form
-Combination
What is SINSS ?
Measuring patients symptoms through …
Severity
Irritability
Nature
Stage
Stability
What is included when talking about the Severity of a symptom in SINSS?
Intensity of symptoms as related to functional activity
-Minimal= 0-3/10
-Moderate= 4-7/10
-High= 8-10/10
What is irritability in SINSS and what does it tell us?
Time for symptoms to come and go away; how long it takes for things to flare up and then settle down
-Minimal (low)- tolerates repetitive, sustained activities; pain eases quickly
-Moderate- tolerates brief activities for <10 minutes; onset=ease time
-Maximal (high)- activity not tolerated due to pain; symptoms persist > 30 minutes
What does nature in SINSS tell us? What does it include?
Musculoskeletal vs. non- musculoskeletal
-Type of pain/symptoms=information regarding tissue involved
-Reflection of systems review and differential diagnoses
Ex. When someone says predictable things that irritate them such as certain movements, it would be more musculoskeletal
What does stage tell us in SINSS?
Time frame with symptoms
- realize that the type of injury also affects these timeframes
-Acute Pain: recent onset (0-<3 weeks)
-Subacute pain: later stage of healing or early chronicity (3-<6 weeks)
-Chronic: extended duration, past expected recovery (>6 weeks)
What does the stability stage of SINSS tell us/include?
Progression of patients pain/symptoms over time
-Getting better=improving
-Staying the same= not changing
-Becoming worse= worsening
What type of patients does SINSS mostly deal with?
Musculoskeletal
What is the purpose of a body chart and what type of patient is it typically used for?
Purpose: means of documenting and identifying where patients symptoms are
-Typically used for musculoskeletal patients
-Documented as P1,P2,P3,P4 for different pain areas with a rating scale of 0-10
When looking at a body chart, what type of things are you as a PT gathering ?
-Location of each area of pain/symptoms (P1,P2,..) rated on a 0-10 scale
-Quality/ Type of symptoms: aching, numbness, tingling, burning, stabbing, tightness
-Depth of symptoms: deep/superficial/indescribable
-Frequency/Constancy of symptoms: Constant (C), Intermittent (times where they may not have it)(I) or variable (V)
-Relationships: between areas of symptoms (when pain is present in one area is it present in the other?)
-Clearing all other areas
What is a radicular symptom on a body chart?
Direct stimulation of a nerve root results in a sharp,lancinating pain, well-localized to dermatome
What is a visceral referral when considering a body chart?
Kidney, pancreas, cardiac, etc. can mimic as musculoskeletal pain
What is a somatic referral when considering a body chart?
Symptoms that arise from referral of a musculoskeletal structure (e.g. facet joint)
What are aggravating/easing factors?
What makes the symptoms worse?=aggravating
What makes the symptoms better?= easing
Interpret this:
P2: Int,Deep ache; 3/10
Intermittent pain, deep ache, and 3/10 pain
What does a check mark on a body chart indicate?
That area of the body has been cleared and there appears to be no symptoms of pain that are being derived from that area
What is a “red flag”
-Information gathered that may suggest serious pathology
-Should act as a STOP sign; decide WHO a referral should be made to
-Sometimes based on situation, we immediately refer without continuing examination/evaluation, other times we continue AND REFER
-regardless if it is a red flag you HAVE TO refer
What is an example of a red flag?
-unexplained weight loss
-Severe pain that is unchanged by position/movement
-changes in bowel/bladder function
-Recent persistent history of fever,chills,night sweats, nausea, vomiting
-Symptoms that awaken a patient at night and are not altered by change in position
-Uncontrolled co-more items such as diabetes, hypertension, eating disorder
-Undiagnosed fractures
-Suicide plans or attempts
What is a yellow flag?
-Non emergent conditions or psychosocial factors which require cation and can be monitored while the patient is still being treated; May hinder prognosis
-Must be monitored because they can become emergent or “red flags”
-Can either refer and treat if you feel a referral is necessary or treat and monitor the concern
Factors:
-developing/perpetuating long term disability
-controlled Co-morbidities (that are taken care of;want to watch/pay attention to)(diabetes, HTN,etc)
-depression,anxiety, fear avoidance are yellow flags
What is a review of systems?
Asking the patient about different systems in their body (cardiopulmonary, endocrine, GI, neurological and many more to find out any medical history you may need to know for treatment/that are of concern
What type of information is gained in the social history part of patient history information
-Support systems-family, friends, caregivers etc
-Home environment- city or rural, single or multiple level, steps/stairs/location/handrails, Tub/shower/grab bars, others
-Religious beliefs
What type of info is gained in current health behaviors section of patient history
Drinks per day/week/both
Smoking history-packs per day
Nutrition
Sleep-hours per night
Physical activity- active/sedentary etc
Stress level
What types of motions use osteokinematic/physiological movements?
Active ROM
Active Assistive ROM
Passive ROM
(All the ROMS)
What are osteokinematic/physiologic movements?
Normal types and directions of movements that occur in everyday life
Ex. Raising arms over head for shoulder abduction etc.
- What are Movements that occur between bony surfaces within the joint capsules; essentially invisible to see when someone moves; we aren’t seeing them occur
- where do they occur?
Arthrokinematic/accessory movements
Joint play
AROM
-controlled movements generated by the BODY region that you’re assessing
-no external assistance (no other body parts or people or devices)
-one of the first components of every physical exam
-Helps determine patient willingness to move, quality/quantity of motion, and muscle function
PROM
-patient allows SOMEONE ELSE to take their joints through their available range of motion
-joints and tissues are relaxed and not assisting!
-commonly used to treat individuals where AROM might be contraindicated to keep them moving while minimizing adverse affects from AROM or no movement at all
-want to compare with opposite side
AAROM
Active assistive range of motion
-Motion performed by PATIENT with some amount of OUTSIDE assistance (another person/body parts/external devices like wall/cane/strap etc)
-Typically used to help the transition from PROM to AROM
-Helps determine the amount of assistance necessary to improve the quality or quantity of motion
Joint play is what kind of motion?
Arthrokinematic/Accessory
-Motions that occur between JOINT surfaces that enable the osteokinematic motions to occur
-Can be assesed passively by examiner but cannot be performed actively by the patient
-Not the angular motion the joint is going through but what is going on inside
Close packed position
-Ligaments and capsules are taut (No slack)
-Maximal congruency between joint surface
-Position of maximal joint stability
-Position to avoid for assesment of joint play and mobilization (very little motion available)
What is an example of the close packed position?
Full extension of the knee with external rotation of the tibia
Loose-packed position
-Ligaments and capsule have greatest amount of laxity (slack)
-Joint surfaces maximally separated (least amount of congruency)
-Appropriate position to initiate assessment and joint mobilization
Open-packed position
-Anything outside of the close-packed position (including but not limited to loose packed)
-Appropriate position for mobility assesment and joint mobilization
What position is appropriate to initiate assessment and joint mobilization?
-Loose packed and open packed
Would you use ROM assessments to measure strength? Why or why not?
No
-With AROM you only need as much strength as it takes to move your arm etc but it’s not actively a measurement of how strong you are (that is more manual muscle testing or others to measure strength)
-ROM is only really telling you if something is weak/wrong
what are the two main components of muscle testing?
Muscle length testing (flexibility)
and
muscle strength testing (MMT, gross MT, myotome testig, functional strength testing)
What do we use to determine muscle length?
Flexibility tests to determine if muscle length is normal, limited, or excessive.
-Accomplished by taking all involved joints through their ROM to maximize the distance between the muscle’s origin and insertion
What is the purpose of muscle strength testing?
-how is it performed?
To determine if strength of muscles (muscle groups) is normal or diminished (to determine how they might be impacting someone’s function)
-Accomplished by isolating muscles (muscle groups) and testing their ability to resist movement as provided by the clinician
what are some examples of muscle strength testing?
Manual muscle testing (MMT)
Gross muscle testing (GMT)
Myotome testing
Functional strength testing
Why would you perform muscle strength testing? What are some indications that you need to?
-Diagnoses of peripheral nerve injury or nerve root injuries
-Effects of spinal cord injury and potential recover (can determine level of injury then moitor their recovery)
-Basis for treatment planning and prognosis (any level of strength measured can help us determine their prognosis and guide our decisions for best treatment interventions)
-Determination for need of supportive devices/orthoses(brace)
-Provide measure for treatment progress (see if our treatments are working)
what test is this describing?…
-requires standardized positions
-useful for differentiation at root level of peripheral nerve lesions, muscle pathology, and specific muscle strength
-Determines someone’s ability to voluntarily contract an individual or group of muscles (against manual resistance by therapist)
-used in all settings
Manual Muscle Testing
what test is this describing?…
-variety of positions
-General test of planar movements to assess baseline strength of a muscle or groups of muscles
-want to know amount of weakness present due to injury/disuse to use and monitor for recovery
-Documentation includes position the test was performed
-All settings
Gross Muscle Testing
What type of test assesses the general neurological status of a group of muscles innervated by a specific spinal nerve root
-Graded
“+” finding= significant weakness or diminished resistance relative to the opposite side
“-“ finding= WNL, normal, or intact (specify body region)
-All settings
Myotome testing
What are some examples of functional strength training? How id it graded? What settings is it used in? How is it documented?
-Standardized tests of functional strength
-ex. sit to stand 5 times
-30 second sit-stand test
-arm curl test
-Test specific grading
-All settings
-Documentation [name of test][result]
What are the steps to performing Manual Muscle Testing
- Explain assessment, answer questions, ask permission
- Position patient
- Asses PROM (visually measuring)(necessary to determine what motion is necessary for 3/5 grade
- Screen AROM (to determine if patient has 3/5 strength
- Stabilize as needed (need to stabilize typically proximal tissues to the joint)
- Apply resistance (progressively build over 3-5 seconds)
- Determine grade
- Palpate as needed, if <2/5 and/or when assessing for possible compensations (only with permission)
What does it mean if someone has a grade of MMT of 0/5
-No activity
-Palpation or visual inspection fail to provide evidence of a contraction
What does it mean if someone has a grade of MMT of 1/5
Trace activity
-can detect visually some contractile activity in one or more of the muscles for the action being tested
What does it mean if someone has a grade of MMT of 2/5
Poor
-Able to move the body segment through full ROM when gravity is minimized (typically horizontal plane of motion)
What does it mean if someone has a grade of MMT of 3/5
Fair
- Full ROM against gravity but can only tolerate small/mild amount of resistance?
What does it mean if someone has a grade of MMT of 4/5
Good
- Full ROM against gravity, but unable to hold test position against max resistance (therapist able to break test position)
What does it mean if someone has a grade of MMT of 5/5
Normal
-Full ROM against gravity and able to hold test position against max resistance (therapist unable to break test position)
What can affect “norms” for strength ?
age
gender
area of body
What are some factors reducing grading accuracy and reliability?
Pain
Limited Joint ROM
Muscle Hypertonicity/Spasticity
Lack of Standard Patient Positioning
Others: fatigue, cognition, cultural/social norms
What is anthropometry?
The science that defines physical measurements of a person’s size, form, and functional capacities as defined by the NIOSH (national institute for occupational safety and health)
What are some examples of anthropometrics?
Height
Weight
Body composition
Girth measurements
Volumetric measurements
What does it mean when we are measuring the anthropometric body composition?
Measuring the proportion of lean tissue (also called fat free mass or FFM) to body fat tissue
- Fat free mass=any mass accounted for by muscles, connective tissue, bones, blood, nervous tissue, skin, and organs
What does underwater weighing do and what are the benefits/non-beneficial things about it?
-Computes body composition
-Called a hydrodensitometry (underwater weighing tank with scale and a machine to measure RV)
-Very accurate
-Expensive
-Not the most convenient (takes up lots of space, and some patients may not tolerate being under water/hard transition)
-Nearly all other methods are based on formulas derived from this approach
Sum of skinfolds (calipers)
Least expensive
Grabbing subcutaneous skin and not muscle
3-7 standard locations to perform it
Errors more likely in individuals who are obese or extremely thin
Most widely accessible
Accurate when done correctly
Why would we take girth measurements?
Muscle atrophy/hypertrophy
Edema (many cond. listed under this)
Fitting equipment
Track progress via comparisons to baseline measurements or contralateral extremity
ALWAYS TAKE MEASUREMENTS BILATERALLY (both sides when possible but if not then at least take measurement of un-injured side to have a baseline)
What are some guidelines when using a tape measure?
-Use bony landmarks or weight bearing surface as starting point or location that are easy to reproduce (15cm distal to knee joint line)
-Mark starting point with skin safe marker
-use nonelastic yet flexible tape
-Tape should be snug but avoid excessive indentation of the skin
-Maintain contact with skin (or through tight form fitted clothing)
-2 measurements and take the average
-Allow 20-30 seconds between measurements (incase there is any indentation in the skin)
What should be included when documenting girth measurements?
-Patient positioning
-Distance from easy to identify landmarks
-Units of Measurement (cm. vs. inches)
-Baseline measures, contralateral “norms” (when available)
Why do we use volumetric measurement?
-For complicated extremities like the hand or foot that are not easily measured by regular measuring tape for girth
-Uses concept of displacement
-More accurate than girth measurements
-Best for distal extremities
-Equipment: volumeter with spout and calibrated collection container
-Be careful if working with open wounds (avoid cross-contamination)
Line of gravity
-straight through axial spine
-line that extends from center of gravity through base of support (feet)
(remember the pictures of people forward bending or carrying things without proper positioning)
Center of gravity
-Lies right at the level of S2 in the spine/sacrum
-Want to get lower and hold things closer to keep them in your center of gravity
-ex. holding a box out in front of you therefore it shifts center of gravity from S2 point out to somewhere in between the box and your spine
ex. holding a weight close to you rather (lowers strain on spine)
Base of Support
Foot position
-Width=under hips
-Or one foot forward
Direction:
-Pointed toward movement
-Approximately perpendicular
What are the 5 cardinal rules of body mechanics
-keep load close
-create appropriate base of support
-Use isometric contraction of trunk
-Lift with legs (corset affect)
-Do not twist
Rank these from lowest to highest stress on the spine:
-Supine
sitting
-standing erect
-Standing with forward lean
-Sitting with forward lead
Lowest=
supine
standing erect
sitting
standing with forward lean
Highest stress: sitting with forward lean
Definition and purpose of body mechanics
-the use of ones body to produce motion that is safe, energy efficient and maintains body balance and control
-Limit stress and prevent cumulative trauma
What are the three components of body mechanics
gravity
base of support
movement
what is it called when your base of support is one foot forward
T position
what is the corset affect
using larger muscles to move while maintaining stable core
what are three safety considerations when using body mechanics?
Plan ahead
Alternatives
Equipment
what is part of the planning ahead portion of the safety considerations of body mechanics?
Visualize- path of movements and hazards
Help- know limitations and have good communication
