Exam 1 Flashcards
Active cancer (treatment ongoing, treatment
within last 6 months or receiving palliative
care) Well’s score? Well’s score?
+1
Calf swelling ≥ 3 mm compared to
asymptomatic calf (measured 10 cm below
tibial tuberosity) Well’s score?
+1
Swollen unilateral superficial veins (nonvaricose,
in symptomatic leg) Well’s score?
+1
Unilateral pitting edema (in symptomatic leg) Well’s score?
+1
Swelling of entire leg Well’s score?
+1
Localized tenderness in center of posterior
calf, popliteal space, or femoral vein in
anterior thigh/groin, or along distribution of
Deep Venous System Well’s score?
+1
Paralysis, paresis, or recent immobilization of
lower extremities Well’s score?
+1
Recently bedridden ≥ 3 days, or major
surgery in last 12 weeks requiring general or
regional anesthesia Well’s score?
+1
Alternative diagnosis at least as likely (i.e.
cellulitis, postoperative swelling, calf strain) Well’s score?
-2
-2 to 0 Well’s score?
Low probability of DVT (3%)
1 to 2 Well’s score?
Moderate probability of DVT (17%)
≥ 3 Well’s score?
≥ 3 High probability of DVT (75%)
FLACC stands for?
Face Legs Activity Cry Consolability
For FLACC Each category is scored on the 0–2 scale, which results in a total score of ?
0–10
FLACC score of 0 means?
Relaxed and comfortable
FLACC score of 1-3 means?
Mild discomfort
FLACC score of 4-6 means?
Moderate pain
FLACC score of 7-10 means?
Severe discomfort or pain or both
Using the FLACC in patients who are awake?
Observe for 1 to 5 minutes or longer. Observe legs and body uncovered. Reposition patient or observe activity. Assess body for tenseness and tone. Initiate consoling interventions if needed.
Using the FLACC in patients who are asleep?
Observe for 5 minutes or longer. Observe body and legs uncovered. If possible, reposition the patient. Touch the body and assess for tenseness and tone.
The McGill Pain Questionnaire can be used to?
Evaluate a person experiencing significant pain. It can be used to monitor the pain over time and to determine the effectiveness of any intervention.
The McGill Pain Questionnaire minimum pain score?
0 (would not be seen in a person with true pain)
The McGill Pain Questionnaire maximum pain score?
78
The McGill Pain Questionnaire, the higher the pain score?
The greater the pain
An embolus (a mass of undissolved matter present in a blood or lymphatic vessel) in a pulmonary artery or one its branches?
Pulmonary Embolism
PE Well’s score for Clinical signs of DVT?
3
PE Well’s score for HR >100 bpm?
1.5
PE Well’s score for immobilization for 3 days or longer, or surgery in previous 4 weeks?
1.5
PE Well’s score for previous dx of PE or DVT?
1.5
PE Well’s score for hemoptysis?
1
PE Well’s score for patients receiving cancer tx, stopped in past 6 months, or receiving palliative care?
1
PE Well’s score for alternative dx less likely than PE?
3
PE Well’s score of <2 pts?
Low
PE Well’s score of 2-6 pts?
Moderate
PE Well’s score of >6 pts?
High
This scale quantifies muscle spasticity by assessing the response of the muscle to stretch applied at
specified velocities?
TARDIEU scale
For Tardieu grading is always performed at?
The same time of day, in a constant position of the body for a given limb.
For Tardieu each muscle group, reaction to stretch is rated at?
A specified stretch velocity with 2 parameters x and y.
For Tardieu V1 is used to measure?
PROM
For Tardieu V2 & V3 are used to rate?
Spasticity
For Tardieu V means?
Velocity to stretch
For Tardieu X means?
Quality of muscle reaction
For Tardieu Y means?
Angle of muscle reaction
No resistance throughout passive movement = Tardieu?
Tardieu score 0
Slight resistance throughout, with no clear catch at a precise angle= Tardieu?
Tardieu score 1
Clear catch at a precise angle, followed by release = Tardieu?
Tardieu score 2
Fatigable clonus (<10 secs) occurring at a precise angle = Tardieu?
Tardieu score 3
Unfatigable clonus (>10 secs) occurring at a precise angle
Tardieu score 4
Joint immobile= Tardieu?
Tardieu score 5
Angle of catch seen at Velocity V2 or V3 ?
R1
Full range of motion achieved when muscle is at rest and
tested at V1 velocity?
R2
A large difference between R1 & R2 values in the outer to middle range of normal m. length indicates?
A large dynamic component
A small difference in the R1 & R2 measurement in the middle to inner range indicates?
Predominantly fixed contracture
No increase in muscle tone
Modified Ashworth score of?
0
Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension
Modified Ashworth score of?
1
Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the ROM
Modified Ashworth score of?
1+
More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved
Modified Ashworth score of?
2
Considerable increase in muscle tone, passive movement difficult
Modified Ashworth score of?
3
Affected part(s) rigid in flexion or extension Modified Ashworth score of?
4
Which is the newest special interest group?
Assistive Technology/Seating & Wheeled Mobility
PD, MS, ALS, HD & others fall under which special interest group?
Degenerative Diseases
Payment for each patient is based on information in the?
Patient Assessment Instrument (PAI)
IRF PPS stands for?
Inpatient Rehabilitation Facility Prospective Payment System
Section GG?
Functional Abilities and Goals**
Section GG: Prior Function: Scores range from?
Dependent (1) - Independent (3)
Unknown (8)
N/A (9)
Section GG: Mobility: Scores range from?
Dependent (1) - Independent (6)
Patient refused (7)
N/A (9) for both self care and mobility
Interdisciplinary Team Model 3 key elements?
Activities
Problem solving
Collaboration
Scheduling: for easier patients?
Early
Scheduling: more debilitated patients?
Later
Scheduling: morning?
ADL’s
Transfers
(HOAC II) stands for?
The Hypothesis-Oriented Algorithm for Clinicians II
APTA Client Management Model order?
Examination Evaluation Diagnosis Prognosis Intervention Outcomes
What is Phase 1?
Medical screening (systems review) for disease and pathology
What is Phase 2?
Examination and Evaluation
Categorizing examination findings into specific categories through evaluation that will generate diagnosis of movement dysfunction, prognosis and guide choice of interventions.
Client remains within the scope of physical/occupational therapy practice and proceeds with the diagnostic process
The Guide to PT Practice describes the systems review: brief or
limited examination of the anatomical and physiological status of?
- cardiovascular/pulmonary system
- integumentary system
- musculoskeletal system
- neuromuscular system
RLQ pain?
McBurney’s Appendix
Examination consists of?
History
System Screening
Tests and Measures**
(ICF) stands for?
International Classification of Functioning
Disability and Health
Domestic, community, social, civic life situations,
education life, work life. (e.g questionnaires)
What part of ICF?
Participation
Self care, domestic care (i.e. ADL, IADL respectively)
what part of ICF?
Functional activities
Systems and subsystems, identification of strengths and impairments
what part of ICF?
Body functions and structures
First: Choose Appropriate Test and Measures
Start with tests that fall under?
- Participation
2. Activity/Functional Performance
Second: Analyze?
Posture and Strategy
Divide Functional Activity Observed into 3 phases?
Initiation
Transition
Completion
Ability to carry out purposeful movement?
Apraxia
CNS integration – it weighs: what 3 things?
- 1) somatosensory input first
- 2) vision input second
- 3) vestibular input third
What test looks at the 3 CNS integrations?
CTSIB test looks at these
Location in space?
Proprioception
Perception of the movement?
Kinesthesia
Purpose of Evaluation? order?
Diagnosis
Prognosis
Goals
Interventions
DON’T use impairment goals*** (not ideal), instead use?
Activity goals
Participation goals
“The ? is the determination of the predicted optimal level of improvement in function and the amount of time needed to reach that level and also may include a prediction of levels of improvement that may be reached at various intervals during the course of therapy”
Prognosis
Standardized tests that have predictive validity?
Motricity index
NIHSS (National Institute of Health Stroke Scale)
Fugl-Meyer Assessment Scale
***Orpington Prognostic Scale
5 Essential Components of Plan of Care?
- 1) goals and outcomes
- 2) rehabilitation potential
- 3) specific interventions to be used
- 4) duration and frequency of interventions
- 5) criteria for discharge
Goal Writing must be what 3 things?
- Objective
- Measurable
- Time limited
List of Interventions Should Include?
1) Coordination, communication, documentation
2) Patient/client-related instruction
3) Procedural intervention
An upward and equal force which is equal to the fluid
which the body has displaced?
Buoyancy
Archimedes prinicple
If in water up to ASIS?
50% weight bearing
If in water up to Xiphoid Process?
30% WB
If in water up to C7?
10% WB
The pressure exerted by a fluid on any body at
rest?
Hydrostatic pressure
Hydrostatic pressure at the surface?
14.7 lbs/in²
A person of average height at neck level will
experience how much hydrostatic pressure?
16.43 lbs/in²
at the calf: for reference – an ace bandage can produce
pressure from ? around the calf
1-7 lbs/in²
? ml vital capacity contraindicated to
be in chest-deep
<1400 ml
The resistance occurring between molecules of a
liquid, affecting flow?
Viscosity
Water becomes ? viscous as temperature rises
less
The tendency of masses to resist changes in motion?
Which Newton law?
Law of inertia ***
(e.g) having pt. quickly switch from 1 direction to another direction
the acceleration of an object is directly proportional to a force acting upon that object, inversely proportional to the mass, and has the same direction as the resultant force?
Which Newton law?
Law of Acceleration
For every action, there is an equal and opposite reaction.
Which Newton law?
Law of Action/Reaction
The product of the force times the length of the force arm is equal to the product of the resistance times the length
of the resistance arm
Which Newton law?
Law of leverage
HOW LONG CAN A THERAPIST BE IN THE WATER?
No more than 4 continuous hours per day
WHAT TEMPERATURE IS THE WATER SUPPOSED TO BE? for more active patients or patients with MS
82-88
WHAT TEMPERATURE IS THE WATER SUPPOSED TO BE?
for less active patients such as those with arthritis or women
88-92
WHAT TEMPERATURE IS THE WATER SUPPOSED TO BE? for less active patients with hypertonicity/spasticity issues
92-96
Psychosocial adaptation phases?
Shock Anxiety Denial Depression Internalized Anger Externalized Hostility Acknowledgement Adjustment
Refusing to participate in therapy because the nurse got them up too early
Acting out
Patient will stop therapy to go open the door for each patient entering the gym.
Altruism
A patient fantasizes about winning the lottery and what they would do with all of their money
Autistic fantasy
A patient with a C6 level injury requests to leave the hospital AMA to go home and take care of her toddler
Denial
The patient has 10 nicely (or not so nicely) placed criticisms for the therapist before they even leave the hospital room for therapy.
Devaluation
Patient reflects her anger on her PT when she is really mad that her husband is responsible for the accident that caused her SCI
Displacement
Patient stares off in the middle of the therapy session and stops participating
Dissociation
Patient constantly asking for help but nothing is good enough when they get it.
Help-rejecting
Patient jokes about his tendency to set off the alarm at the airport.
Humor
A patient will tell you she has the best husband in the world, when clearly she does NOT
Idealization
Patient will talk about the mechanics of his new knee joint and
external fixator rather than discuss his feelings.
Intellectualization
The patient talks “matter of fact” about a devastating car accident that left them paralyzed at T9, 2 weeks ago
Isolation of affect
A patient brags about how much better he is doing than his roommate in the hospital and makes up his own way to
do exercises that is better than the PT’s way
Omnipotence
A patient tells you that her nurse doesn’t like her and is jealous of her pretty hair and clothes
Projection
A patient tells you that she needs reliable transportation, that is safe for her and her family to justify purchasing a new car
that is way over her budget.
Rationalization
A patient overhears his spouse telling someone that she loves them on the phone, and rather than ask about it, purposefully forgets it, out of fear. This is dangerous!
Repression
Patient tells the therapist “you are the only therapist that understands me” but when it comes time for this therapist to discharge her from therapy, she is vilified as being uncaring
and thoughtless.
Splitting
A patient who has suffered a divorce may work hard to lose weight and update appearance
Sublimation
The patient refuses to talk about the incident that brought him to
therapy
Suppression
A patient who feels antagonistic towards his therapist, will bring him his favorite dessert on the next visit
Undoing
A patient who feels antagonistic towards his therapist, will bring him his favorite dessert on the next visit
Undoing
Basic (Self-Care) aka
ADL
Instrumental (domestic life)
IADL
•Personal hygiene and grooming •Dressing and Undressing •Self-feeding •Functional Transfers (on/off bed, on/off toilet, in/out of w/c) •Bowel and bladder management •Ambulation (with or without AD)
Specific Examples of BADLs (Self-Care)
- Housework
- Taking medications as prescribed
- Money management
- Shopping for groceries/clothing
- Use of telephone
- Meal preparation and management
- Transportation within community
- Care of pets
- Child rearing
Specific Examples of IADLs (Domestic Life)
Goal of BADL and IADL Training?
Ultimate goal: Maximal level of independence possible
Dressing evaluation should be arranged at what time?
Early in the morning
Self-feeding evaluation should occur at what time?
Meal times
Assessment Tools – BADLs (Self-Care)?
- The Barthel Index *** (gold standard)
- KATZ Basic Activities of Daily Living (ADL) Scale
- FIM
- OASIS
- SF-36 *** (gold standard)
Assessment Tools: IADLS (Domestic Care)?
- Lawton-Brody Instrumental Activities of Daily Living Scale
- OASIS
- SF-36
- Community Integration Questionnaire II
Assessment Tools: IADLS (Domestic Care) For Stroke Survivors?:
- Nottingham Extended ADL (a self-report scale)
- Hamrin Activity Index (pt interview)
- Frenchay Activities Index (pt interview)
- Household section of the Rivermead ADL Assessment (a performance index).
first 3 are participation level
• Anything that assists with activities of daily living is not covered
under most insurances or Medicare = ?
Considered luxury items
- Bathing devices
- Dressing devices
- Eating devices etc.
Hospital Beds covered?
Covered by Medicare/Medicaid
as a rental item
Trapeze bar covered?
Can be covered if needed.
Transfer Boards covered?
May be considered medically necessary and covered under Medicare/Medicaid
Bathtub Access covered?
Most insurance companies including Medicare/Medicaid will not cover
Bedside Commode?
• If it is for use in the bathroom (i.e. to make seat higher, a.k.a. elevated toilet seat), then NOT
covered
• If it is documented that it is for use outside of the bathroom, in the bedroom, then IS covered
Elevated Toilet Seats?
Not covered under insurance but generally inexpensive.
Grab Bars?
Not covered under Medicaid/Medicare
Assistive Devices?
Medicare and insurance will cover these every 5 years
• However: if a patient ALSO needs a wheelchair, it will not cover both
Wheelchairs?
Cushions and back of chair are purchased items
• Covered if medically necessary i.e. for pressure relief or posturing
• NOT covered if for comfort
Chair is rental up to ? months, then becomes the patient’s
10
Wheelchairs Can get a new one every?
5 years (adults) 2 years (children <21 y/o)
Ramps?
These are currently not covered under Medicare/Medicaid
Standing Frames?
These will often be covered under Medicaid/Medicare
Hoyer Lifts?
These are covered as rental items (up to 15 months) by Medicare
Healthcare that “customizes treatment
recommendations and decision making in response to patients’
preferences and beliefs…This partnership also is
characterized by informed, shared decision making,
development of patient knowledge, skills needed for self management of illness, and preventative behaviors. “
Patient- Centered Care
People in a crisis: ?
“hear poorly, process little, remember even less….”
Provide some opportunities for give and take aka?
(patient-centered care)
How is the scapula stabilized?
• Clavicle
- Muscles:
- Latissimus dorsi
- Pectoralis major
- Serratus anterior
- Trapezius
- Levator scapulae
- Rhomboids
- Pectoralis minor
Scapula Neutral Position and Alignment
Scapula down, adducted, glenoid fossa slightly up (slight upward rotation)
Mulligan’s mobilization
Mob with movement
Scapulohumeral movement: First 30°?
Glenohumeral motion
Scapulohumeral movement: Remaining roughly?
2:1 glenohumeral/scapular motion
- Ideas for how to challenge trunk control:
* Level I: Basic movement components?
- Upper body initiated movement
- Lower body initiated movement
- Anterior/Posterior/Lateral direction
• Ideas for how to challenge trunk control: • Level II: Coordinated trunk and extremity patterns?
• Anticipatory postural control needed here as well
Ideas for how to challenge trunk control: Level III:?
Power production
Movement Analysis: Look first at?
Trunk and ribcage
Movement Analysis: Look 2nd at?
Does the scapula move?
Movement Analysis: Look 3rd at?
Are the forearm, wrist and hand alignment appropriate for support?
Brunnstrom Levels Motor Recovery after a Stroke:
Flaccidity?
1
Brunnstrom Levels Motor Recovery after a Stroke:
Basic limb synergies or portion of them
Minimal voluntary movement
Spasticity begins
2
Brunnstrom Levels Motor Recovery after a Stroke:
Voluntary control of portion of limb synergy
Spasticity increases
3
Brunnstrom Levels Motor Recovery after a Stroke:
Some movement patterns outside of synergy are mastered
Spasticity declines some
4
Brunnstrom Levels Motor Recovery after a Stroke:
If cont. progress more difficult movement combos are learned
Basic synergy lose dominance
5
Brunnstrom Levels Motor Recovery after a Stroke:
With no spasticity, the person joint move and coordination is becoming normal
6
Brunnstrom Levels Motor Recovery after a Stroke:
Normal
7
Order of Challenges?
- Isometric (hold that position)
- Eccentric (slowly lower from that position)
- Concentric (go to that position)
Weight bearing with control before non-weight bearing with
control
*
Postural control in a position before postural control with
movement
*
Control of an open hand before grasping activities
*
Grasping stable objects before unstable ones
*
These patients will benefit from early mobilization, ROM, positioning strategies, weight bearing
At or below brunnstrom stage 3
*reminder, brunnstrom stage ? = Voluntary control of portions of limb synergies, Spasticity increases
3
Sitting»_space; modified plantigrade»_space; standing
*
Quadruped only for very advanced patients
*
- Repetitive, intense task-oriented therapy
- Aimed at posture, reaching, manipulation
- Best outcomes when patient has some active movement
At or above stage 4
Reminder, stage ? = Some movement patterns outside of synergy are mastered, Spasticity begins to decline some
4
Power grip is usually first step
*
- Release externally stabilized object
- Practice release with wrist in neutral
- Progress to release of objects into container
- Progress to stacking objects
• Erhardt’s suggested progression:
Repetition is KEY
• Animal studies done: 400 – 600 reps per day of a challenging
functional task can lead to structural neurological changes
following an induced stroke to the hand area in nonhuman
primates*
*
- Arm supported at all times
- In standing, it needs to be in weight bearing as much as possible
- Supine and sitting:
- Slight abduction and slight external rotation*
Managing the Flaccid Shoulder
- NMES
- Supportive devices as indicated
- Facilitation of AAROM of UE and trunk
- Biofeedback
- Education of all who transfer and position patient
Managing the Flaccid Shoulder Treatment
- Appropriate mobilization techniques (grade 1 and 2)
- Gentle stretching
- Cryotherapy
- EMG biofeedback
- Relaxation therapy
- Adhesive capsulitis
- Mobilization
- PROM techniques
- Ultrasound
- Education of all who transfer and position patient
Managing the Spastic Shoulder
**Managing the spastic upper extremity is a key for improving body alignment.
*
4. Effective results so far found in research for: • Wrist extensors • Deltoid • Supraspinatous • Glenohumeral alignment with reduced subluxation 5. Optimal with task-oriented training
Neuromuscular Electrical Stimulation
• With training of the dominant arm, the non-dominant arm performance
improved substantially in terms of linearity and initial direction control.
• However, if the initial training was on the non-dominant arm, there was no
effect on subsequent performance with the dominant arm.*
Interlimb Transfer
Spastic presentation:
• Muscle tone contributes to poor scapular position (depression, retraction, downward rotation)
*
• Wrist assumes flexed posture (intense pain with wrist extension)
• Chronic Regional Pain Syndrome (also known as RSD)
Follows mild trauma without nerve injury
Chronic Regional Pain Syndrome (also known as RSD)?
Type 1:
• Follows trauma with nerve injury
Chronic Regional Pain Syndrome (also known as RSD)?
Type 2
- Vasomotor changes (pale pink, cool) with alteration in temperature
- Guarded against movement (pain with wrist extension)
- Chance of reversal: high
Complex Regional Pain Syndrome
• Stage I (1-3 months)
- Subsiding pain
- Muscle and skin atrophy
- Vasospasm
- Hyperhidrosis (sweating)
- Course hair and nails
- Radiographic evidence of early osteoporosis
- Chance of reversal: variable
Complex Regional Pain Syndrome
• Stage II (3-6 months)
- Atrophic phase
- Pain and vasomotor changes are rare
- Progressive atrophy of skin, muscles, bone
- Severe osteoporosis
- Pericapsular fibrosis and articular changes notable
- Hand contracted in a clawed position
- MP extended, IP flexion (like intrinsic minus)
- Atrophy of thenar and hypothenar muscles
- Flattening of hand
- Chance of reversal: poor
Complex Regional Pain Syndrome
• Stage III
provides humeral support with slight external rotation
• Allows elbow extension
• May provide some reduction of shoulder subluxation
• Can be worn longer: does not restrict elbow/hand or lend to contractures
or increased tone
Humeral Cuff Sling
• 1. Slings appropriate for initial transfer and gait training
• 2. Overall should be minimized during rehabilitation
• 3. Slings which position in UE flexion used only for select upright
activities for short periods
• 4. Selection should be carefully done and closely monitored
Gillen’s Guidelines
Neural re-organization that occurs as a result of increased use of
involved body segments in behaviorally relevant tasks
function-induced
Different and under-utilized areas of the brain (i.e. cortical
supplementary and association areas) can take over
functions of the damaged tissue
cortical remapping
CNS has back-up parallel cortical maps that may become
operational when the primary system breaks down
parallel cortical maps)
Whole areas of the brain are capable of reprogramming
(substitution)
Stages of Motor Learning
Stage 1: Cognitive Stage
Stage 2: Associative Stage
Stage 3: Autonomous Stage
Person experiments with strategies, keeping ones that work
Performance is variable
Improvements in performance are quite large
Stage 1: Cognitive Stage
Demonstrate ideal performance of the task to establish a
reference for correctness
Direct attention to critical task elements
Select appropriate feedback
o High dependence on vision
o Pair intrinsic with extrinsic feedback
o Only focus on errors that become consistent (KP)
o Focus on success of movement outcome (KR)
Ask patient to evaluate own performance and discuss
solutions, also praise and provide motivation
Treatment for Stage 1: Cognitive Stage
“the ability of the brain to change and
repair itself”
Neuroplasticity
Restorative Interventions therapeutic outcome
Improved motor function and functional independence
Task-Oriented Training: Who is this approach NOT meant for?**
- Recent injury/lesions
- Those with a lack of voluntary control
- Those with a lack of cognition
A learned skill is one that can be done:
- efficiently
- consistently
- and is transferable
what % of 1 RM for Neuro pts?
40-70%
What % of 1 RM for severe weakness?
50%
What % for aerobic training?
40-70%
Passive Stretching, Static for how long?
20-30 seconds at end-range x 4-5 reps
Learning to relax specific muscle groups while paying attention to the feelings associated both with the tensed and relaxed states.
Progressive Relaxation Training
Systematic review of the skeletal muscle groups in the body
o Patients identify any tension in muscle group addressed and release it.
o These techniques can be taken to the workplace
o Take less time
o More easily used by those with disabilities (tone!)
Passive Muscular Relaxation:
o Jacobson (1938) developed this technique o Muscles engaged in activities need to engage the least amount of tension necessary to produce the task. o (i.e. Squinting while writing)
Differential Relaxation:
Normal movement patterns stressed and compensations avoided
NDT
Postural control is viewed as the foundation for all skill learning
NDT
KEY POINTS OF CONTROL for NDT handling:
o Key parts of the body therapists use to control movement and
postures
• Proximal:?
pelvis, shoulder
KEY POINTS OF CONTROL for NDT handling:
o Key parts of the body therapists use to control movement and
postures
• Distal?
extremities; usually hands and feet
Most beneficial to patients with weak muscles (MMT 1-3)
Biofeedback:
Most beneficial to patients with weak muscles (MMT 1-3)
Biofeedback
reduce tone, re-educate muscle, improve ROM,
decrease edema, treat disuse atrophy
Neuromuscular Electrical Stimulation:
Loss of strength =?
immediate effect on balance
First 30 to 45°of hip flexion, ?
femur moves without pelvis
From 45 to 90°the pelvis ?
flexes with the femur (posterior
pelvic tilt)
After 90°of movement?
the upper trunk flexes
normal Gait Speed Test:
1.0 – 1.2 m/sec
gait speed difficulty in real world environment
0.8 m/sec
gait speed difficulty even in home
0.6 m/sec
information about spatial, temporal parameters and motion
patterns
Kinematics:
information about forces (ground reaction, joint torques, CoM, CoP, moments, force, power, joint reaction forces, intrinsic foot pressure)
Kinetics:
the net vertical and shear or horizontal
forces acting between the foot and the supporting surface
Ground reaction force:
Force Platforms Measure?
kinetics
Predicting discharge walking ability from admission to an
inpatient rehabilitation facility: Berg Balance Scale and FIM item scores explained most of the variance in discharge walk speed.
o Berg score of ≤ 20 and a FIM of 1 or 2 =?
highly likely to achieve only
household ambulation speeds
Pre-Gait Training
Developmental approach to address this progression:
o A. Mobility
o B. Stability
o C. Dynamic stability
o D. Skill
ability to move from one posture to another
Mobility:
maintain posture against gravity
Stability:
ability to maintain postural control
during weight shifting and movement
Dynamic stability:
discrete motor control with proximal stability
Skill:
General Progression of decreasing stability:
Parallel bars»_space; walker»_space; quad cane or hemi-walker»_space;
single point cane»_space; no assistive device
Parallel bars >> walker >> quad cane or hemi-walker >> single point cane >> no assistive device
General Progression of decreasing stability:
Parallel bars»_space; walker»_space; quad cane or hemi-walker»_space;
single point cane»_space; no assistive device
Parallel bars >> walker >> quad cane or hemi-walker >> single point cane >> no assistive device
BERG SCORE OF 0–20
high fall risk, wheelchair bound
BERG SCORE OF
21–40
medium fall risk , walking with assistance
BERG SCORE OF
41–56
independent
Q: When during an examination, is the best time to evaluate “participation”?
This is often self-reported information and when this is the case, it is very useful to give ahead of the
therapy session. In these cases, this information will provide a lot of insight into the patient, the
patient’s family, struggles, function, perceived abilities and disabilities and frustration levels prior to
even the subjective examination, and may guide the entire exam in some cases.
Q: When during the examination, is the best time to evaluate “functional activities” and administer a
functional (activities) outcome measure?
A: This is ideally done after the history has been taken and the medical screening has been completed
(review of systems). WHY? it is efficient use of time. If the therapist identifies the activities the patient
is not able to do and has them demonstrate their attempts at these skills, a hypothesis can be generated
for “why” the patient cannot complete these tasks. This is where the ability to analyze movement
comes in. From here these hypotheses can be followed up with testing for impairments to validate of
refute suspicions. If further information necessary in order for you to choose wisely, then put it later in
the examination.
Set up: 30 m with cones at each end. Patient
cannot sit down but can lean against wall for rest.
Ok to use usual walking aid. Use only
encouragement as dictated in protocol. Course is
marked off every 3 meters. For the purpose of
test/re-test to measure improvement or decline.
6 Minute Walk Test
6 Minute Walk Test Minimal detectable change:
29 meters
6 Minute Walk Test Minimal detectable change: *O’Sullivan: older adults:
~50 m
6 Minute Walk Test Minimal detectable change: patients with stroke
54 m
6 Minute Walk Test Minimal detectable change: patients with SCI
46 m
10 Meter Walk Test,
Test/re-test, Minimal Clinically Important
Difference (MCID) =
0.16 m/s
5 Times Sit to Stand Cutoff score ? s was predictive of fallers in
elderly
15 s
Test/re-test findings to chart changes in UE
function
Action Research Arm Test
BERG score of less than ? high fall risk per strokeedge?
less than 45
Dynamic Gait Index ≤19/24 =
predictive of falls
Dynamic Gait Index >22/24 =
safe ambulators
Functional Reach Test ≤ 6 inches =
significant increased risk for falls
Functional Reach Test 6 – 10 inches=
moderate risk for falls
Orpington Prognostic Scale Predictive: <3.2
were d/c home within 3 wks of
stroke
Orpington Prognostic Scale Predictive: 3.2-5.2
benefit from intensive rehabilitation
Orpington Prognostic Scale Predictive: > 5.2
required long term care
Good predictor of patient’s own assessment of
recovery (9 items with rating, 5 meaning not
affected at all by stroke and 1 being cannot do
because of stroke) – higher number is better.
Stroke Impact Scale
*In any rehabilitation setting, efficiency must be met:
Much can be obtained at a screening level about a person’s sensation, awareness, cognition,
perception, communication in the first few minutes of interaction. Try walking up to the patient and
putting hand on involved shoulder for instance, is there a reaction? How do they follow commands?
Interact?
The screening then rolls seamlessly into the examination – if the patient is appropriate for
physical therapy services, once you’ve screened their systems, look further where deficits were found
that need to be addressed (in order to meet patient goals).
***Once Systems Screen is complete, the next step is to decide if you will:
not treat
not treat and need to refer or consult another professional
treat and refer/consult
treat
denial and lack of awareness of one’s paralysis
Anosognosia:
unaware of one’s body part
Asomatognosia:
Tone: 0 =
Flaccid
Tone 1+=
hypotonia
Tone 2+=
normal
Tone 3+=
exaggerated
Tone 4+=
sustained
