Exam 2 Flashcards
Three Point
NWB
walker if indicated and then progress to bilateral crutches
four point and two point assistive devices and weight bearing status
WBAT to FWB
reciprocal walker, bilateral crutches, bilateral canes
Four Point Gait Pattern
bilateral assistive devices WBAT right crutch, left foot left crutch, right foot Safest pattern in crowded areas Max Stability and requires low energy expenditure
Two-point Gait pattern
bilateral assistive devices
simultaneous reciprocal pattern: left foot and right crutch, then right foot and left crutch
more mobile patient
low energy expenditure
similar to normal gait but it requires coordination
less stability than four point
WBAT and FWB
Three Point modified weight bearing status and assistive device
PWB
walker, bilateral crutches
Two or Four point modified weight bearing status and assistive device
WBAT
axillary crutch or one cane
progression of assistive device
walker to axillary crutches to forearm crutches to bilateral canes to single cane to independent of walking aids
Modified four or two point
not appropriate for true PWB pt
can be used with patient that has only one functional upper extremity or who have a lower extremity medical condition for which less stress is required
Device is held in the opposite UE to the effected LE to widen to base of support, held on the good side
three point gait pattern
NWB, requires use of both UE and one good LE
step through or step to
can use walker or crutches
Ascending Curb with walker
Walker, strong leg, involved leg
Descending Curb with walker
walker, involved leg, uninvolved leg
Ascending Stairs (Cane or crutches on one side)
uninvolved LE, cane AND involved LE or uninvolved LE and cane followed by involved
Descending Stairs (cane or walker)
involved LE and cane then uninvolved LE
Sit to stand: ortho patient PWB or NWB
involved LE needs to be positioned in front of the uninvolved LE
Sit to stand: Hemiplegic patient
Both legs can be positioned symmetrically
Stand to sit in chair: orthopedic patient with PWB or NWB status
make sure that the chair is there by touching the seat with the back of the uninvolved LE. Pt should reach for the armrest or for the seat and control the descent using uninvolved LE muscles
Stand to Sit: hemiplegic patient
have the patient look for the chair behind them.
Chair should not be more than 2 inches away from his/her LE
May reach for the armrest or seat with the uninvolved side
GUARD the patient’s involved side as they use their uninvolved side
Guarding during ambulation: hemiplegic patient
guard the involved side always- also makes patient more aware of the involved side
Sit to stand with crutches
crutches go on the weak side and PT stands on the weak side
what walker should you use with bilateral LE generalized weakness
rolling walker
Pre-gait activities
Use parallel bars or a pick up walker
sit to stand
stand to sit
weight shifting
balance activities (lift one hand, alternate lifting hands off the bars)
making single steps forward and backwards
walking in the parallel bars
when is swing to or swing through gait mostly used
patients with SCI who are unable to actively use lower trunk and LE muscles (use of double upright lower extremity orthoses)
three-point modified
used with TDWB/PWB/WBAT through 1 LE and FWB though the other
use bilateral cane, crutches or walker
crutches/walker with PWB foot, followed by the FWB foot
types of canes
LBQC
SBQC
straight cane
two points for where the handgrip can be measured to
ulnar styloid or the wrist crease
measuring height of cane in supine
tape measure is used to determine length of cane/handgrip. measure from the greater trochanter to the heel with the knee extended
confirm fit procedure:
20-25 degrees of elbow flexion with the cane tip 2” lateral and 4-6” anterior to the toe of the show
precautions with canes
with a quad cane, all four legs need to be on the ground before patient pushes down on the cane
when ascending or descending stairs, the quad cane can be turned sideways
canes are good to use with patients that have…
CVA/ UE or LE injury or when progressing from a walker/hemi-walker
Cane WB status
FWB or WBAT
NOT for PWB or NWB
Adjusting axillary crutches
adjust the height first (2-3 finger widths (2 in”) from the floor of the axilla to the top of the crutch arm
then adjust the height of the handgrip crease or ulnar styloid
measuring a crutch in supine
measure from anterior axillary fold to a point 6-8 inches lateral to the patient’s lateral heel. Handgrip is measured from anterior axillary fold to the greater trochanter or ulnar styloid
still confirm fit in standing!
measure crutch length in sitting
measure the distance from the tip of middle finger to olecranon process of bent elbow. (measuring wingspan with one arm bent to 90 d
precautions with crutches
axillary crutches: instruct the pt and the caregiver in preventing injury to axillary vessels and nerves
Forearm crutches: may be difficult to remove due to cuffs
forearm crutch measurement
cuff positioned 1-1.5” distal to the olecranon process
20-25 degrees of elbow flexion with the crutch tip 2” lateral and 4-6 inches anterior to the toe of the shoe
handgrip even with the wrist crease or ulnar styloid
forearm crutch use
SCI, MS or CP
Crutch usage and considerations
mostly for ortho patients who need less stability than a walker
requires strong trunk and UEs
not for children under 4
patient must be cognitive and ready to work
allows for a greater selection of gait patterns
can be used in narrow and crowded areas and on stairs
precautions of a walker
do not step forward to or past the front horizontal bar of the walker
when advancing the walker, all four legs should be placed on the ground at the same time
hemi-walker use
with a patient who needs increased support or can’t use one UE
Reverse wheeled walker
good for patients with CP
Rolling walker
WBAT or FWB, only PWB if stable
good for energy conservation and with coordination problems/joint replacements
Positioning of the patient during soft tissue on back
Supine, bolster under ankles, towels under shoulders if it rounds their back and a pillow under stomach if there is excessive lordosis
Why do we place a bolster under the patients ankles in prone
To relax their hamstrings
Therapists position during most STM
As parallel to the body as you can be to the patient
Position for two hands figure eight-paraspinals-one side
Perpendicular
What part of the hand do you use to do deep effleurage running underneath the scapula
You use the medial (ulnar) side of your hand
If you are doing the patient’s right scapula your right arm to lift their shoulder and stroke with the left hand
Locations to deep effleurage (rub) with one hand
Paraspinals, scapular area, quadratus lumborum (around the pelvic crest)
Petrissage to the neck
Use your fingertips over the cervical paraspinals
Where do you do cupping and why?
Around the lungs to facilitate the movement of mucous/fluid out of the lungs
Where do you not do percussion (tapotement)
Around the neck and the kidneys
Hacking
Parallel to fibers, fingers relaxed, medial side of palm taps
Rapping
Use the dorsum of your fingers
Tapping
Use your fingers
Pincements
Used to wake up the muscle, you lightly “pinch” the skin
Vibration position of the hands
Should have a hollow hand and shake the muscle
Position of therapist when alternating superficial/deep glide-
Perpendicular to the patient
When would you not use the rolling technique
Don’t use with adhesions or scarring
Where on the body is petrissage (kneading) the easiest to perform
Quads/thighs/hamstrings
Where in the knee joint to we avoid with soft tissue mobilization?
The popliteal fossa
When working on the lower extremity what segment to you start on and which direction do you progress in?
Proximal segment first (glutes) and work your way distally (foot/ankle)
Your strokes should always be in the direction of the….
Heart
Sequence of segments mobilized in the LE
Thigh>knee joint>Lower leg>foot
STM: What stroke ( and what side of leg: lateral or medial) would be the only time you would stand on the opposite side of the patient (lower extremity)
For sawing on the lateral portion of the leg
Why do we use superficial or deep vibration?
When the patient isn’t relaxed
Superficial vibration
One muscle
Deep vibration
Multiple muscle groups
What is a good technique of STM to use for heel spurs?
A deep glide thumb or thumb spiral around the calcaneous
Deep gliding on the lateral thigh alternate technique
You can put one hand on top of the other and deeply press
What technique can you use for the extensor foot tendons, tibialis anterior tendon and first metatarsal head?
Thumb spiral
How do you do longitudinal friction of the Achilles’ tendon?
With your thumb, the Achilles should move if it is healthy
Technique used for scar tissue
transverse friction: use both thumbs or medial sides of palm, one pushes, one pulls
Where is raking done?
On the rib intercostals or the foot
What do you want to avoid at the wrist joint with STM
The palmar side- there is a lot of vasculature
STM Technique for the wrist joint
Thumb spiral on the dorsal, medial and lateral sides of the jt
Rubbing is performed using a
A three finger or thumb spiral
Sequence of segments mobilized in UE for STM
Upper arm, elbow joint, forearm, wrist joint, hand
What areas do we avoid in the elbow joint with soft tissue mobilization
Area medial to the olecranon (ulnar nerve)
Anterior surface of the joint
Autonomic phenomena of myofascial trigger points
Localized vasoconstriction
Sweating
Salivation
Etc
Where do we find myofascial trigger points
They can be anywhere but the medial border of the scapula and the upper trap area are common
Definition of myofascial trigger point
A hyperactive spot located within a taut band of skeletal muscle or in the muscle’s fascia. It is characterized by pain upon compression that can evoke referred pain tenderness and autonomic phenomena
Tenderness caused by myofascial trigger point
Direct activation of a trigger point
Caused by muscle overload, overwork fatigue, direct trauma or chilling
Referred pain from myofascial trigger point leads to
protective muscle guarding/spasms which leads to restricted stretch ROM
Referred pain (myofascial trigger points)
Has specific characteristics of each muscle, without actual pain reported directly over the trigger point
Is dull and aching
Is often deep
May be of variable intensity
Can be elicited by pressure on trigger points
Deep friction of the sciatic north
Right over the ischial tuberosity almost you start by circling with light pressure and get progressively deeper. Then you let off the pressure progressively as well
Examples of soft tissue mobilization techniques
Massage/classical STM Lymphatic drainage Myofascial release Acupressure Cranio-sacral therapy Visceral therapy Energy techniques Instrument assisted STM
Definition of soft-tissue mobilization
The intentional and systematic manipulation of myofascial layers of the body performed for therapeutic purposes
Uses of STM
One of the oldest ways of treatment, can be a diagnostic tool to give you info to what is going on under the skin
Underlying theory of STM
Stimulation of mechanoreceptors in skin, muscles, joints, internal organs and blood vessels
Nerves transmit signal to the CNS where these signals are processed
Brain and the spinal cord generate impulses that are sent to the corresponding areas of the body
Functional changes occur in body systems
Physiological and Mechanical Effects of STM: Integumentary system
Stimulate sensory receptors, removal of dead skill cells, increase superficial circulatory movement and improve drainage
Physiological and Mechanical Effects of STM: Fascia
Improves the pliability
Physiological and Mechanical Effects of STM: Cardiovascular and lymphatic system
Increases blood and lymph circulation, decreases BP and HR= decreased stress= pts feel better and move better
It can stabilize the HR in infants
Decrease RR for better breathing
Physiological and Mechanical Effects of STM: Musculoskeletal system
Drains metabolic waste, muscle relaxation for more range on whatever area you’re working with
Physiological and Mechanical Effects of STM: Nervous system
Relaxation- effects the PNS
Decrease pain, increase sleep, induces thirst and sweat
Physiological and Mechanical Effects of STM: Digestive system
Influence peristalsis
Physiological and Mechanical Effects of STM: Growth and development
Enhances the relationship between mother/parent and child, when you decrease stress growth occurs better
Physiological and emotional effects of STM
Reduce anxiety, increase mental clarity, induce a general feeling of well being, increase amount of time infants spend in a quiet by alert state, improve mother-infant interaction, communication and bonding
Contraindications to STM
Fever, skin lesions and infections, bone infections, acute circulatory conditions, low blood pressure, bruising, acute inflammation, acute fractures, unsealed wounds and burns, rash, persisting negative response to STM
Indications for STM
Strains, sprains, tendinitis, arthritis, contractures, scarring and adhesions, fibromyalgia, hyper/hypo toxicity, peripheral nerve lesions, circulatory conditions, respiratory conditions, agitation, lethargy
What is hypertonicity
Increased tone of the muscle, tight
Hypotonicity
Flaccid and the tone is low
What technique should be performed at the beginning and transitioning to a different soft tissue technique
Superficial effleurage
What is the speed of petrissage
30-40 movements per minute
Speed of deep effleurage
60-100 per minute
What lotion would you use for scar mobilization
Massage creams
What lubricants can be used
Lotions, vegetable or mineral oils, baby powder/lotion/oils, massage creams
Effleurages and petrissages are repeated approximately…
3-6 times
Pressure relief ankle foot orthosis
boot worn on the calf and foot to prevent skin breakdown
- heel suspension
- mostly commonly heel ulcers
- allows for neutral hip, knee, ankle alignment
pulse oximeter:
do not want saturation below 90%
swanz-gathz catheter (PA line)
IV catheter usually inserted into the basilic or subclavian vein used for cardiac functioning monitor
Check to see if the patient is on bedrest before moving them
Mean arterial pressure (MAP)
determined by CO, systemic vascular resistance and CVP
what is the typically desired MAP
> 60
Central Venous Pressure (CVP)
reflects the amount of blood returning to the heart and the ability of the heart to pump blood into the arterial system
Peripheral Inserted Catheter (PICC line)
a long catheter introduced through a vein in the arm, follows through the subclavian vein into the superior vena cava or right atrium to administer fluid, blood draws, or measure CVP
IV :
administration of fluids into a vein through the use of a steel needle or plastic catheter
Arterial monitoring line (A-line):
inserted into the artery and attached to a monitoring system to directly measure arterial blood pressure and can be used for blood draws
swanz-ganz considerations
check with RN to ensure line is locked
check to see if the patient is on bedrest, ipsilateral shoulder flexion is limited to 90 degrees
triple lumen of swanz-ganz
central line located in the jugular, subclavian of femoral vein with three external ports, assists with IV med administration, blood tests and CVP monitoring
consideration for catheters
increased risk of UTI
keep drainage bag below the bladder to prevent reflux and retention and thus infection
always monitor bag prior, during and post treatment
avoid touching the floor with bag and monitor fullness
avoid excessive pulling.tension
nasogastric tube
plastic tube inserted through a nostril that terminates in the stomach and assists with removing fluid or gas, evaluating GI activity, administering meds and feeding patient
nasal cannula
delivery of low to moderate oxygen concentrations to patient via nostrils
oronasal mask
mask with small vent holes to expel exhaled air cover the pt’s nose/mouth
moderate to high concentrations of air, usually short term
tracheostomy mask
placed over the trach tube, usually high concentration
what can you use to breathe for mobility
oxygen tanks and portable holders, store tanks before and after use
if a pt has oropharyngeal or nasopharyngeal intubation
check with the RN to ensure PT appropriate prior to session
Chest tube/Drain
remove air, blood, purulent matter or undesirable materials from chest
ostomy
surgically produced opening in the abdomen to eliminate feces \; plastic bag collects waste
rectal catheter
used to collect gas/feces
4 bed rails up=
a restraint
soft limb restraints used for
for patients who pull at lines or self-harm
dialysis precautions
avoid blood pressure on the UE with the fistula
close monitoring of vitals
always check with nursing prior to any PT, facility and patient dependent if allowed to treat (typically only bedside activites)
THA posterior lateral approach precautions
no hip flexion beyond 90
no adduction beyond neutral
in internal rotation
anterior approach THA precautions
no excessive hip extension and ER
Spinal fusion, laminextomy, discectomy (compressed nerves) precautions
no bending (flexion/sidebending) no lifting (8-10 lbs), no twisting for 6-8 weeks post sx
Coronary artery bypass graft precautions
no pushing, no pulling, no lifting 5-10 lbs
avoid shoulder flexion/abduction greater than 90 degrees and scapular adduction
Ischemic stroke
loss of perfusion to area of the brain
embolus
solid, liquid or gas block flow
thrombus
plaque occludes flow
hemorrhagic stroke
abnormal bleeding in the brain due to a rupture in the blood supply
transient ischemic attack
temporary occlusion that resolves quickly
types of bandages
muslin woven, elastic, porous cotton rolled gauze stockinette adhesive tape
what material don’t you use for bandaging or dressing
polyester- use cotton for moisture control
improper application of bandaging:
color of distal segment: don't want it to be white complaints of pain segments feels cold edema bandaged changed position
areas to avoid skin breakdown
low back, ankle, heel, elbow, buttocks
positioning of stroke patients is to prevent:
gleno-humeral joint probelms
SCI precautions with bed mobility
lift slowly, moving them too fast will cause fainting
THA
adductor splints, remember the precautions
LE amputation
should elevate the residual limb to help with swelling; however, be attentive of hip flexor contracture-prone
hemiplegia
side lying is appropriate- roll to weak side if sitting them up, but side-lying for positioning can be either side
RA conditions
keep joint moving; frequently reposition
Burn patients susceptible to
contractures and infections so avoid positions of comfort or extended periods of time
complete independence
no physical or verbal assistance needed
modified independent
requires a device, safety concerns or extra time
always record the device in the chart
contact-guard assist
slight touch but no help
supervision
requires verbal cueing, coaxing, encouragement, equipment set up, pt. performs 100% of the activity but supervision is required
minimum assist
requires touching, contact guard or guided assistance. Patient performs 75-99% of the task and needs physical assistance
moderate assistance
patient performs 50-74% of the work
max assist
patient performs 25-49% of the work
total assist
patient participates in less than 25% of the task, two or more persons are required to physically assist
use a hoyer lift or follow with a wheelchair then they are automatically rated a total assist
FIM score 7
independence
FIM score 1
total assistance
or wheelchair follow
effects of immobility: respiratory
pneumonia, atelectasis, O2 desaturation
Cardiovascular system effects of immobility
impaired circulation, HR/BP changes, orthostatic
Bone immobility effects
osteoporosis, decreased growth and development
joint effects on immobility
contractures, cartilage damage (decreased fluid movement)
muscle effects of immobility
muscle weakness, atrophy, loss of muscle fiber length leading to contractures
POM limitations
doesn’t prevent muscle atrophy
does not maintain or increase muscle tone
does not increase muscle strength and endurance
does not reduce adipose tissue formation
is not as effective as active exercise in maintaining local circulation
indication for POM
patient is at risk for developing joint contractures or other problems resulting from immobility
patient is unable to perform active exercise due to: paralysis, coma, significant pain, active is contraindicated
demonstrate active exercise to a patient
passive motion is used to assess joint ROM, stability and muscle
indications for AAROM and AROM
contractures or other problems resulting from immobility
pt has voluntary control of muscle contraction
pain scale < or equal to 5
pt is in a reconditioned physiological state
MMT below 3 use AAROM
MMT above 3 use AROM
benefits of AAROM or AROM
maintain structural integrity of bone-muscle interface due to stress produced by muscle contractions
maintain muscle strength, physiological elasticity and endurance
may increase muscle strength, when muscles can’t hold against resistance
increase coordination, proprioception and kinesthesia
maintain and improve cardiac function
assist in preventing the development of thrombosis, thrombophlebitis, or phlebitis in LE peripheral veins (ankle pumps)
limitations of AAROM and AROM
active exercise will not increase strength in muscles with grade above 4
will not increase cardiopulm function if pt is well conditioned
ROM with spasticity and hypertonicity (CP or brain injury)
slow movement
minimize excessive stimulation
exceptions for SCI with ROM
avoid elongation in erector spinae; work to improve trunk stability
pelvic belt in wheelchairs
keeps pelvis in alignment
seat belt of the wheelchair
for safety
is positioning belt a restraint in IL?
no
a wheelchair tilt
everything moves (hip, torso, seat) used to relieve pressure/reposition the patient
recline of the wheelchair
just the torso/seat back moves
a dump position in the wheelchair- what is it and what is it used for
flexes knees in the chair by either raising the knees or lowing the seat
used for trunk stability when someone has a weak core
a squeeze position
more of a tilt
hemiplegia seat to floor height
18 inches
foot rests position
2 inches above the ground
power assist chair
when you push on a wheel it gives the chair an oomph
-use for college kid
what tilt do you do to stand a pt up
anterior tilt: there are leg supporters
preferred wheelchair provider
HMO
time it takes to get a wheelchair:
17 weeks/ 4 months +
what are the benefits of a patient sitting up
stabilize BP
starts getting pt on a normal sleep/wake schedule
postural control
prevent muscle contractures and bed sores
midline orientation
prevents compromises to other systems like GI, respiratory, cardiac
normal width chair
18”
standard adult wheelchair
pt weighs less than 200 lbs
heavy duty adult wheelchair
pt weighs more than 200 lbs or for vigorous activity
intermediate or junior wheelchair
persons smaller than an adult but larger than a child
growing wheelchair
frame can be adapted according to the growth of the person
child or youth
children up to approx. 6 years
amputee wheelchair
rear wheel axles are positioned 2 inches posterior compared to standard WC
one-hand drive
two handrims are attached to one wheel and the larger rim propels the wheel on the other side
sports wheelchair
light weight, low profile, low back, cantered rear wheels, small handrims, adjustable axles
reclining wheelchair
the back can recline to a full horizontal position (semi reclining- reclines only approx 30 degrees) also has elevated footrests and a headrest extension
patients to do a lateral transfer with
paraplegic or lower extremity B/L weakness
patients to do a standing pivot with
stroke patients with good trunk stability
patients to do a squat pivot with
generalized weakness everywhere
stroke patient with okay leg support
patients that you do a full dependent transfer with
quadriplegia
Lite Gait Advantages
can assist in walking
can walk in the air or treadmill
supports body weight
can hold up to 400 lbs- keeps obese patients active
with the lite gait you shouldn’t take more than ____ % of the pts body weight
30
if you go higher than 30% using the lite gait the screen turns ___
purple
when would you not use the lite gait
PWB/NWB, rib fractures, acute pelvic problems
Types of pts the lite gait is used for
stroke- when there are leg strength and trunk control deficits
SCI when walking is a functional goal
neuro patients because repetition is a huge rehab goal
pts that you can use a standing frame with
lower level pts that don't tolerate standing SCI TBI fluctuations in BP MS Neurologic stroke pts with poor trunk control
when wouldn’t you use a standing frame
if someone has weight bearing precautions
TKR is contraindicated because of the knee pads
with a standing frame it is important to take vitals
a. just before use
b. before and after use
c. before, during and after use
c. before, during and after use
in a standing frame move the knee pads _____ _______ when the patient is tall
further away
the standing frame is a good intermediate step between
what does it allow the PT to see..
sitting and standing to see how the pt tolerates the position, how many things they can do and what their vital signs look like in that position
a standing frame position will help with neck _____ and allow the patient to be more _____
extension, alert
hoyer lift harness supports the ____ and _____
trunk and thighs
With the Hoyer lift the _____ you turn the nob the faster the pt drops
further
top part of the harness needs to be ______ the shoulders
below
if you want the patient to be sitting more upright when you place them from the hoyer lift you should use the (long or short) straps?
short
What don’t we want the patient to do when using the Hoyer lift?
grab onto the lift; it might rotate them
When would you use the Hoyer lift
neurological lower level pt, stroke, TBI, higher SCI with fixation, post Covid when respiratory/endurance is really low, OBESITY
can you still use a Hoyer lift if the patient doesn’t have head control?
yes, there is a head attachment for the harness
