Exam 2 Flashcards
Thoracic Spine Facet Joints
- most rigid part of the vertebral column
- ribs, ligaments, muscles
- aligned in a mild kyphosis
- mobile platform for the movement
- upper extremities via scapulothoracic and SC joints
- cervical spine
Resting position of Thoracic Spine Facet Joints
- midway between flexion and extension
Closed pack position of thoracic Spine facet joints
- extension
Capsular pattern of Thoracic spine facet joints
- side flexion and rotation equally limited
- then extension
Infrasternal angle above and below 90deg
- above 90deg: tightness in internal obliques
- less than 90deg: tightness in external obliques
Manubriosternal joint (sternal angle)
- 2nd ribs
Xiphosternal joint
- T9 vertebra
- T6 dermatome
Ribs 2-12
- most rounded inferior rib felt anterolaterally is the 10th rib and it’s costochondral junction
- inferior and postereolateral to that is the tip of rib 11, ending just anterior to mid-axillary line
- rib 12, inferior and medial to rib 11, it is about an inch or so below rib 11, about 2-4 inches from the spinous process
Rib Angles
- ribs 2-10
- 1st rib doesnt posses an angle and 11th and 12th are slight if present
- 3-4cm lateral to the tips of the transverse process
Root of spine of scapular
T3/4
Inferior Scap Angle
- T7
Level of Umbilicus
- T10
Costovertebral (CV) Joints
- ribs and vertebral bodies
- ribs 1,10,11,12 have one vertebral body articulation
- ribs 2-9 articulate with the 2 adjacent vertebra
costotransverse (CT) Joints
- ribs and transverse processes of the same level
- ribs 1-10
- ribs 11 and 12 do not have these joints
Costochondral Joints
- ribs and costal cartilage
- ribs 1-7 = true ribs
- ribs 8-10 = false ribs
- ribs 11-12 = floating
Thoracic Rules of Threes
- T1-3: SP at level with TP
- T4-6: SP are 1/2 level down than TP
- T7-9: SP are one full level down from TP
- T10-12: starts to come back up (T10 is one full level below TP, T11 SP is one half level below TP, T12 SP is even with TP)
External Obliques OIA
- O: ribs 5-12
- I: iliac crest, pubis, lineal alba
- A: Bilaterally compress abdomen and flex spine. Unilaterally ipsilateral side bending and contralateral rotation
- I: lower intercostal, iliohypogastric, ilioinguinal nn
Internal Obliques OIA
- O: lateral inguinal lig, middle lip of iliac crest, thoracolumbar fascia
- I: pubis, inferior border of ribs 9-12, linea alba
- A: bilaterally compress abdomen and flexes the spine, unilaterally ipsilaterally flexes and rotates to same side
- I: lower 5 thoracic nn, 1st lumbar n, iliogypogastric, ilioinguinal n
Rectus Abdom OIA
- O: crest of pubis and pubic tubercle, pubic symphsis
- I: cartilages of the 5-7 ribs and xiphoid process
- A: flexes vertebral column compresses abdomen
- I: spinal nerves T7-12
Transverse Ab OIA
- O: lateral 3rd of inguinal lig, inner lip of iliac crest, inner cartilage of lower 6 ribs, thoracolumbar fascia
- I: ends in aponeurosis, fron and back of rectus sheath to linea alba and pubis
- A: compresses ab viscera and tenses abdominal wall
- I: lower sic thoracic n, first lumbar n, iliohypograstic and ilioinguinal n
Pump Handle Action
- move by rotating around their long axis
- rotate up with accompaniment of the manubrium
- T1-6
Bucket Handle Action
- move upward, backward, and medially
- T7-10
- T2-6 at a much lesser degree
Abdominals Double Leg Lowering (Kendall)
- patient supine on a firm surface, forearms crossed on chest
- examiner assists patient in raising legs to a vertical position
- patient is instructed to perform a posterior pelvic tilt flattening back to table
- instructed to Hold it flat while patient lowers legs
- ending position is when therapist notices loss of neutral pelvic position
- the ankle between the extended legs and the table determines the strength grade
Sahrmann Core Stability Test
- ability of a patient to perform specific levels of stability while maintaining a neutral/flat spine
- test is stopped if patient cannot maintain flat spine
- test is graded by the level the patient can perform
Sharmann Core Stability Level 1A
- fair
- initial position to be used for rest of levels
- hooklying. tighten your core keeping back flat and slowly lift 1 leg to 90deg keeping knee bent
- keeping 1st leg up, slowly bring 2nd leg to same position
- “up, up position”
Sahrmann Core STability Level 1B
- poor (motor training)
- for the patient that cannot performm level 1A
- hooklying. keeping back flat. slide one heel along floor out to straight leg and return to starting position
Sahrmann Core Stability Level 2
- fair +
- starting in position 1A (both legs up)
- slowly lower 1 leg down until heel touches table
- slide heel along table out until leg is straight
- slide it back until knee is bent
- return to position 1A
- “one heel slide”
Sahrmann Core Stability Level 3
- good
- starting in position 1A (both legs up)
- slowly lower 1 leg until it is a few inches above table
- glide heel above table out until leg is straight
- glide it back until knee is bent
- return to position 1A
- “one heel glide”
Sahrmann Core Stability Level 4
- sport level
- starting in position 1A (both legs up)
- slowly lower both legs until heels touch the table
- slide both heels out until both legs are straight
- slide them back until knees bent
- return to position 1A
- “double heel slide”
Sahrmann Core Stability Level 5
- Sport Level
- starting in position 1A (both legs up)
- slowly lower both legs until heels are a few inches above table
- glide both legs out until legs are straight
- glide back until knees are bent
- return to position 1A
- “double heel glide”
L2 Myotome
- hip flexion
L3 Myotome
- knee extension
L4 Myotome
- ankle dorsiflexion
L5 MYotome
- great toe extension
S1 Myotome
- ankle eversion
- hip extension
- plantar flexion
S2 Myotome
- knee flexion
L3/4 Reflex
- quads
S1/2 Reflex
- achilles
L5/S1 Reflex
- hamstrings
ROM Thoracic Flexion
- 20deg
ROM Thoracic Extension
- 10deg
ROM Thoracic Lateral Flexion
- 10deg
Thoracolumbar Flexion ROM
- 80deg
ROM Thoracolumbar Extension
- 35deg
ROM Thoracolumbar lateral Flexion
- 35deg
ROM Thoracolumbar Rotation
- 45deg
ROM Lumbar Flexion
- 60deg
ROM Lumbar Extension
- 25deg
ROM Lumbar Lateral Flexion (side bending)
- 25deg
ROM Thoracolumbar Lateral Flexion
- 35deg
ROM Thoracolumbar Rotation
- 45deg
Thoracic Spine Region
- T1-12
Thoracolumbar Spine Region
- T1-S2
Lumbar Spine Region
- L1-S2
Postural Control
- controlling body position in space for stability and orientation
Balance
- ability to hold center of mass in relation to base of support
Center of Gravity
- vertical projection of the COM (slightly anterior to L2 in standing)
Base of Support
- area of body in contact with a support surface
Postural Orientation
- ability to maintain an appropriate relation between body segment and between the body and the environment
- involves the active alignment of the trunk and head with respect to gravity, support surfaces, the visual surround and internal references
- sensory information from somatosensory, vestibular and visual systems is integrated, and the relative weights placed on each of these inputs are dependent on the goals of the movement task and the Enviornment context
Limits of Stability
- internal representation of how far the body can move over it’s base of support before changin the support or losing balance
Anticipatory Postural response
- active movement of the body’s COM in anticipation of a postural transition from one body position to another
Reactionary Postural Responses
- active response to an external perturbation
Sensory interaction/prientation
- ability to maintain balance during altering sensory conditions
Postural Equilibrium
- involves coordination of movement strategies to stabilize the center of body mass during both self-initiated and externally triggered disturbances of stability
- the specific response strategy selected depends not only on the characteristics of the external postural displacement but also on the individual’s expectations, goals, and prior experience
What is included in the initial examination?
- taking a history
- systems review
- tests and measures (body structure/function, activity, participation)
Taking a History for Balance Exam
- chief complaint
- medical history
- recent history of falls/close falls
- medications
- confidence level (participation level)
What is included in the systems review?
- Cardiovascular: Vitals
- Integumentary: skin integ, color, scores
- Neuromuscular: reflexes, gait, tone
- Musculoskeletal: ROM, MMT, posture BMI
ICF Model for Balance Examination
- health condition (disorder or disease)
- body functions and structures
- activities
- participation
- environmental factors
- personal factors
Ankle Strategy in Balance
- control of postural sway from ankles and feet
- head and hips travel in the same directions at the same time with the body moving as a unit over the feet
- appropriate to use on firm surface, well supported, slow moving with minimal displacement
Hip Strategy in Balance
- control of postural sway from pelvis and trunk
- head and hips travel in opposite directions
- appropriate to use when foot not completely supported and when there is quick and large displacements
Stepping strategy in Balance
- steps with the feet to establish a new base of support when the center of gravity has exceeded the original base of support
- appropriate to use when other strategies are not sufficient enough to maintain equilibrium
Balance Exams for Body Functions and Structure
- modified clinical test for sensory interaction in balance
- balance errors scoring system (BESS)
- single leg stance (eyes open/closed)
- romberg/sharpened romberg
CTSIB (Clinical test for sensory interaction in balance)
- clinical version of the sensory organization test that does NOT require computerized force plates
- designed to assess the patient’s ability to select and combine sensory information in different environments
- does not measure the integrity of the three sensory systems
Sensory weighting on a firm surface
- 70% somatosensory
- 20% vestibular
- 10% vision
Sensory weighting on an unstable surface
- 10% somatosensory
- 60% vestibular
- 30% vision
CTSIG Conditions
- 1: firm surface, eyes open
- 2: firm surface, eyes closed
- 3: firm surface, dome
- 4: foam surface, eyes open
- 5: foam surface, eyes closed
- 6: foam surface, dome
Purpose of the BESS and population
- objective measure of assessing static postural stability (designed for the mild head injury population, to assist in return to sports)
- population tested: concussion, mild TBI, ankle instability, vestibular disorders
BESS Conditions
- 6 conditions, barefoot, eyes closed, 20 seconds each
- double leg stance (feet together): firm, foam
- single leg stance (non dom foot): firm, foam
- tandem stance (non dom in back): firm, foam
BESS types of errors to be counted
- up to 10 errors in each trial before terminating
- up to 60 errors total
- moving hands off hips
- opening eyes
- step, stumble, or fall
- abduction or flexion of hip beyond 30deg
- lifting the forefoot or heel off of the testing surface
- remaining out of the proper testing position for greater than 5 seconds
BESS scores that are good vs. not good
- lower scores = better balance
- MDC (minimal detectable change) = 7 to 9 points
Single Leg Stance Balance Exam (Anticipatory)
- person stands with knee flexed 90deg
- legs should NOT be touching each other
- arms crossed around shoulders
- document # of attemps, time, visual observation during trial
Romberg/Tandem Romberg Balance Exam (Anticipatory)
- person stands with feet together (romberg) and eyes open
- repeat the test with eyes closed
- person stands with one foot directly in front of the other (tandem romberg)
- normal is the ability to hold the test position for 30 seconds
- document # of attempts, time, visual observation during trial
Activity Balance Measures
- Berg Balance Score
- Tinetti Performance Oriented Mobility Assessment
- Functional Reach test
- TUG, TUG manual, TUG cognitive
Participation Balance Measures
- activities based confidence scale
Berg Balance Score Conditions
- 14 test items intended to assess a person’s ability to perform common ADLs safely
- items are scored from 0 to 4, max score is 56
- min detec change: 3-8 points
Berg Balance Score cut offs in older adults
- history of falls and Berg <51
- no history of falls and Berg <42
- predictive 91% sensitivity, 82% specificity
- score of <40 on Berg associated with almost 100% fall risk
- CVA risk 45/56
Tinetti Performance Oriented Mobility Assessment (POMA) Conditions
- consists of 2 subscales to screen for balance and mobility skills in older adults and determine likelihood of falls (balance (9), gait (7))
- 16 items total
- scored 0-2
Cutoff scores for Tinetti
- chronic stroke <20
- older adults 19-21
- PD <20 (AUC 72%, sensitivity 76%, specificity 66%)
General Tinetti scores
- score 19-24 are at moderate risk of falls
- score <19 are considered high risk for falls
- minimal detectable change: 4
Functional Reach Test Conditions
- define max distance one can reach forward beyond arm’s length while maintaining fixed base of support in standing
- examines limits of stability in forward direction
- person stands near wall with feet parallel
- raises arm nearest wall to 90deg of shoulder flex
- makes fist and leans as far forward as possible
- three trials, average of the last 2!!
Cutoffs with Functional Reach Test
- less than or equal to 6 inches predictive of increased risk of falls in community dwelling elderly
- <18.5cm in frail elderly (75% sensitivity, 67% specificity)
- PD 25.4cm (30% sensitivity, 92% specificity)
- PD 30.1 cm (56% sensitivity, 77% specificity)
Activities Based Confidence Scale Conditions
- 16 item questionnaire
- measure of balance self-efficacy
- subjects rate their confidence performing a variety of in-home and community based functional activities such as walking in a variety of environments, reaching, picking things up from the floor
- scores range 0-100 where higher scores indicate greater balance confidence
Activities Based Confidence (ABC) scale cut-offs
- <67% fallers and non-fallers
- <69% PD
- <81% CVA
- MDC for PD: 11-13%
TUG
- individuals are given instructions to stand up from chair
- walk 3 meters as quickly and safely as possible
- cross a line on floor
- turn
- walk back as quickly and safely as possible
- sit down
- patient may use assistive device
- time patient
TUG Manual
- does the TUG
- patient must walk holding a cup filled with water
TUG Cognitive
- do the TUG
- patient asked to complete test while counting back by 3s from a randomly selected # between 20 and 100
- or could ask patient to do alternating letters of alphabet
TUG scores interpretation
- > 15 seconds = 90% prediction rate for faller
Documentation of Balance
- subjective: history of falls, close falls, fear of falling
- objective: name of test, trials, assistive device
- assessment: interpretation of score
- Plan: implementation of balance into plan of care
Balance exams looking at body structure/function
- CTSIG
- BESS
- single leg stance
- romberg
- tandem romberg
Balance exams looking at activity
- Berg
- Tinetti
- Functional reach
- TUG
- TUG manual
- TUG cognitive
Balance exams looking at participation
- ABC scale
What sense dominates when doing CTSIG Condition 1
- firm, eyes open
- somatosensory dominates
What sense dominates in CTSIG Condition 2
- firm, eyes closed
- somatosensory dominates
What sense dominates in CTSIG Condition 3
- firm, dome
- vestibular dominates
What sense dominates in CTSIG Condition 4
- foam, eyes open
- vision dominates
What sense dominates in CTSIG Condition 5
- vestibular dominates
Berg Balance test what score indicates a fall risk close to 100%
- scores less than 36
What does SPLATT stand for, and why do you use it?
- helps to get overall idea of fall/fall risk of patient
- Symptoms before fall
- Previous falls
- Location of fall
- Activity during fall
- Time of fall
- Trauma
Tinetti scores at moderate and high risk of falls
- scores 19-24 are moderate risk for falls
- scores under 19 are high risk
3 Joints of Pelvis
- 2 posterior: left and right SI joint
- 1 anterior: pubic symphysis
SI Joints
- synovial articulations with irregular surfaces
- strong ligamentous support and strong support from bony contour
- some movement. can have effect on pain, stretch, muscle gaurding
Nutation and Counter-nutation
- nutation: base (top) of sacrum moves forward
- counternutation: base (top) of sacrum moves backwards (causes shearing)
Resting Position of SI Joint
- neutral between flexion and extension
Closed Pack Position of SI Joint
Nutation
Capsular pattern of SI Joint
- pain when joints are stressed (compression/gap test)
Pubic Symphysis
- cartilaginous joint united by an interpubic fibrocartilage disc
- movement = rotation and translation
Rotation of pubic symphysis in males and females
- 2deg for males and females
Vertical displacement of pubic symphysis for males and females
- .08mm males
- 1.6mm females
Anterior/Posterior Translation in Pubic Symphysis
- 0.5-0.7
Hip Joint
- acetabulum and femur
- one of largest and most stable joints in body
- multi-axial ball and socket joint
- significantly deeper than GH joint
- acetabular labrum increases articular surface area and creates a seal for the central compartment (resists distraction by maintaining a negative pressure)
Resting position for the hip joint
- 30deg fledxion
- 30deg abduction
- slight lateral rotation
Closed pack position for hip joint
- full extension
- medial rotation
- abduction
Capsular pattern for hip joint
- flexion > abduction > medial rotation
- order of restriction may vary
What is the most superior aspect of the pelvis?
Iliac crest
Size of the Iliac Tubercle?
- widest point of the crest
- 3 inches from top of crest
What originates at the ASIS?
- Sartorius
- Transverse Abdominis
- Internus Abdominis
- TFL
What originates at the AIIS?
- rectus femoris
What is just lateral the pubic tubercle?
- pubic rami
What is at the level of the gluteal fold?
- Ischial tuberosity
What common sources of pain are found at the Ischial tuberosity?
- muscle pain
- bursitis
What is the most prominent lateral aspect of the femur?
- Greater Trochanter
What is a common source of pain at the Greater Trochanter?
- trochanteric bursa
- just posterior to most lateral aspect
What landmark is used clinically to check for hip anteversion or retroversion?
Greater Trochanter
What is found between the PSIS
- spinous process of S2
What is the innervation of the Semimembranosus and Semitendinosus?
- sciatic nerve (tibial division)
Biceps femoris Long Head Origin and Insertion
- O: ischial tub and sacrotuberous ligament
- I: head of the fibula
- N: sciatic (tibial division)
Biceps Femoris Short Head Origin and Insertion
- O: linea aspera of femur
- I: head of fibula
- N: sciatic nerve (common peroneal division)
TFL and ITB Origin and Insertion
- TFL: anterior outer lip of iliac crest and ASIS to ITB
- ITB: anterolateral iliac tubercle to lateral condyle of tibia
- nerve: superior gluteal nerve
Glut Med and Min innervation
- superior gluteal nerve
Glut Max O/I/N
- O: posterior gluteal line and crest of ilium, dorsal sacrum, lateral coccyx and ST lig
- I: ITB and gluteal tuberosity
- N: inferior gluteal n
Piriformis O/I/A
- anterior sacrum and gluteal surface of ilium to superior greater trochanter
- nerve to piriformis
Borders of the Femoral Triangle
- superior: inguinal ligament
- lateral: sartorius
- medial: adductor longus
- inferior: pectineus, adductor longus, iliopsoas
Contents of Femoral Triangle Medial to Lat
- femoral Canal (lymphatics, lymph nodes)
- femoral vein
- femoral artery
- femoral nerve
True leg length discrepancy
- actual bone length inequality