Final Exam Prep Flashcards
What is traction?
-A force applied to separate two joint surfaces and elongate surrounding tissue
-Distraction
What is medical traction? What is it used for?
-Continuous and static traction
-Used to promote reduction and immobilization following trauma
What is spinal traction?
-Encourages separation and/or movement within the spine between individual segments
-Can be applied manually or mechanically
-Can be continuous or intermittent
What are the grades of manual traction?
-Grade I
-Grade II
-Grade III
What are manual traction characteristics?
-Oscillatory
-Progressive
-Positional
How did Kaltenborn describe traction to a joint?
-With use of three-dimensional traction, which described traction that has been positioned with respect to cardinal planes of motion
-Ex: painful joint positioned into pain-free range
-Ex: hip was positioned in flexion and abduction
What can traction do to different types of tissues?
-Stretches soft tissue
-Relaxes muscles
-Mobilizes joints
-Separates joint surfaces
-Reduces protrusion of nuclear disc material
What must occur in order to have true distraction?
A force strong enough must be applied to elongate the surrounding tissue and allow the joint surfaces to separate
What percentage of a patients body weight is required to increase the length of the lumbar spine?
30-50%
What percentage of a patients body weight is required to increase the length of the cervical spine?
7%
What pathologies are treated with traction?
-Nerve impingement
-Disc herniation/prolapse
-Joint hypomobility
-Arthritic conditions of facet joints
-Muscle spasm
-Generalized joint pain
What tissues are affected by spinal traction?
-Ligaments
-Intervertebral discs
-Facet joints
-Muscles
-Nerves
What does ligament deformation allow for?
It allows spinal vertebrae to temporarily move apart
How does traction affect ligaments?
-Ligaments can be contracted or shortened by injury or chronic postural problems
-Traction encourages adaptive changes in length and strength
-Places pressure on structures within the ligamentous complex (proprioceptive nerves)
-Activation of proprioceptive fibers provide a gating mechanism similar to TENS
What is the function of normal intervertebral discs?
-Act to dissipate compressive forces within the spine
-Internal pressure increase, but nucleus pulposus does not move out with change in weight bearing forces
-80% of compressive load in spine is taken up by the disc
What happens to the intervertebral discs when they are herniated?
-Lose fullness, which moves vertebrae closer together
-Annular fibers bulge
-Nucleus shifts according to fluid-dynamic principles (path of least resistance if annulus is damaged)
How does traction help treat intervertebral disc abnormality?
-Decreases central pressure
-Return of nucleus to central position
-Tension on annulus fibrosus and ligaments surrounding disc (helps to push disc material more centrally)
-Movement of structures relieves pain if pressure is on vascular or nervous tissues
-Allows for improved fluid exchange within disc and spinal canal
-Possible reduction of disc herniation
How does traction affect the facet joints?
-Traction separates joint surfaces up to 1-2mm
-Decompresses articular cartilage, increasing synovial fluid exchange to the cartilage
-Stimulates proprioceptive nerves at the facet joint capsules
What type of traction is best if you are trying to promote fluid movement?
Intermittent traction, because traction, then release will move the fluid around
How does traction affect muscles?
-Decrease in spinal musculature EMG from 1-10 minutes of traction
-Increased muscle EMG from 10-15 minutes of traction
-For muscle tone, use high load, continuous traction less than 10 minutes
What can pressure on nerves be from?
-Bulging disc material
-Irritated facet joints
-Bone spurs
-Narrowed intervertebral foramen
How does traction affect the nerves?
-Can decrease pressure on the nerve
-Can increase blood flow to the nerve, decreasing edema and allowing return to normal function if there is no permanent damage
What are indications for traction?
-Nerve root impingement
-Disc herniation
-Spondylolysthesis
-Osteophyte formation
-Degenerative joint disease (arthritis)
-Sub acute sprain
-Joint hypomobility
-Discogenic pain
-Muscle spasm or guarding
-Muscle strain
-Ligament or connective tissue contractures
What are contraindications for traction?
-Acute sprains or strains
-Acute inflammation
-Fractures
-Joint instability
-Tumors
-Bone disease
-Osteoporosis
-Infections in bones/joints
-Vascular conditions
-Pregnancy (loose ligaments)
-Cardiac or pulmonary problems (because strap around chest can compress chest)
What are the different types of traction?
-Continuous
-Intermittent
-Manual
-Positional
-Gravity-assisted
-Hydrotherapy traction
What is continuous traction?
Constant force that is sustained over a period of time
What is intermittent traction?
Applies force, then releases force for brief intervals of time
What is manual traction?
Force applied by the therapist and can vary from constant, intermittent, or sudden thrust
What is positional traction?
Positioning in a way to effect bony tissue and alleviate pressure
What is gravity-assisted traction?
-Using gravity to traction a joint
-Inversion
-Hanging
What is unilateral leg pull manual traction used for?
-Hip problems
-Lateral shifts
-SI joint problems
-Caudal force w/ leg in 30 degrees flexion, 30 degrees abduction, and full ER
What is a bilateral leg pull manual traction used for?
-Lumbar traction
-Done in hook lying
What are the parameters for mechanical lumbar traction?
-Pt. position (prone, supine, hip position)
-Force
-Intermittent vs. sustained
-Duration of treatment
How should patients be positioned for mechanical lumbar tractioning?
-Neutral spine because it allows for the greatest IVF opening
-Prone may allow application of further modalities and easier assessment of spinous process separation
-Supine & hips flexed to 90 degrees allows for greater intervertebral separation
-Overall determined by patient comfort level
What is short time (< 10sec.) intermittent tractioning used for?
Activates joint and muscle receptors and facet joint movement
What is longer time (> 10sec.) intermittent tractioning used for?
Stretches ligamentous and muscular tissues for separation
How long should rest times be for intermittent tractioning?
They should be long enough for the patients to relax between cycles
How long should continuous tractioning be applied?
-Suspected disc protrusion: 8-10 minutes
-If symptoms only partially relieve, can gradually increase up to 30 minutes
What is progressive vs regressive tractioning?
-Progressive: force slowly increases during the time of traction
-Regressive: force slowly decreases during the time of traction
What are contraindications for inversion table tractioning?
-Circulatory issues
-GERD
How long should cervical traction be applied for?
3-10 minutes
What is the positioning for cervical traction?
-Supine
-Cervical spine flexed at 30 degrees for greater intervertebral foramen separation
-Neutral head position for greater O-A and A-A separation
What is the on/off ratio for intermittent cervical traction?
30:10 seconds
What is independent (I) level of assistance?
-Pt requires no assistance or supervision
-Patient provides 100% effort
What is modified independence (Mod I) level of assistance?
-Patient completes task using an assistive device (walker, cane, BSC) or requires extra time to complete task
-Pt provides 100% of the effort
What is supervision (S) or stand by assist (SBA) level of assistance?
-Pt does not require any physical contact from PT, but due to fall risk or cognitive impairments, the PT should be close by
-Pt provides 100% of the effort
What is contact guarding (CGA) level of assistance?
-Pt requires light physical contact from PT
-Less than 5% effort from PT
-Greater than 95% effort from pt
What is minimal assistance (Min A) level of assistance?
-PT provides 25% or less physical support
-Pt provides 75% of the effort
What is moderate assistance (Mod A) level of assistance?
-Pt provides 50% effort
-PT provides 50% support
What is maximal assistance (Max A) level of assistance?
-Pt requires 75% support from PT
What is dependent total assistance (Total A) level of assistance?
Pt requires 100% assistance to complete transfer
What are the different weight bearing levels?
-Full weight bearing (FWB)
-Weight bearing as tolerated (WBAT)
-Partial weight bearing (PWB)
-Toe touch weight bearing (TTWB)
-Heel touch weight bearing (HTWB)
-Non weight bearing (NWB)
What percentage of body weight can be placed on a limb for partial weight bearing (PWB)?
50%
What percentage of body weight can be placed on a limb for toe touch weight bearing (TTWB)?
25%
What percentage of body weight can be placed on a limb for heel touch weight bearing (HTWB)?
25%
Are there any weight bearing precautions for total knee arthroplasty (TKA)?
Weight bearing as tolerated (WBAT) due to pain
Are there any weight bearing precautions for total hip arthroplasty (THA)?
Weight bearing as tolerated (WBAT) due to pain
What precautions are there for a THA lateral approach?
None
What precautions are there for a THA anterior approach?
-No extension past neutral
-No external rotation of hip
-No adduction
What precautions are there for a THA posterior approach?
-No internal rotation
-No hip flexion greater than 90 degrees
-No adduction
What precautions are there for open reduction internal fixation (ORIF)?
-Typically non weight bearing (NWB)
-Precautions will be set by surgeon
What is open reduction internal fixation (ORIF)?
When pins/rods or screws are placed following a fracture to keep the bone in place
What are traditional sternal precautions?
-No flexion past 90 degrees
-No abduction past 90 degrees
-No reaching behind back
-No lifting more than 5-8 pounds
-No pushing w/ arms (i.e. out of a chair)
-Beneficial to hold onto a pillow during functional tasks or when coughing or sneezing
What are cervical spine precautions following surgery?
-If aspen/cervical collar is in place, no lifting more than 10 pounds
-No shoulder flexion greater than 90 degrees
-Other precautions per surgeon
What are lumbar spinal precautions following surgery?
-Usually after spinal laminectomy
-No twisting
-No forward bending past 90 degrees
-No side bending
-Use log roll to get up
-Most surgeons require spinal orthosis
What is endurance?
-The ability to sustain an activity over a period of time
-Both cardiovascular and muscular endurance
What is activity tolerance?
The amount of activity/exercise that can be sustained before becoming overexerted as measured physiologically and symptomatically (vitals, VO2 max, etc.)
How should we monitor patients pre and post endurance tests?
-Vitals!!!
-HR
-Oxygen saturation
-Blood pressure
-Rate of perceived exertion (RPE)
-Dyspnea scale
What scale is used for the rate of perceived exertion (RPE)?
-Borg scale (6-20)
-Modified Borg Scale (0-10)
What grades are used in the dyspnea scale?
-Grade 0: no dyspnea
-Grade 1: slight dyspnea
-Grade 2: moderate dyspnea
-Grade 3: severe dyspnea
-Grade 4: very severe dyspnea
What is grade 0 on the dyspnea scale?
-No dyspnea
-Not troubled by breathlessness except with strenuous exercise
What is grade 1 on the dyspnea scale?
-Slight dyspnea
-Troubled by shortness of breath when hurrying on a level surface or walking up a slight hill
What is grade 2 on the dyspnea scale?
-Moderate dyspnea
-Walks slower than normal based on age on a level surface due to breathlessness or has to stop for breath when walking on a level surface at own pace
What is grade 3 on the dyspnea scale?
-Severe dyspnea
-Stops for breath after walking 100 yards or after a few minutes on a level surface
What is grade 4 on the dyspnea scale?
-Very severe dyspnea
-Too breathless to leave the house or becomes breathless while dressing or undressing
What tests/functional outcome measures can be used to assess endurance?
-6 minute walk test
-2 minute walk test
-2 minute step test
What tests/functional outcome measures can be used to assess functional strength?
-30 second chair raise
-5 times sit to stand
-Functional strength such as glute bridge, straight leg raise, etc.
What types of assistive devices can be used for gait?
-Cane
-Crutches
-Walker
How are canes useful for gait?
-Least stable assistive device
-Offloads 10-30% of body weight
-Mostly used for balance
What side should someone use a cane on?
Their non-affected side to distribute/shift weight off the injured/painful side
What types of canes are there?
-Standard
-Tripod
-Quad
What should the height of the cane be?
-Pt should be standing in a relaxed position
-The lowest point of the handle should line up w/ the ulnar styloid process
What can crutches be used for during gait?
-Can offload varying degrees of body weight w/ PWB
-Can be used w/ NWB
-Different types of crutches have different UE strength requirements
-Typically used in pairs
What types of crutches are there?
-Standard (axillary)
-Forearm
What are the measurements for axillary crutches?
-3 fingers or 10 cm below the axillary fold (armpit)
-Hand grips should align w/ ulnar styloid processes
What are the measurements for forearm crutches?
-Handgrip should be level w/ ulnar styloid process
-Forearm cuff should be 2 inches distal to the tip of olecranon process
What types of walkers are there?
-Standard
-2 wheeled walker/front wheeled walker (FWW)
-4 wheeled walker
What are the pros and cons of a standard walker?
Pros
-Very stable
-Can slow impulsive patients down
-Can be used w/ weight bearing restrictions
-Helps w/ pain and weakness
Cons
-Bulky
-Heavy
-Inhibits normal gait pattern
-Can get in the way
-Demand more energy than FWW
What are the pros and cons of a front wheeled walker (FWW)?
Pros
-Smooth
-Allows for a more normal gait pattern
-More energy efficient
-Can be used w/ weight bearing restrictions
Cons
-A little less stable than standard
-Can “get away” from patient
What should be the measurements for the walker?
-Patients should stand inside the walker
-Handles should be at the ulnar styloid process
What is a 4 wheeled walker good for?
-Not very stable
-Good for poor endurance
-Easy maneuver
-Large wheels make it easier to use outdoors
-Good for patients with decreased endurance because most have a seat and have breaks that lock
-Not able to use with partial weight bearing or non weight bearing
What is a hemi-walker used for?
-Used for individuals w/ stroke
-People with a fractured arm or has to have their arm in a sling but also requires assistance from a walker
What should the measurement for a hemi-walker be?
The handle should be at the ulnar styloid process
What kind of assistive devices are there for toileting?
-Bed side commode
-Drop arm commode
-Metal hand bar near toilet for support
What kind of assistive devices are there for bathing?
-Bath bench
-Sliding toilet/shower bench
-Shower chair
What kinds of items are needed for shower safety?
-Grip/shower mat to avoid slipping
-Rails if needed
-Shower chair or other bathing assistive devices if needed
What are considerations for safe ambulation?
-Use of gait belt
-Weight bearing status
-Pain during weight bearing
-Decreased strength
-Impaired balance
-Alteration in coordinated movements
-Attention to lines and equipment
-Type of surface ambulating on
-Altered stability
-Absence of a lower extremity
-Ability to use upper extremities
-Patient cognition and attentiveness
-Use of a second person
-Proper stance, guarding, and hand placement
What is involved in preparing for ambulation?
Review medical chart
Assess patient
-ROM
-Muscle performance
-Sensation screen
-Balance/coordination
-Cognition/attentiveness/ability to follow commands
What are pre-ambulation considerations?
-Assistive device to use
-Amount of assistance required (height, weight)
-Safety (1 or 2 person)
Where should the therapist stand when guarding a patient on level ground?
-Stand behind and slightly to one side of the patient
-Stand on patients affected/weak side (unless they have weight bearing restrictions)
-Grasp under the gait belt w/ forearm supinated
-Other hand above or on nearest shoulder
How can ambulation be progressed?
-Decrease level of assistance
-Able to meet modified surface challenges
-Improvement in impairments
-Increase in safety awareness
What type of gait patterns are there with assistive devices?
-Four point
-Two point
-Three point
What is a four point gait pattern?
-Used with 2 canes or 2 crutches
-Four points touch the floor in sequence (1-2-3-4) with three points always on the ground
-Crutch-opposite foot-crutch-opposite foot
-Used for people with poor balance
-Patient unable to lift more than one point off the ground safely
-Cannot use with non weight bearing
What is a two point gait pattern?
-Used with 2 canes or 2 crutches
-Two points are on the ground at all times (1-2-1-2)
-Right crutch, left leg- left crutch, right leg
-Approximates a normal gait pattern
-Cannot be used for non weight bearing
-More stable than four point pattern
What is a three point gait pattern?
-Three points touch the ground, not in sequence
-2 crutches or a walker
-During stance phase, 1 point is on the ground, during the other stance phase, two points are on the ground
-Used for non weight bearing, PWB, or WBAT
-Fast ambulation is possible
-High energy expenditure
What is three point non weight bearing pattern?
-Patient able to bear full weight on one leg, but non weight bearing on the other leg
-Bilateral ambulation aids (crutches) or a walker
What is three point partial weight bearing pattern?
-Crutches or a walker
-FWB on one LE and PWB on the other
-Walker or crutches advance simultaneously with the PWB LE, then the FWB LE is advanced
What functional activities can be done with assistive devices?
-Stairs
-Curbs
-Rough or uneven surfaces
-Sitting in and standing from different types of chairs
Where should the therapist stand when guarding a patient who is ascending stairs?
-Stand behind and slightly to the side of the patient
-Outside foot on stair where the patient is standing and inside foot on the step below
-Advance your feet up one step after the patient has advanced one step
Where should the therapist stand when guarding a patient who is ascending stairs with a handrail and walker?
-Position walker along the side farthest from handrail with closed side of the walker towards the patient
-Front wheel of walker placed one step above the patient
-Patient grabs handrail and other hand holds middle point of the walker
-PT stands behind and slightly to the side of the patient
Where should the therapist stand when guarding a patient who is descending stairs?
-Stand in front and to the side of the patient
-Outside foot on the step where the patient will be stepping
-Inside foot on the step that is one lower
Where should the therapist stand when guarding a patient who is descending stairs with a handrail and walker?
-Walker should be on opposite side of the patient from the handrail w/ closed side towards the patient
-Front wheel of walker placed one step below the step where the patient is standing
-Rear feet of walker on the step where the patient is standing
-Weaker LE lowered first
-Therapist should stand in front of the patient
Where should the therapist stand when a patient is ascending a curb?
-Stand behind and slightly to one side of the patient
-Pt steps onto the curb, then the therapist does
How should a patient go up the curb with a walker or a cane?
-Walker or cane gets placed on the curb first
-Stronger LE steps up first and the pt elevates the body using UE and LE
Where should the therapist stand when a patient is descending a curb?
-Stand in front of and slightly to one side of the patient
-Place outside foot on the curb
-Inside foot on the surface where the patient will step
How should a patient descend a curb with a walker?
-Move to the edge of the curb
-Place walker down first
-Weaker LE down first and lower the body down with the UE and stronger LE
How should a patient descend a curb with a cane?
-Step down simultaneously with weaker LE and cane
-Lower body with stronger LE
Who is on the interdisciplinary team that is involved in discharge?
-Nursing
-Family/friends
-Rehab team (OT, PT, ST)
-Healing and spiritual services
-Physician
-Discharge planner/case manager (usually an RN)
What are skilled services?
-Skills of a therapist are necessary to provide safe and effective interventions whose goal is to improve impairments of functional limitations
-Includes therapeutic exercise, training for transfers, wheelchair and assistive device training, ambulation with assistive device
What are non-skilled services?
-Services that can be safely and effectively provided by non-skilled personnel or family members
-Includes use of hoyer lift, personal hygiene, ROM
What are the key elements for clinical reasoning for acute care PT’s?
-Examination
-Evaluation
-Diagnosis
-Prognosis
-Intervention
-Outcomes
-Discharge planning
-Reassessment
What are the elements of the examination in acute care?
-Pt history/chart review
-Systems review
What are the objective measures that PT’s should evaluate in acute care?
-Aerobic capacity/endurance
-Anthropometric
-Assistive device need
-Balance
-Circulation
-CN testing
-Environmental factors
-Gait
-Integumentary integrity
-Joint integrity
-ROM
-Cognitive function
-Muscle strength
-Pain
-Posture
-Skeletal integrity
-RR
-ADL’s and IADL’s
What is considered when making discharge recommendations?
-Structural impairments & activity limitations/participation restrictions
-Patient ability and willingness to participate
-Discharge environment
-Patient/family wants & needs
-Caregiver support
-Insurance
-Prognosis
What does discharge to home health care look like?
-Wide range of health care services
-Services provided by nursing, OT, PT, ST
-Length of time can vary depending on diagnosis but is typically needed for 4-6 weeks
What does discharge to a skilled nursing facility (SNF) look like?
-High level of medical care needed that must be provided by licensed professionals
-Average length of stay is 28 days
-Pt will receive one or more therapies per day (PT/OT/ST)
-Therapy length 1-2 hours per day
What does discharge to sub-acute care look like?
-Needed for those with high level medical care needs such as intensive wound care, IV treatment, GI tube issues, long lasting stroke, critical illness
-Therapy lasts for 2 hours or less each day
-Frequent meetings with family and patient
-Goal is to return patients to their normal, daily environments with the highest level of strength and functionality possible
What does discharge to acute rehab look like?
-For patients that will benefit from intensive multidisciplinary rehab
-Pts receive PT, OT, and ST as needed
-Average length of stay is 16 days
-Pt must participate in a minimum of 3 hours of therapy per day, 5 days a week
What does discharge to long term acute care hospital (LTACH) look like?
-Patients that require extended hospitalization
-Average stay greater than 25 days
What are the basic principles to consider when prescribing wheel chairs?
-Independence
-Function
-Setting
-Physical attributes of patient
-Prognosis
-Consult interdisciplinary team
-Patient resources
What are specifications for home accessibility in wheel chairs?
-Standard hallway and door width must be 36”
-Doorways must be less than 24” deep
-Ramps need to have 1 inch of run for every inch of rise and be no more than 30 feet if it doesn’t have a level platform
-Lever door handles
What should be considered when prescribing a patient a wheelchair that would be appropriate for that persons body type?
-Height
-Femur length
-Tibia length
-Width across trunk
-Width across hips
What is the measurement for seat width, depth, and height?
-Trochanter to trochanter
-Posterior buttocks to popliteal fossa
-Ensure there is 2 inches in between front edge and popliteal fossa
-Popliteal fossa to sole of foot w/ shoes on
What should be the height of the backrest of the wheelchair on the patient?
Backrest should be at the inferior angle of the scapula
What should the armrest height be at for a wheelchair?
It should allow the elbows and shoulders to relax (not too high where someone has to shrug)
What are the differences in frame for manual wheelchairs?
-Folding vs rigid
-Weight
What are the differences in backrests for manual wheelchairs?
Fixed height vs adjustable
What are the differences in the seats for manual wheelchairs?
-Solid vs sling
-Standard height vs hemi-height (17” from ground)
What are the differences in tires for manual wheelchairs?
-Pneumatic (softer, more friction) vs solid
-Large castor (front wheels) vs small castor
What are the differences in front rigging for manual wheelchairs?
-Rigid vs detachable, swing away, elevating
-Heel loops
What are the differences in arm rests for manual wheelchairs?
-Fixed vs adjustable, removable, or swing away
-Desk length vs full length
What are considerations for using cushions on wheelchairs?
-Posture for back support
-Comfort
-SKIN!!!!!
-Pressure relief
-Foam, gel, or air
-How much use it will get
-Graded for weight of user
What material cushion is better for pressure relief?
Gel and air
What are common types of cushions for wheelchairs?
-Foam flat
-Foam contoured
-Fluid
-Air filled
-Gel
-Hybrid (foam plus gel)
What are advantages to foam flat cushions? What are disadvantages?
-Advantages: less expensive, stable
-Disadvantages: Frequent replacement, bottoms out, risk for pressure ulcers
What are advantages to foam contoured cushions? What are disadvantages?
-Advantages: easy to use, inexpensive, maximize contact with patient
-Disadvantages: may interfere with transfers, risk for pressure ulcers
What are advantages to fluid cushions? What are disadvantages?
-Advantages: decreases shearing forces as fluid moves with person
-Disadvantages: less stable, bottom out, requires maintenance to redistribute fluid
What are advantages to air-filled cushions? What are disadvantages?
-Advantages: light weight, pressure distribution, multiple styles
-Disadvantages: may interfere with transfers, maintenance required, can puncture
What are advantages to gel cushions? What are disadvantages?
-Advantages: stable with good pelvic control, molds to buttocks, more even pressure distribution, conducts heat away from skin
-Disadvantages: more expensive, heavy, may leak
What are advantages to hybrid cushions? What are disadvantages?
-Advantages: combines materials for better control of seating variables (heat, pressure, etc.)
-Disadvantages: weakness of construction components
