Final Review Flashcards
ROM
Limitation can be caused from trauma or disease
-The maximum distance that bones move about a connecting joint
AROM
Contract muscles that control motion
SROM
Self ROM use unaffected side to help affected side
AAROM*
Active assisted therapist/client help during AROM
PROM*
- Therapist moves client, usually more than AROM
- Stretching, and moist heat to improve a client’s range of motion
Discrepancy
- Tendon not intact: Laceration or an avulsion of a tendon (need a repair, rest)
- Muscle weakness: Need strengthening
- Pain: Increased during contraction
- Scar tissue: (in hand or finger after surgery); restricted in the amount of range of motion that they’re allowed to perform for a long time (scar tissue adhering to different soft tissue in the hand)
Both AROM & PROM affected
Bony block, capsular tightness, muscle tightness, edema, contractures, and extensive scar tissue
End Feels
- Bony end
- Capsular
- Soft
- Spasm
- Empty
- Springy
- Boggy
Bony End-Feel
Movement is stopped because bony surfaces meet
Capsular End Feel
Firm/leathery, some give
Soft End Feel
Tissue against tissue
Spasm (End Feel)
Tissue responds with harsh movement in other direction
Empty End Feel
Stops due to pain
Springy End Feel
Rebounds/bounces back, abnormal ROM
Boggy End Feel
Edema
Note client substitutions such as: (ROM)
Leaning, side bending, shoulder hiking
Potential adverse consequences of edema include:
- Decreased range of motion
- Pain
- Decreased sensation
- Impaired occupational participation
How to measure for Edema
Tape measure, Volume Meter
Tape Measure to measure edema
We use a millimeter tape measure, larger parts of body when it’s not proven to submerge a body part in water
-Recent surgery, and they had sutures and weren’t supposed to submerge the body part into water, then we would use a tape measure rather than a volume meter
Volume meter to measure edema
Used to measure edema in an entire hand.
- If we only wanted to measure one finger, then we could use a millimeter tape measurement
- Volume meter gold standard more accurate but tape more common
- Measures mass of a body part by looking at water displacement as measured by a graduated cylinder
Gross Manual Muscle Testing*
- When we just want our clients to get up and moving (bathroom or to get up and get dressed)
- Not seeing them for a specific muscle weakness or impairment, but maybe something more generalized, like in a skilled nursing facility or in an inpatient facility
- Person wasn’t allowed to move their body part in a full range of motion– if they had lifting restrictions, then you would not perform mmt
- Wouldn’t perform mmt after fractures or surgeries or injuries until it was cleared by the physician
Strength Measurement
- Specific MMT
- Gross MMT
- Grip strength
- Pinch strength
Grip Strength
Generally measured by a Jamar dynamometer (most commonly in the second rung)
Pinch Strength
- Usually measured with a pinch meter
- Three different types of pinch: Tip, lateral, and palmar pinch
Dexterity
- Refers to our ability to manipulate objects (ROM, strength, sensation)
- Need dexterity in order to button a shirt, Writing, using a key to open a door, or playing with a child
- Involves many different components, including range of motion, strength, and sensation
Activity Tolerance=
Endurance
Cardiovascular Component (activity tolerance - endurance)
- Circulatory and respiratory system’s ability to function appropriately during continuous physical activity, adequate amount of oxygen for the task
- Cardiac or pulmonary problem or deficit, it’s important that you monitor their O2 saturation during activity
Muscular Endurance (activity tolerance - endurance)
- Muscles’ ability to continue to work without being overly fatigued
- Prosthesis or using adaptive equipment (crutches) - puts more strain or stress on other muscles, that need to substitute or compensate for the person’s inability
- Increases the strain on our cardiovascular and pulmonary systems.
Borg Rate of Perceived Exertion Scale* (activity tolerance- endurance)
Muscle Length
- On full stretch, the end-feel will feel firm, feel a pulling, or maybe a little bit of pain
- Amount of passive ROM that the client has at the last joint that the muscle crosses that you move can be measured with a goni **Indirectly represents the length of the muscle that has been shortened
Capacity Evaluation/Motor Capacity Evaluation
- Contra-indications and precautions to range of motion and strength testing
- Whether or not an individual is able to comprehend what you’re asking them to perform
- Underlying factors that influence movements- vision, cognition, sensation, pain, or other factors
- *Assess active range of motion and then passive range of motion, muscle-length testing and then move on to strength
- Have to have full active range of motion against gravity before even considering manual muscle testing
Special Tests
Generally performed in order to identify underlying pathologies such as:
- Tendon Tears
- Tendonitis
- Strains
- Impingement
- Nerve Entrapments
Finkelstein’s for Tenosynovitis*
- 1st dorsal compartment extensor pollicis brevis and abductor pollicis longus (APL)
- Hand hang over edge move into ulnar deviation w/ thumb in fist, must be passive
- DeQuervain’s tenosynovitis
DeQuervain’s Tenosynovitis*
- Tendonitis of tendons in 1st dorsal compartment APL EPB
- *Common for new moms, golfers, knitters, racquet sports players
- Mommy’s thumb
- Avoid sustain thumb radial abduction and pinching w wrist dev
Cozens for Lat Epicondylitis*
- Resisted wrist extension (tennis), elbow flex, pronated, extend and radial dev wrist
- ECRB & ECRL contraction
Mill’s for Lat Epicondylitis*
Stretch, pronate, elbow flex and wrist flex, then extend elbow ask for pain (stretch of the muscles)
Hawkins-Kennedy Supraspinatus Impingement*
- Test for shoulder impingement
- Passive IR while shoulder abd to 90, and elbow flex, pronation
Empty Can - Supraspinatus Tendonitis
MMT in scaption w full pronation or supination
- Empty can: IR thumb pointed down, hold, resist at proximal to elbow
- Full can: thumb pointed up
Drop Arm Test
Full-thickness tear of supra and infraspinatus tendons
-Abduction 90 degrees, externally rotated thumb up, hold, slowly lower hand down (slow controlled movement) into adduction
(arm would drop of the test is positive)
CMC Grind Test
CMC OA of the thumb
Elbow Flexion Test
Cubital tunnel - ulnar nerve
Tinel’s Sign
Carpal Tunnel/Cubital Tunnel
AC Shear
AC joint pathology
Neer Impingement
Supraspinatus/Infraspinatus Impingement
Muscle Length Testing
- When moving pt into the PROM, identify the end feels
- Looking for if there is a shortness of the muscle (Could explain why someone didn’t have full ROM)
Elbow Flexion End-Feel
Soft
Elbow Extention End-Feel
Hard (bone on bone)
Triceps
Cross shoulder and elbow
- Shouler: Articulation with scapula (long-head)
- Inserts distal to elbow (extends)
- Flex Shoulder: Start elbow extended and move into flexion
- Measure elbow joint angle
Biceps
- Origin: supraglenoid tubercle of GH joint (long) and coracoid process (short) to bicipital apo & radial tuberosity
- Crosses shoulder and elbow
- Stretch GH (extend) and elbow on slack (flex), shoulder extend
- Start extending elbow tightness feels firm, measure elbow with goni
Pec Major
Supine : scaption, ER, 90 degrees, bring into full abduction
endurance and strength needed to perform an activity or exercise is dependent on
- Amount of motor units being fired,
- The frequency of the motor units being fired,
- The relationship between the link tension of the muscle
- Varying muscle fiber types and sizes
Type 1
- Slow twitch endurance -
- Better suited for fine motor task, stabilizing actions, and overall smaller movements
Type 2
- Fast twitch: big power biceps hamstrings - needed for larger contractions
- Isotonic, Concentric, Eccentric, Isometric
Isotonic (Type 2, Fast Twitch)
Eccentric and Concentric
Concentric Contraction (Type 2, Fast Twitch)
The muscle shortens the moving limb in the same direction of the muscle pull (Picking up a dog)
*Eccentric Contraction (Type 2, Fast Twitch)
The contracted muscle moves like a break against the external force, creating a smooth and controlled movement (quadriceps as you descend stairs or hill.)
*Isometric (Type 2, Fast Twitch)
Contracted muscle is neither shortened nor lengthened. (holding a grocery bag)
Aerobic Exercise
- Exercise that is rhythmic, involves the use of large muscle groups, and can be maintained
- Depend on aerobic metabolism to extract energy from carbohydrates, amino acids, and fatty acids
- Dancing, cycling, swimming, and hiking
- People of all ages and conditions such as heart disease, arthritis, diabetes, and cancer
- Energy that may be inhaled via oxygen intake??
Anaerobic Exercise
- Consists of short bouts of intense physical activity
- Muscles are fueled by the existing energy sources contained within the contracting muscle
- Sprinting, power lifting, and high intensity interval training
Open Chain Exercise
- The distal end of the extremity is not fixed to a stable surface.
- Bicep curls, shoulder shrugs, knee extension, and hamstring curls
Closed Chain Exercises
The distal end is fixed (considered more functional)
- Body is being moved either to or away from the stabilized extremity
- Pull-ups, pushups, dips, squats, and deadlifts
Exercise Dosing
A careful systematic approach to increasing the client’s strength or endurance
For strength to increase… (exercise dosing)
An increase of stress or resistance on the muscles is needed
After reviewing medical history, conducting an occupational profile, and completing an evaluation, therapists should… (exercise dosing)
Utilize clinical judgment as well as the information gathered from the standardized equipment and manual muscle testing to determine a starting point
How to start exercise dosing
Start by determining a client’s one-repetition maximum, or more simply stated, one rep max
One Rep Max (exercise dosing)
Highest weight a muscle can move through the available range of motion for just one time
Intensity Training Program (exercise dosing)
Can be determined based on a percentage of that maximum amount
Initial Stages of their Rehabilitation (exercise dosing)
- Prescribe an exercise regimen at a lower percentage, such as 40 to 60% of the client’s one rep max
- Progress, 80% one rep max
Parameters that may be manipulated to increase strength include: (exercise dosing)
Volume, rest, velocity, type of contraction, and exercise frequency
Training Volume (exercise dosing)
The number of reps and sets performed during one session multiplied by the resistance used
Strengthen the Muscles (exercise dosing)
Fewer repetitions and greater resistance are recommended
Improve Muscle Endurance (exercise dosing)
More reps and less resistance
The period of rest between the lifting should be lengthened when… (rest- exercise dosing)
Performing a high-intensity activity or exercise
The period of rest should be shortened when…
Intensity is lower or there are fewer reps to complete
*When lifting heavy loads and high reps the rest breaks should be… (rest- exercise dosing)
Equal rest breaks of three to four minutes long
When lifting low loads and low reps rest breaks should be… (rest- exercise dosing)
Equal rest breaks of one to two minutes long
To determine the velocity and type of muscle contraction for a strengthening program consider… (exercise dosing)
The physical capabilities of the client and the demands of the task
Dynamic, Concentric Muscle Contractions (exercise dosing)
The muscle’s velocity can be manipulated to match the demands of the activity
Faster Dynamic Concentric Muscle Contractions (exercise dosing)
Can simulate the demands of a sports activity such as basketball
Slower Dynamic Concentric Contractions
Can be used to simulate an activity such as painting
Dynamic Eccentric Muscle Contractions (exercise dosing)
The load is easier to control and therefore takes less effort.
-Lowering a weight will take less effort from the client than lifting it
Active Eccentric Exercises
Ideal for our clients that are very weak
Isometric Strengthening (exercise dosing)
Beneficial when strengthening is warranted, but there’s limited joint movement or the joint movement is contraindicated, as sometimes seen in soft tissue repairs
Why should individuals with cardiovascular issues such as hypertension not engage in isometric strengthening?
Because they can potentially lead to increases in heart rate and blood pressure
Exercise Frequency (exercise dosing)
Based on the patient’s goals, the rest needed for muscle recovery, and their willingness to adhere to an exercise program at home
Beginning a new exercise program (exercise dosing)
- Prescribe exercise 2-3 days a week
- Increased to 3-5 days a week as the client’s strength improves
Active Stretching
Occupational therapists utilize occupation-based tasks to actively stretch shortened tissues
How to stretch a client with contractures
- Provide the client with an occupation that requires slow, repetitive, isotonic contractions targeting the muscle that is opposite the contracture, or by creating a position that requires a prolonged passive stretch of the contracted tissue
- Require a range slightly beyond the client’s limitation
Contract Relax
- Proprioceptive neuromuscular facilitation technique
- Engages the tight or contracted muscle in an isometric contraction held against resistance for 3 to 10 seconds
- During the relaxation phase, the therapist will move the part in the opposite direction of the contraction and hold it
- Ex. Contracted elbow extensors: Place the elbow in as much flexion as available, then instruct your client to maximally contract the extensors isometrically and then relax; Smoothly flex the elbow into a range greater than the initial one
Passive Stretching
Often used as a preparatory method to increase the range of motion
Manual Stretching
- Environment should be calming to the patient
- Explain to your client what you’re doing, explain what you’re stretching, for how long you’ll hold each stretch, and remind them that the pain should be tolerable
- Stabilize the bone distal and proximal to the joint being moved to avoid compensatory movements
- Move the extremity slowly and gently in the line of the muscle pull to the point of maximum stretch
- Encourage clients to participate if possible
- Hold the limb at a point of maximum stretch for 15 to 60 seconds
- Relief should be felt immediately following the release
- If client complains of residual pain, future stretching should be executed at a slower rate and with less force
- Use of orthotics like splints and casts
Strengthening Interventions
Can include things like muscle reeducation, biofeedback, progressive resistance exercises, and electrical stimulation
Isometric Strengthening
- A trace(1) muscle grade or the force of the contraction is not enough to move the part
- Instruct the client to contract and hold the weak muscle
- Maximum effort, the client should hold the contraction as long as possible while breathing normally
- Repeat this exercise 10 times
- Duration of holding the contraction will increase as they get stronger
Dynamic Assistive Strengthening
- Also known as the active assistive range of motion is used with clients demonstrating poor minus or fair minus strength
- Poor minus (2-) strength, you must ensure the client is in a gravity eliminated plane
- Fair minus, the limb should be placed so that it may move against gravity
- The therapist would provide external force to complete the motion
Dynamic Active/AROM Strengthening
- Appropriate for clients with poor or fair strength
- Muscle strength grade of two, ensure the limb is in a gravity eliminated position
- For a muscle strength grade three, make sure they are moving against gravity
- Move the weak muscle through their full available range of motion
- Repeating the motion for 3 sets of 10 repetitions with rest breaks taken between sets
Dynamic Active Resistant/Active Resistance Range of Motion Strengthening
- Reserved for clients demonstrating poor plus, fair, fair plus, good, and good plus
- Poor plus and fair muscle, ensure the limb is positioned in a gravity eliminated position
- Fair plus and higher, the limbs should be moved against gravity
- Client will move the weak muscle through their full available range of motion against resistance
- 3/4 sets of 10 reps may be prescribed with rest breaks taken between each set.
Manual Muscle Testing Procedures
Improving Endurance
- Low-intensity muscle contractions with a higher or larger number of repetitions over an extended period until the muscle is overloaded
- Clients being rehabilitated at 40 to 60% of their one-rep max should lift light to moderate loads greater than 15 reps with less than 90 second rest periods
Optimizing Motor Planning and Performance
Absence of mechanical constraints, adequate postural control, kinesthetic understanding of what the task requires, understanding of what constitutes success for this task, and a match between the individual’s abilities and task demands
Freedom from Mechanical Constraints
- Joint Mobility
- Dissociation
- Poor Postural Alignment
- Freedom from Secondary Impairment
- Capacity to Generate Muscle Contractions
Joint Mobility (freedom from mechanical constraints)
- Impaired by scar tissue, tissue shortening, edema
- Weakness, spasticity, or an impairment of tone, motor planning or motor control, tissues can lose their distance ability
- Immobility will lead to shortening of soft tissues, starting with muscles and tendons, and eventually leading to shortening of tissues at the joint capsule
- Acquired brain injury from either a stroke or a traumatic brain injury
Dissociation (freedom from mechanical constraints)
- The ability of the body segments to move independently of one another
- Appropriate muscle length
Poor Postural Alignment (freedom from mechanical constraints)
- Due to musculoskeletal imbalance can negatively affect balance, transfers, gait, and engagement in a variety of occupations, as well as presenting a safety risk
- Post-stroke, we often see a posterior lateral pelvic tilt, which can be towards or away from the paretic side
- We want center of mass within BOS
maladaptive behaviors (poor postural alignment- freedom from mechanical constraints)
- CNS dysfunction
- Shift weight from an involved lower extremity, even when it is not necessary
- Overly rely on a wider base of support, or they may excessively hold on to objects for postural stability
Freedom from Secondary Impairment (freedom from mechanical constraints)
Edema & pain
Recovering from an acquired brain injury can not rely on the natural kinesiological mechanisms for typical movement
- A learned nonuse
- Part of the original presentation of the client’s impairment is due to cell death, and part is due to restricted cerebral blood flow, restricted cerebral metabolism, and edema in the brain
- Latter group began to improve, the client experiences improvement in motor capacity
- Client does not necessarily know that it has returned and they may not use these abilities as they return
- Aware of some return in motor capacity, but may find it too difficult to use functionally, and so continue to use the uninvolved upper extremity for all tasks
- Lack of use makes the client more vulnerable to the secondary deficits that we have discussed previously, such as loss of range of motion and edema.
When motor memory is impacted…
We must utilize the principles of motor learning
Praxis:
- Ability to analyze the motor requirements of a task and determine the best solutions to potential problems that may arise when performing the task
- Analyze the task and the environment in which it is to be performed in order to create an appropriate motor plan for that task
- Connections between various neural networks allow us to plan for the task and to utilize feedforward control
Feedforward control occurs… (praxis)
Before an individual makes contact
Feedforward mechanism allows us to… (praxis)
Make adjustments in the middle of a task and to be successful at that task
Feedback occurs after… (praxis)
A task has been performed and it’s in response to errors
Brunnstrom’s Stages of Recovery
- Flaccid, no voluntary movement, no tone, no reflexes
- Reflexive synergies present, spasticity begins
- Voluntary movement in synergy can have significant spasticity
- Spasticity is decreasing, beginning to be able to perform movements that slightly deviate from synergy
- Isolated voluntary movement increasingly independent from synergy
- Minimal spasticity, isolated motor control
- Typical speed and coordination
Stages of Recovery
Sensory Testing
2-point discrimination, Semmes Weinstein
Edema
Volumeter
Range of Motion
Goni
Grip Strength Test
Dynamometer
Manual Muscle Testing
Upper extremity
Coordination Testing
Finger to nose/rapid alternating movements
Cognition Testing
MoCA
Discrete Task
Has a beginning & end (putting on a t shirt)
Continuous Task
No clear end (running, riding a bike)
