MS Exam and treatment

Question 1

exam flow

Answer 1

1- screen
2- structural exam: observe 
3- mobility exam
4- strength exam
5- neurological exam
6- palpation
7- special tests

Question 2

normal categories of end feel

Answer 2

Normal muscle stretch
resistance= elastic, slow

Normal ligament:
resistance= firm arrest, no creep

Normal capsule:
resistance: firm arrest, creep (with time)

Normal cartilage/bone
resistance: hard/rigid sudden stop

Normal muscle/soft tissue approximation:
resistance: soft, spongy

Question 3

what resistance is felt with capsule tightness?

Answer 3

harsh resistance with reduced or absent creep

examples: abnormal in ROM, characteristic capsular pattern

Question 4

what resistance is felt with joint adhesion?

Answer 4

sudden sharp arrest in 1 direction

example: intracapsular

Question 5

what resistance is felt with a bony block?

Answer 5

sudden hard/rigid stop

example: callus formation, periarticular ossification (eg. myositis ossificans)

Question 6

what resistance is felt with abnormal cartilage?

Answer 6

rough grating

example: chondromalacia, osteoarthritis

Question 7

what resistance is felt with a displaced meniscus?

Answer 7

springy rebound, bouncing back

example: luxated meniscus, joint mouse (free floating cartilage)

Question 8

what resistance is felt with capsule/ligament laxity?

Answer 8

increased movement without firm arrest

example:capsule torn with hyper mobility grade 2 ligament laxity

Question 9

what resistance is felt with pannus?

Answer 9

soft with crunchy

tissue implicated: synovium and capsule

example: elbow extension

Question 10

what resistance is felt with swelling?

Answer 10

boggy, soft

example: effusion, synovitis, hemiarthrosis edema

Question 11

what resistance is felt with abnormal muscle?

Answer 11

abnormal contractile resistance

example: muscle contracture, adaptive muscle shortening

Question 12

Accessory mobility scale:

Answer 12

0= ankylosed joint
1= considerable limitation
2= slight limitation
3= normal mobility
4= slight hypermobility
5= considerable hypermobility
6= pathologically unstable

Question 13

MMT grading

Answer 13

5/5 = normal
can move into test position against gravity with max pressure

4/5 = good
same as normal but can only resist moderate pressure

3+/5 = Fair+
same as good but can only resist minimal pressure

3/5 = Fair
can only move into the test position against gravity and hold

3-/5 = Fair-
same as fair but gradual release against gravity

2+/5 = Poor+
can move against gravity in a small ROM

2/5 = Poor
can move in full ROM with gravity eliminated

2-/5 = Poor-
can only initiate ROM with gravity eliminated

1/5 = Trace
fasciculation or palpable muscle contraction but unable to move

0/5 = no visible or palpable contraction

Question 14

Lower quarter screen:

Answer 14

STANDING

• postural assessment
• active fwd, backward, and lateral bending of lumbar spine
• standing flexion test/ Gillet’s test
• toe raises (S1, tibial nerve)
• heel walking (L4, L5, deep fibular nerve)

SITTING
-sitting flexion test
-active rotation of lumbar spine
passive overpressure if symptom free
-resisted hip flexion (L1-2 femoral nerve)
-resisted knee extension (L3-4, femoral nerve)
-resisted ankle DF (L4-5, deep fibular nerve)
-resisted big toe extension (L5, deep fibular nerve)
-resisted ankle eversion (L5, S1, superficial fibular nerve)
-DTRs: patellar (L3-4), achilles tendon (S1-2)

SUPINE

• dermatome sensory assessment
• SLR (L4-S1)
• passive hip ROM
• sciatic nerve tension test

PRONE

• femoral nerve tension test
• Babinski’s reflex test

Question 15

Upper quarter screen:

Answer 15

postural assessment
AROM of c-spine
passive overpressure if painfree
VBI
quadrant test
resisted muscle tests in c-spine (C1)
resisted shoulder flexion (C2-4)
resisted shoulder abduction (C5)
active shoulder flexion, abd, IR/ER
resisted elbow flexion (C6)
resisted elbow extension (C7)
AROM of elbow
resisted wrist flexion (C7)
resisted wrist extension (C6)
resisted thumb extension (C8)
resisted finger abduction (T1)
Babinski's reflex test (UMN)

Question 16

Neurological exam:

Answer 16

determine if problem related to spinal nerve root, peripheral nerve or CNS

Resisted muscle testing by myotome

Sensory testing

• light touch used to test dermatomes for nerve roots and cutaneous nerve fields for peripheral nerves
• asymmetries or decreased light touch determines further testing such as pin prick, vibration, 2point discrimination, or proprioception

DTRs

Neural tension tests

UMN testing

Question 17

DTRs:

Commonly tested muscles?

Answer 17

biceps C5-6
brachioradialis C6
triceps C7
patellar tendon L3-4
achilles tendon S1-2

Question 18

DTR responses

Answer 18

0= Areflexia = absent
1+ = Hyporeflexia = generally indicates LMN injury
2+ = normal 
3+ = Hyperreflexia (brisk) =generally indicates UMN injury or disease

Question 19

what are neural tension tests?

examples?

Answer 19

essential to determine whether normal neural movement is present

Tests the mobility of the spinal dura and nerve roots by stretching the peripheral nerves with specific body movements

Examples:

• passive SLR- sciatic nerve
• passive SLR with DF and eversion -tibial nerve
• passive SLR with PF and inversion- peroneal (fibular) nerve
• passive SLR with DF and inversion- sural nerve
• prone knee bent-femoral nerve
• passive neck flexion- spinal dura
• slump test

these tests may produce a reported deep ache of vague location- important to make bilateral comparisons for ROM and pain reports

Question 20

what are 2 tests used to screen for SC signs?

Answer 20

1- ankle clonus

• position in slight knee flexion and rapidly DF the ankle
• spasmodic alternations of muscle contraction (clonus) = +test

2- Babinski’s test
-stroke the plantar aspect of the foot from the heel to the base of the great toe with a blunt instrument
+test= great toe moves into DF and the other toes fan out

Question 21

contract relax stretching

indications?
contraindications?

Answer 21

uses a max isometric contraction against the clinician followed by a complete relaxation of the muscle fibers

the limb is moved to a position that causes a stretch to the contractile and inert tissues

after full relaxation, the limb is moved to a new position of stretch. This can be repeated several times

indications: utilized to increase local mobility of a joint and flexibility of a specific muscle group
contraindications: acute muscle spasm, joint instability or hyper mobility, acute muscle strain or joint sprain, inflammation or joint effusion, unhealed fracture, osteoporosis and excessive pain

Question 22

extremity mobilization

indications?
contraindications?
types?

Answer 22

indications: painful or hypomobile joints, subluxed joint reposition, joint dysfunction
contraindications: malignancy, recent or unhealed fracture, active inflammation or infections, pregnancy, total joint replacement, excessive pain

TYPES:

1- oscillations: graded, restore joint play and decrease pain
-Grade 1- small amplitude at beginning of end range
-Grade 2- larger amplitude performed at midrange
(grades 1&2 maintain joint mobility, relieve pain and are indicated in the subacute stage of joint inflammation or sprain)
-Grade 3- large oscillations performed through available range of joint and into tissue resistance (maintains joint mobility)
-Grade 4- small amplitude oscillations performed at tissue resistance (increases joint mobility)
(grades 3&4 are both indicated in more advanced stages of hypomobility or for joint impingement or motion restrictions. These grades should not be used when the joint has inflammation and pain (acute RA exacerbation))

2- sustained mobilizations

• held for 20-30 seconds into the accessory ROM
• grade 1- very small movements into the accessory range and separate joint surfaces while other mobs are performed
• Grade 2- move the joint through the available accessory range without stretching the ligaments or joint capsule (aka “taking up the slack”) and maintain joint mobility
• Grade 3- move the joint through the available range stretching into the limitation and restoring joint play

Question 23

Rules of convex and concave

Answer 23

concave surfaces slide in the SAME direction as the bone

convex surface slide in the OPPOSITE direction as the bone

Question 24

massage

Answer 24

gives temporary physiological effects such as increased blood flow, relaxation, decreased muscle spasm, and decreased pain

Question 25

transverse friction massage

Answer 25

technique that involves deep massage directly to the site of a lesion, in a perpendicular direction to the normal collagen fiber orientation used to normalize soft tissue modeling in the post acute phase of injury to tendons and ligaments

Question 26

muscle energy techniques (MET)

Answer 26

through a submax contract/relax and positional technique, the MS structure of the body is balanced the joint is positioned in an inter barrier zone, which is located prior to a muscle barrier within the normal AROM of the body part there is a gentle isometric contraction followed by full relaxation result is improved articular balance, decreased hypertonicity of the surrounding musculature and increased joint mobility and ROM

Question 27

myofascial stretching/release

Answer 27

a STM technique that is performed slowly and in stages with a release phenomenon that is perceived by both clinical and patient

Question 28

Fryer's laws of spinal motion

Answer 28

Law I - if lumbar or thoracic segments are in neutral without locking the facets, rotation is in the OPPOSITE direction of side bending - in the cervical spine, rotation and side bending occur in the SAME direction Law II -if the cervical, thoracic and lumbar segments are in full flexion or extension with the facets engaged or locked, rotation and side bending occur in the SAME direction Law III - if motion is introduced into a segment in any plane, motion in the other planes are reduced - movement into 1 plane lessens the ROM available in the other 2 planes

Question 29

what are ergonomics?

Answer 29

focuses on the study of work performance with an emphasis on worker safety and productivity ergonomics makes modifications of the job to fit the worker can be defined as a body of knowledge about human abilities, human limitations and other human characteristics that are relevant to the design of tools, machines, systems, tasks, jobs and environments for safe, comfortable and effective human use

Question 30

what is industrial rehab?

Answer 30

the treatment of workers who have injuries related to work attempt to return an individual back to original job or determine what functional capabilities the worker has for other jobs work hardening can be implemented to condition the worker for physically challenging job tasks a job site analysis is utilized to determine what physical requirements are needed for the essential job functions functional capacity evals are 4-6 hour tests that establish the injured worker's functional capabilities and tolerances for job related tasks work tasks are measurable and time-related. Rehab programs need to have goals that are measurable and time-related as well.

Question 31

Selective ergonomic and body mechanical techniques: lifting, standing and sitting

Answer 31

LIFTING MECHANICS: when lifting objects from below the waist, keep your back straight or slightly arched, knees bent and abdominals tight. Keep close to the load and always face the object to be lifted. Pivot your feet and avoid twisting the trunk STANDING POSTURE: if standing for a long period of time, provide a low step stool to alternate placing a foot on- will decompress the lumbar spine and take pressure off of the back SITTING WORKSTATION: feet on the floor, hips above or even with knee, back supported, elbows at or near the side and bent >90deg, wrists straight and hands within 20 inches of the body. The computer screen should be directly in front of the person and between 18-24 inches from their eyes. The keyboard and mouse should be on an adjustable tray together

Question 32

interventions for patients with acute conditions

Answer 32

immobilization with limited (1-2) days bed rest control inflammatory response (RICE) - agents - compression/elevation - NSAIDS - rest/relax - STM assisted movement of injured tissues joint oscillations grades 1-2 for pain relief therapeutic exercise - dose 40-60% of 1RM ( high rep, low resistance) to stimulate regeneration of tissue and revascularization - exercise should be non traumatic- no pain or ^edema educate patient SUBACUTE PHASE - avoid continued irritation and repetitive trauma - joint mobs - continued ther ex- strengthen, coordinate, endurance - postural re-ed - biomechanical education FUNCTIONAL RESTORATION PHASE - maintain/return to optimum level of pt. function - normalize flexibility of joint - restore loading capacity of CT to normal strength - functional strengthening exercises - functional stabilize of involved joint/region

Question 33

interventions for patients with a chronic condition

Answer 33

determine possible causative factors - abnormal remodeling of injured tissues - chronic low grade inflammation due to repetitive stresses of tissues - reduce stresses to tissues - regain structural integrity - ^ flexibility - postural re-ed - ^ tissue's capacity to tolerate loading - functional strengthening, endurance, coordination resume optimal patient functional and prevention of reoccurrence

Question 34

Soft tissue/myofascial techniques

Answer 34

aid in reduction of metabolites from muscle, reactivating a muscle that has not been functioning secondary to guarding and ischemia, revascularization of muscle, and also decrease muscle guarding Autonomic: stimulation of skin and superficial fascia to facilitate a decrease in muscle tension Mechanical: histological and mechanical changes to occur in soft tissues to produce improved mobility and function (acupressure and osteopathic mechanical stretching techniques) Goals: decrease pain, edema, and muscle spasm, increase metabolism and cutaneous temperature, stretch tight muscles and other soft tissues, improve circulation, strengthen weak muscles and mobilize joint restrictions Contraindications: - Absolute: soft tissue breakdown, infection, cellulitis, inflammation and/or neoplasm - Relative: hypermobility, sensitivity Traditional massages: - effleurage: long strokes - petrissage: kneading Functional massage: reactivate debilitated muscle and/or increase vascularity - Soft tissue without motion - Soft tissue with passive pumping - Soft tissue with active pumping Transverse friction massage Movement approaches require patient to actively participate in tx - Feldenkrais: facilities development of normal movement patterns by guided movement possibilities in small, easily available increments - Muscle energy techniques - PNF hold relax contract technique

Question 35

Transverse friction massage

Answer 35

used to initiate an acute inflammatory response for a tissue that is in metabolic stasis (tendonosis) Involved tendon is briskly massaged in a transverse fashion (perpendicular to fibers) performed 5-10 min and tends to be uncomfortable for patient

Question 36

muscle energy techniques

Answer 36

include voluntary contraction in a precisely controlled direction, at varying levels of intensity, against an applied counterforce from PT purpose: to gain motion that is limited by restrictions of the neuromuscular system modification of proprioceptive neuromuscular facilitation (PNF) technique

Question 37

PNF hold relax contract technique

Answer 37

antagonist of the shortened muscle is contracted to achieve reciprocal inhibition and increased range

Question 38

joint oscillations

Answer 38

- inhibit pain and/or muscle guarding - lubricate joint surfaces - provide nutrition to joint surfaces Grade I: small amplitude at beginning of joint play Grade II: large amplitude at midrange of joint play Grade III: large amplitude at end range of joint play Grade IV: small amplitude at end range of joint play Grade V: manipulation of high velocity and low amplitude to anatomical endpoint of a joint (not an oscillation) Grades I&II: used to improve joint lubrication/nutrition, and decrease pain and guarding Grades III&IV: used to stretch tight muscles, capsules and ligaments Grade V: used to regain normal joint mechanics and decrease pain and guarding Contraindications: - Absolute: joint ankylosis, malignancy involving bone, diseases that affect the integrity of ligaments (RA and DS), arterial insufficiency, and active inflammatory and/or infective process - Relative: arthrosis (DJD), metabolic bone disease (osteoporosis, Paget's disease, and TB), hyper mobility, total joint replacement, pregnancy, spondylolisthesis, use of steroids and radicular symptoms

Question 39

traction

Answer 39

- vertebral bodies separating - distraction and gliding of facet joints - tensing of the ligamentous structures of spinal segment - intervertebral foramen widening - spinal muscles stretching Contraindications: - Absolute: joint ankylosis, malignancy involving bone, diseases that affect the integrity of ligaments (RA and DS), arterial insufficiency, and active inflammatory and/or infective process - Relative: arthrosis (DJD), metabolic bone disease (osteoporosis, Paget's disease, and TB), hyper mobility, total joint replacement, pregnancy, spondylolisthesis, use of steroids and radicular symptoms

Question 40

Neural tissue mobilization

Answer 40

movement of neural structures to regain normal mobility tension tests for UE and LE -movement of soft tissues that may be restricting neural structures (cross friction massage for adhesions of the radial nerve to the humerus at a fracture site) Indications: used for patients who have some type of restriction in neural mobility, anywhere along the course of a nerve

Question 41

Therapeutic exercise

Answer 41

Indications: - decrease muscle guarding - decrease pain - increase vascularity of tissue - proote regeneration and/or speed up recovery of CT - mobilize restricted tissue to increase flexibility - increase endurance - increase coordination - increase strength - sensitize muscles to minimize joints going into excessive range, in cases of hyper mobility - develop dynamic stabilize and functional movement patterns, allowing for optimal function w/in environment HEP: necessary to perform enough reps for desired physiological effect on appropriate tissues

Question 42

Malingering

Answer 42

"symptom magnification syndrome" =behavioral response where displays of symptoms control the life of the patient, leading to functional disability psychological advantages: - patient may feel protected from threatening world - uncertanty or fear about the future - social gain - reduces stretsses Special tests: - Hoover test: amount of pressure the patient's heels place on the PT's hands when asked to raise 1 LE while in supine - Burn's test: requires patient to kneel and bend over a chair to touch the floor - Waddell's signs: evaluate tenderness, simulation tests, distraction tests, regional disturbances and overreaction. *emphasize regaining functional outcomes, not pain reduction

Question 43

Secondary gain

Answer 43

usually some type of financial gain for staying ill - workers comp - larger settlement for injury claims