MS Exam and treatment Flashcards
exam flow
1- screen 2- structural exam: observe 3- mobility exam 4- strength exam 5- neurological exam 6- palpation 7- special tests
normal categories of end feel
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
what resistance is felt with capsule tightness?
harsh resistance with reduced or absent creep
examples: abnormal in ROM, characteristic capsular pattern
what resistance is felt with joint adhesion?
sudden sharp arrest in 1 direction
example: intracapsular
what resistance is felt with a bony block?
sudden hard/rigid stop
example: callus formation, periarticular ossification (eg. myositis ossificans)
what resistance is felt with abnormal cartilage?
rough grating
example: chondromalacia, osteoarthritis
what resistance is felt with a displaced meniscus?
springy rebound, bouncing back
example: luxated meniscus, joint mouse (free floating cartilage)
what resistance is felt with capsule/ligament laxity?
increased movement without firm arrest
example:capsule torn with hyper mobility grade 2 ligament laxity
what resistance is felt with pannus?
soft with crunchy
tissue implicated: synovium and capsule
example: elbow extension
what resistance is felt with swelling?
boggy, soft
example: effusion, synovitis, hemiarthrosis edema
what resistance is felt with abnormal muscle?
abnormal contractile resistance
example: muscle contracture, adaptive muscle shortening
Accessory mobility scale:
0= ankylosed joint 1= considerable limitation 2= slight limitation 3= normal mobility 4= slight hypermobility 5= considerable hypermobility 6= pathologically unstable
MMT grading
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
Lower quarter screen:
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
Upper quarter screen:
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)
Neurological exam:
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
DTRs:
Commonly tested muscles?
biceps C5-6 brachioradialis C6 triceps C7 patellar tendon L3-4 achilles tendon S1-2
DTR responses
0= Areflexia = absent 1+ = Hyporeflexia = generally indicates LMN injury 2+ = normal 3+ = Hyperreflexia (brisk) =generally indicates UMN injury or disease
what are neural tension tests?
examples?
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
what are 2 tests used to screen for SC signs?
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
contract relax stretching
indications?
contraindications?
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
extremity mobilization
indications?
contraindications?
types?
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
Rules of convex and concave
concave surfaces slide in the SAME direction as the bone
convex surface slide in the OPPOSITE direction as the bone
massage
gives temporary physiological effects such as increased blood flow, relaxation, decreased muscle spasm, and decreased pain
transverse friction massage
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
muscle energy techniques (MET)
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
myofascial stretching/release
a STM technique that is performed slowly and in stages with a release phenomenon that is perceived by both clinical and patient
Fryer’s laws of spinal motion
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
what are ergonomics?
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
what is industrial rehab?
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.
Selective ergonomic and body mechanical techniques:
lifting, standing and sitting
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
interventions for patients with acute conditions
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
interventions for patients with a chronic condition
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
Soft tissue/myofascial techniques
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
Transverse friction massage
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
muscle energy techniques
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
PNF hold relax contract technique
antagonist of the shortened muscle is contracted to achieve reciprocal inhibition and increased range
joint oscillations
- 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
traction
- 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
Neural tissue mobilization
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
Therapeutic exercise
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
Malingering
“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
Secondary gain
usually some type of financial gain for staying ill
- workers comp
- larger settlement for injury claims
