ORTHO 3 EXAM done printed Flashcards
Intro to an Ortho examination
• Similar format to what was done in UQ/LQ Screen
• However now the PT is
more focused on a specific joint
Introduction
• At this point in time, the PT has already conducted ahistory, a medical screening, and an UQ and/or LQ scan
• PT has already r/o non somatic causes of pain
• During the UQ or LQ scan, a joint should have been positive for orthopedic dysfunction.
• Either a limitation in motion or pain
• The PT now does a more thorough examination of all the affected joint(s)
.
What are the components of an Ortho Examination?
• Observe
• Edema, color changes, asymmetries
• Palpation
• For Hypertonicity, myofascial assessment, temperature
changes, pain
• AROM/PROM
• Already done in UQ/LQ Screen, but focus on other mo-tions that may not been tested
• Note ROM and pain
• MMT
• Noting for strength and pain. Cause of weakness
• Accessory Motion
• Assessing for joint motion (not covered in this class)
• Special Tests
How does a PT interpret the Results?
- Beyond the scope of this class
- Instead will focus on three musculoskeletalphenomenon
- Fractures
- Sprains
- Strains
- Other diagnoses may be discussed as well
Fractures
• Three common causes
• Sudden impact (most common)
• Stress fracture – associated with repetitiveactivities
• Pathologic fracture – associated with dis-
ease, such as cancer
Sign and sx’s of a Fracture
- Pain and local tenderness
- Deformity
- Immediate Edema
- Ecchymosis
- Pain with WB
- Pain with vibration
- Ultrasound
- Tuning fork (256 Hz)
- Painful weakness with MMT
Fractures associated with OP
• Those with OP, will get fx will less impacted trauma• OP don’t always apply to post menopausal
women
• Those who are at great risk are:
• Smokers, alcohol abuse
• Low vitamin D intake
• 5F’s = Female, Fifty, Fair skin, Fair haired, Frail
• Prolong corticosteroid and anti coagulant use
• Bed ridden
Muscle Strain is?
- Disruption of the muscle fibers
- Due to a fall, a sudden twist, or a pull-ing a ms tendon.
- Due to overstressing the ms or doing an improper technique
Sign and sx’s of a strain
- Pain to injured area
- Tender to touch
- Swelling
- Bruising
- Inflammation
- Cramping
- Pain with stretch, I say stretched at full range, that the muscle is fully stretched.
- Weakness
- Loss of the ability to move joint
Sprain is?
- Disruption of the ligaments
- Due to
- Sudden motion
- Long sustained motion
A strain must have muscle weakness?
Yes
A strain must have pain with stretch?
No
When will there be the most muscle weakness at a strain?
Third degree
When will there be the least pain at a strain?
Third degree
When will there be the least weakness for strain
First degree
Is there alway decreased range of motion for strain?
No, by thirdd egree it may increase.
What do we always look for to make sure that there is a strain?
Muscle weakness.
Sign and sx’s of a sprain
- Pain to injured area
- Swelling
- Bruising
- Pain with stretch
- Weakness, due to poor stabilization and/orpain
- Loss of the ability to move joint
For weakness when will the ligament look like a strain?
At first degree
For sprain, must it always have devreased ROM?
No, at third degree it may increase.
Are there a lot of similarities between strains and sprains?
Yes
Where do we a difference between strains and sprains?
At stage 2&3. That by sprain it is min to moderate weakness still but the strain it is min to mod and mod to severe.
Where can we be more sure to differentiate between the strains and sprains?
Pain with isometric contraction. Sprain will never have pain with isometric contraction because the ligaments are not being stretched.
What is the vertebral Artery?
• There are 2 vertebral arteries
• Ascends thru the transverse foramina of the cervi-cal vertebrae
• Turns sharply along the posterior arch of atlas
• Then pierces the AO membrane and enters the
subarachnoid space
• They join each other and form the basillar artery
• Gives off a branch called the posterior inferior
cerebellar artery to the cerebellum
• Supplies blood to the brain stem
• Which houses the cranial nerves
What are s & S which may indicate dysfunction to thevertebral-Basilar Artery (VBA)?
Which we must be aware of so that we can know if we are to go and perform any cervocal PT of increased aggressiveness.
• More than the 5 D’s. Don’t memorize, but understand that theVBA supplies the CN’s
• Dizziness/vertigo/light headedness
• Nausea (often with vomiting)
• Numbness—most often unilateral facial
• Ataxia/unsteadiness of gait is the most common
• Diplopia
• Ipsilateral Horners syndrome
• Ipsilateral limb ataxia
• Ipsilateral sensory abnormalities of face (CN V); most com-
monly a loss of pain and temperature (dissociated sensory
loss); can get diminished/absent ipsilateral corneal reflex
• Ipsilateral cranial nerve IX–XII abnormalities
• Nystagmus; cerebellar or vestibular in origin
• Possible ipsilateral cranial nerve VII deficit
Alot of constituitional issues and alot of CN issues, because the vertebral arteries do supply blood to the brain so vestibular and cerebellar and CN issues are primary to be looked at.
What is the most common VA dysfunction?
• VBA dissection
• Vessel wall weakness, causing the a pieceof the artery to come loose
• This broken piece can travel up into the
vessels of the brain and cause a stroke or death
What motions Narrow the Vertebral Artery?
• Controversial
• However it appears that the majority of articles agree
• Extension (anterior circulation), rotation (past
45 degrees assess post circulation) and traction will occlude the contralateral VA
• Will be compensated by ipsilateral carotid ar-
tery
Look up and turn, it will occlude the artery.
Vertebral artery testing (VAT) is called what?
DeKleyn’s test
How does one perform the deklyn’s test?
Well the head needs to become declined, that they are lying supine and their head is extendeda nd rotated, just the two motions apthat we did just say are prime for occlusion, and so if they do complain of cerebellar, taxic, CN, or vestibular issues, then it is a positive finding.
VAT is extremely controversial
Pros and cons
For it • Screen for assessing VBA • Offers medico-legal protection • Against it • Putting pt at risk if they do have VBA dys-function • Not a common motion done during PT • Puts more stretch than a typical PT proce- dure • Poor sensitivity
Hautant’s Test
Test for
-Used to differentiate dizziness/ vertigo from a articular problem origin or due to vascular dysfunction
To see if the problem is due to the joint or it is due to occlusion of the vasculature.
Patient Position/action of the Hautant’s
- 2 part testing. Pt sitting
- Flexes both shoulders
- then close eyes. If arms move, it is non vascular. If not, have the pt do the next step
- Pt rotate or extend the head, and
then closes their eyes
- Held for 10 – 30 seconds
Since if the vessels are for sure not occluded, because the neck is neither extended not rotated, so why are they presenting with any of the sign of VBA? Rather it is cervical and not vascular.
But if they are okay at closing their eyes, so we need to go and ask them to actually extend and rotate their own head, and then close their eyes and then it will let us know if it is vascular.
Chair rotation test
If negative now, when before with the deklyen’s it was positive, it may be due to vestibular issues.
If the chair rotation test is positive then this might mean…
That they are getting signsa nd symptoms without provoking their vestibular system, so it is more likey the vascular system.
If the chair rotation test is positive, then what will be do next?
The hautant’s.
Because it is positive, it incpdicates vascular, so we perform a less aggressive deklyn’s tests, namely, the hautants.
Why would the hautant’s be able to tell you that it is VBA and not cervicogenic?
Because the hautant’s is a light enough TOM that it will not evoke musculature pain but it is aggressive enough to cause occlusion.
So if the patient is bothered after the hautant’s then it is clear that it is a VBA issue.
Why by the chair rotation test we are not sure if it is VBA ir musculature?
By the CTT it is occluding and it is aggressive enough to cause musculature pain.
So which is it, vascular or musculature?
So we go and do the hautant’s that is aggressive enough for occlusion and not enough for musculature.
So how would you know if it is musculature?
If the hautant’s come out negative, then we know that the CTT did cause a pain, and now we only go and do that which will occlude, and if we see that the person is not getting aches, then we are clear that it is the musculature.
When is the canadian c spine rule made use of?
When there is a GCS of 15 or there is stable trauma.
When is the Canadian C spine rule not used?
Non-trauma • GCS<15 • Hemodynamically unstable • Age <16 • Acute paralysis, previous spinal disease or surgery.
If ANY High Risk factor present – then
Get an x-ray
What are some of these high risks for the cervical which one is to get an x-ray for?
- Age >65 year
- Dangerous mechanism
- fall from elevation ≥ 3 feet / 5 stairs
- axial load to head, e.g. diving
- MVC high speed (>100km/hr), rollover, ejection• motorized recreational vehicles
- bicycle struck or collision
- Paresthesia in extremities
If ANY Low-Risk factor present – then assess
clinically with ROM testing
(If the answer to any of these is NO then get an x-ray)
1.
Simple rear-end MVC which DOES NOT include the fol-lowing
• ! pushed into oncoming traffic
• ! hit by bus / large truck
• ! rollover
• ! hit by high speed vehicle
2. Delayed onset of neck pain
3. Absence midline c-spine tenderness
Able to actively rotate neck?
45 Degree Left and Right? If able then NO x-ray needed. If un-able, get an x-ray.
When do you imeediately get an x-ray?
When the cause of the injury was a high risk.
When do you not immediately get an x-ray?
When it is not a high risk.
Do you never get an x-ray when it is a non-high risk?
No, there are still tomes where you can require a x-ray even though it is not a high risk mechanism.
When will you require an x-ray when the cause of the injury was not a high-risk?
(If the answer to any of these is NO then get an x-ray)
1.
Simple rear-end MVC which DOES NOT include the fol-lowing
• ! pushed into oncoming traffic
• ! hit by bus / large truck
• ! rollover
• ! hit by high speed vehicle
2. Delayed onset of neck pain
3. Absence midline c-spine tenderness
These are not high risk, but they are not calm enough to have us at ease, so we will require an x-ray.
Lets say that there was no high risk and the way that the person was injured did not make it that it would have had them being with pain immediately, meaning that it is calm but not too csalm tonnot require an x ray?
Meaning that it was rougher than usual, and so maybe the fact that they are with pain now is really not because of that event, so would they require a x ray?
It depends if they can or they cannot rotate their rpheads to forty five degrees to each side. If they can,mthen it will not require a x ray, but if they cannot, then yes, they will require an immediate x ray.
When we say that they will require an immediate x ray, what do we mean by that?
That we are not allowed to go and perform treatments on them.
Cervical AA Instability is a danger because…
The ligament that will hold the atlas neutral, by grabbing onto the odontoid of the axis, is lax, and so the head will roll forward, and it will cause the odontoid to go and press against the sojnal cord. So the person will display neural issue.
How do you make sure that it is indeed a cervical AA laxity?
Sharp purser test.
Where the patient is siting and the therapists stabilizes the axis, and then pushes back in the forehead, the therapist might hear a clunk, that the atlas has been put back in the correct spot, or the patient has less pain.
A patient comes in with c/o of tingling to their right
hand.
What are all the possible
causes?
From most severe to least severe • Brain Pathology • Brain Tumor • Multiple Sclerosis • Cervical myelopathy, which may be due to:• AA Instability • Cancer • Cervical Radiculopathy • Carpal Tunnel Syndrome
Brain Tumor will present with
- Headache N & V
- Speech deficits
- Sensory abnormalities • Visual changes
- AMS
- Seizures
- Ataxia
It would really depend on where in the brain, that some places this and some places that.
CPR for Unilateral Cerebral Le-sions
• Combination of 3 tests
- Pronator drift
- Finger tap
- DTR’s
- All three positive SP of 97% and SN of76%
What is the pronator drift test?
The patient is asking to keep their arms out snd suppinated, and then we see if they drift into pronation, their sensory system is nit working well, and so they drift away into pronation, if you ask them to close their eyes they will may do worse, st means, go into pronation faster, because the visual is out.
Multiple sclerosis affect young or old people?
Young, infact for those who are older, it is rare, I guess, for the onset to start.
Subjective for CM?
Q = Poor balance, loss of manual dexter-ity
R = Paresthesia
(B) usually warrants an MRI
Objective
Observation - atrophy of hands intrinsics • UE and/or LE Weakness
Special test for CM?
• UMN Tests: Babinksi, Clonus, Hoff- man’s Reflex, Inverted supinator sign • Hoffman: May be false positive, more significant if it is unilateral (Ep-stein, 2001) • Reflex Changes: • Biceps/brachioradialis attempt --> Finger flexion • Triceps attempt --> elbow flexion Pectoral Reflex • Hit deltopectoral groove, (+) ADD and IR of shoulder
Cervical Radiculopathyntroduction
• Compression of the nerve root at the…
intervertebral level,therefore this is a PNS lesion
A PNS legion is not a _____ and will _____ on the _____ test?
LMN
Negative
UMN
Special test for LMN?
Spurling test.
What is the sequence of the spurling test?
Extension then SB and then compression.
•Upper limb tension testing.
How many do we have and for which nerves?
3
Ulnar, median, and radial.
Why is the ulnar nerve to have flexion of the elbow?
Because the merve goes posteriorly and it will stretch the most like that.
Why is the median nerve stretch at suppination?
Because since the median is center, so then you need to go and stretch it more than at what it is if it is neutral, so it will be to require pronation.
But the radial and the ulna are pronation because the radial will need to be stretch with pronation. And the ulnar will also get stretched at pronation.
All are pronation except the median that is different.
Name me four tests for the CR.
The upper limb tension test.
The distraction.
Spurling
And if the cervical rotation is less 60 degrees.
These are peripheral nerve compression test, and now UMN.
What is carpal tun-nel syndrome (CTS)?
• Median nerve compression syndrome at the level of the carpal tunnel
What else does the median nerve innervate?
- Innervates the thenar ms, severe nerve compressioncan cause atrophy to the thenar muscles
- Any compression of the median nerve in the tunnelwill cause pain t/o its distribution
Besides repetative motion what else can cause CTS?
Pregnancy, Extra fluid
Hypothyroidism, Makes the connective tissueto be more fluidy
Diabetes
Liver Disease,The nitrates that have not broken down, they will hang out.
CTS Special Tests
Tap over the ventral distal wrist
-instruct pt to hold this position for 1 minute, both wrists in flexion against each other.
And if they result in: -Parathesia and tingling into thumb, index finger, middle finger, and lateral half of ring finger, then they are positive for CTS.
CTS CPR• Five tests
• Shaking hands for symptom relief, is the person has pain so they will shake the hand as if to relieve the pain.
• Wrist-ratio index greater than .67
• Age greater than 45. They are older.
• Diminished sensation in median sensation to thumb, this is the median nerve distribution.
Symptom Severity Scale (SSS) score greater than 1.9, it really does hurt them
Load and shift test is a
Test for ?
-test for atraumatic instability of theGH joint
Load and shift test is does in what position?
-pt sitting in good posture
if slouched, it will cause head of thehumerus go anteriorly
Load and shift is done how?
-stabilize the clavicle and scapula with one hand -other hand grasps the head of thehumerus and load it to the joint -and then move anteriorly and posteriorly
What is a positive repsonse for the load ans shift?
-reproduction of sx’s -more than 25% movement.
Apprehension (crank) test/Relocation test Test for?
- for traumatic instability of the GHjoint
- high spec,99
Apprehension (crank) test/Relocation test is do e is which position?
Supine
How is the Apprehension (crank) test/Relocation test done?
The patient lies down supine and the shoulder is abduction to 90 and the elbow is flexed to 90 and the shoulder is slowly ER
Apprehension (crank) test/Relocation test is positive how?
- pain or look of apprehension on pt’s face
- pain decreases with posterior force on the shoulder (this is the relocation test)
Valgus and varus, explain.
Valgus is when the the medial aspect of the elbow os more medial than it should be, and it is stressed by placing force on the lateral part of the elbow and if it moves more than it should it is positive or if there is pain.
and varus is when the medial aspect is more lateral and you press on the lateral aspect of the elbow towards the medial part and see if there excess movement or if there is pain..
Sciatic nerve divides into the
tibialnerve and common peroneal n
Common peroneal divides into the
superficial and deep peroneal nerve
Tibial nerve divides into the
medialand lateral plantar nerve
Dural Test of dural system especially
L4-S2 & Sci-atic tract
How do you do the dura test?
Its very similar tot he straight leg raise.
That you have the patient ins upine and you have their knee is in extension and you just flex the hip, while keeping the knee extended
Howndo you rule out hamstring with the SLR?
Have them dorsiflex and see if that causes pain, and if yes, then ask them to flex their nexk, and see if that causes pain, and spif yes then it is the dura.
Pain to the dura can be because of the following reasons…
• Herniated disc
Tumor
• Adhesion
With the SLR how would you stress the tibial nerve?
Now we need to stretch it to stress it. So we know that our tibia is medial, so we will dorsiflex and we will evert the foot
How do you stress the sural bpnerve?
We know that we have already stressed the tibial neve with dorsiflexion and with eversion, so lets go and try something else, lets go and dorsiflex and invert.
How do you stress the common peroneal nerve?
You know that the peroneal nerve, the fibula nerve, is lateral, so you want to push into media, nut we are not dealing witht he tibial ie the sural, so here, by the peroneal, we will want to go and plantar flex, but we also want to go and IR the hip.
What about if a SLR causes a contralateral pain in their leg?
This bpcan indicate a hige herniated disc, which if they have B&B issue, it might be indications for surgery.
Tests for lumbar instability
Implies that during movement
the pt loses theability to control the movement for a brief period of time(milliseconds)
• May be structurally unstable
• The brief loss of control results in an instabilityjog or sudden shift of movement in part of the
ROM
H and I Test is a test for?
Lumbar instability and muscle spasm
Patient Position/action for H&I test?
- pt standing
- H portion – SB first then does flex and ext- I portion – Flex/ext first then SB
Positive Response for the H& I test.
Discrepancy between the H and I portions
- A negative response may indicate hypomobility
Segmental instability test vs. H&I test. One choose one over the other?
The HI test is for general screen of the instability, but where is that specific joint that is instable? Of course we will not look for the details if the general screen comes out that there is no issue, also why would we just look at the specifics if we have not done a general screen to see if there is any issues or not. Just like by when we go and do the squat to see if there is an issue at the hip or at the knee or at the ankle.
How is the instability segmental test conducted?
The patient is lying prone on the table with their legs hanging off the table, but resting on the floor, you feel the SP of the vertebrae, and if there is pain, you ask the patient to pick off their legs, and then feel it again, and if they now do not have pain, then it is positive for the instability, since now they have more support than before, sp now it should not have pain, when before it did.
Distraction provocation SIJ test is a test for?
Determine if there is SI pathology. Distract anterior aspects of the SIJ
How do you distract the SIJ?
Supine, and place hands on the ASIS and push down and In and it will open up the joint of the sacrum and the ilium.
What is a positive for the distraction of the SIJ?
Pain in the buttox,
How do you compress the SIJ?
You have the patient lie sidelined and push down on the lateral side of the ilium that is more posterior and it will compress the SIJ.
Thigh thrust SIJ provocation test
The patient is supine and the therapist is above the patient. The thigh and the knee are flexed at 90 degrees, and the therapists places their hand behind the sacrum and the flexed leg is pushed posteriorly with pressure through the femur on the sacrum and it will place posterior pressure on the sacrum
Gaenslen’s provocation SIJ test (right sided test).
Test for Determine if there is SI pathology. Posteriorrot of flexed hip side, anterior rot of ext side.
Patient Position/action Supine, with hip flexed (side to be tested). Other hip is extended. (Can also be done in sideline)
PT Actions Extend the hip further
Positive Response Pain to SI region
Sacral thrust provocation SIJ test
PT Actions Downward to the center of thesacrum
Positive Response Pain to SI region
Why would there be the same lack of hip flexion loss when the knee is both flexed and extended?
By flexion there should be more hip flexion.
Because there is something tight at the buttox.
Determining functional vs structural LLD
- Compare LLD in supine vs long sitting
* If there is a discrepancy then it is functional
Weber-Barstow maneuver for lld (manual as-sessment of lld)
Test for LLD
Patient Position/action supine
- Lift pelvis off table in the hookline position
- Then extend hip and knees
PT Actions PT puts thumb inferior to bilateral medial malleolus
-PT looks for difference
- Use dominant eye, and do not tilt
head
Positive Response More than 1-1.5 cm
When do we do sider a 3cm a concern and when do we consider a 1-1.5 cm difference for the LLD a concern?
The 1-1.5 is by the Weber-Barslow and the 3 is by the non-Weber-Barslow.
To measure really for a LLD how far apart are the legs supposed to be in suppine?
4-8 inches apart.
When in suppine and measuring for the LLD, where do you start measurement and to where?
From the ASIS to the medial malleolus.
What clinical predictor rule does a PTuse to r/o a knee fracture?
• The Pittsburgh Decision Rules for theKnee (Seaberg et al. 1998) • 99% sensitive • 60 % specific • positive predictive value of 24.1
What is the Pittsburgh decision rule?
• An X ray is indicated if there was a blunt trauma or a fall and:
• the patient is less than 12 or greater than 50 years of age
or
• injury causes an inability to walk four weight bearingsteps in the emergency department
Special consideration of The Pittsburgh Decision Rules forthe Knee
• The Pittsburgh rules are not applicable for:
• Knee injuries sustained more than 6 days prior to pres-
entation
• Patients with only superficial lacerations and abrasions• Patient history of previous surgeries or fractures on theaffected knee
• Those patients being reassessed for the same injury
What resists valgus, the knee going lateral?
The mcl
What reissts varus, the knee going lateral
Lcl
How do you do varus and valgus testing?
Similar to the elbow, look up, and if there is increased pain or mobility, then it is a positive.
LACHMAN TEST
Test for ACL (posterolateral band)
- Posterior oblique ligament
- Arcuate popliteus complex. High
spec. Mod to high sensitivity
Patient Position/action Supine, with knee flexed to 30 degrees
PT Actions PT stabilize femur with one hand
-other hand pulls proximal tibia
anteriorly (from postmedial
direction)
Positive Response excess motion or a soft end feel
Posterior draw test
Test for PCL
-high sens, spec
Patient Position/action Supine, hip flexed to 45 degrees, andknee flexed to 90 degrees
PT Actions PT sits on pt’s foot
-pushes proximal tibia posterior
Positive Response excess motion/pain
Difference between the anterior draw test and the Lachman’s test?
The position of the patient and the therapist.
The Lachman’s the patient has their hip at neutral and the knee at 30 degrees and the anterior draw test the hip is at 45 and the knee is at 90 of flexion, and again it is pulled anteriorly.
Additionally the structures, besides the ACL that are being stressed are different.
The Lachman’s stresses Posterior oblique ligament
- Arcuate popliteus complex and the anterior draw test also stresses the -posterolateral/medial capsule-MCL
- ITB
- posterior oblique ligament
- arcuate popliteus complex
Determining an ankle fracture
Use Ottwa Ankle Rules
• A clinical predictor rule which determines whether to order an X ray
Ottawa Ankle Rules
• Ankle radiographs indicated when any of thefollowing are present:
Bone tenderness at the posterior edge or
tip of the lateral or medial malleolus
• Inability to bear weight both immediatelyafter the injury and in the ER
Pittsburgh vs the ottawa ankle rule.
The puttsburgh is for the knee area and the ottawa ankle is for the ankle.
The pittsdburgh is after trauma and if the person is less than twelve or more than fifty or truama and that they cannot walk four steps,
The ottawa is for the ankle and it held to if the patient has a pain on either the lateral or the medial malleouli or that they cannot walk.
Ottawa Foot Rules
• A foot series is indicated when any of the follow-ing are present:
• Bone tenderness over the base of the 5th MT• Bone tenderness over the navicular
• Inability to bear weight both immediately
after the injury and in the ER
Anterior draw tests?
ATF
Anterior draw test, for the ankle, position?
Patient Position/action Supine, with foot relaxed
Ankle anterior draw test, what will the therapist do?
- stabilize tibia and fib
- Hold pt’s foot in 20 degrees of pf - Draw the talus fwd in the anklemortise
What is the common theme by all stress testsa nd all draw tests to see if it is positive or not?
If there is excess motion or if there is pain.
Talar tilt
CF Supine or sideline Foot in neutral adduction the ankle Excess motion or pain
Thompson’s Test
Not homan’s
-Achilles tendon rupture
-high sens 0.96
prone
PT squeezes the calf muscles Absence of pf
What is “cause of the cause”.
it is the primary driver, the real cause of their current pain.
do you not at all address their pain?
of course you do treat their pain, but you cannot ignore the primary drivers either.
What must you look for when you are performing an examination?
red flags
Impairments
You must go and see which issues require immediate attention, and what can wait.
How do you differentiate between an UMN and LMN issue?
Babinski, Clonus, Hoffman’s, and if the reflexes are stringer then it is UMN and if it is weaker then it is LMN.
History
- Pt demographics
- Social History
- Current and past medialhistory
- Social Habits
- Family medical history
R/O systemic disease & medication sideeffects
General Checklist
- Change in cognition/ Cognitive abilities
- Fever/chills/sweats
- N&V
- Fatigue
- Malaise
- Weight loss/gain
- Weakness
- Parathesias/numbness
Systems Check
• Cardiac and Vascular systems Pulmonary system • Gastrointestinal (GI) system Genitourinary (GU) System • Endocrine system • Nervous system • Integumentary system • Musculoskeletal system
IQ vs LQ, where is the cut off?
T6
Which is first AROM or PROM, why?
AROM, because if they cannot donsomething themselves, them we can go and…..
What are the components of the Neuro Screen?
Myotomes Deep Tendon Reflexes Dermatomes UMN signs
Which myotome does neck flexion?
C1-C2
Lateral flexion is done by which myotome?
C3
Shoulder shrug myptome
C4
Shoulder Abduction myotome
C5
Elbow flexion, wrist extension myotome
C6
elbow extension wrist flexion myotome
C7
Thumb extension myotome
C8
Finger Abduction myotome
T1
Trunk control myotome
T1-T12
Hip flexion myotome
L1-L2
knee extension hip adduction, like the rockettes
L3
Ankle dorsiflexion myotome
L4
Great toe extension and hip abduction
L5
ankle plantarflexion and knee flexion myotome
S1
Hip extension
S2
C4 is shoulder shrug but what reflex is it?
Rhomboids, but it is very hard to do
C5 is should abduction, but which reflex is it?
Biceps
C6 is elbow flexion and wrist extension, but what reflex is it?
Brachioradialis
C7 is elbow extension and wrist flexion, but which reflex is it?
Triceps
C8 is thumb abduction, but which reflex is it?
Thumb ext
T1 is finger abduction but which reflex is it?
hypothenar eminence
Reflex grading
0 nothing 1+ hypo-reflexive 2+ normal 3+ hyper-reflexive 4+ clonus, it just keeps on going.
What procedures are done in the standing position?
! Posture/Inspection ! Gait ! Standing squat ! AROM of Trunk/hips ! Neurologic Screening
What procedures are done in the sitting position?
! Trunk ROM
! Vertical trunk compression/Decompression! Neurologic Screening
What procedures are done in the supine position?
! Neck Flexion
! Abdominal Palpation
! SI joint stress tests
! Lymph node palpation ! AROM/PROM of LE’s
! Straight leg raise (SLR)! Neuro screening
How does the PT assess a neuro screen in the sitting position?
! Myotomes ! Trunk flex and extension (T1-T12)! Hip flexion (L2) ! Knee extension (L3) ! Dorsiflexion (L4) ! Toe extension (L5) ! Knee flexion (S2) ! Dermatomes ! DTR ! Patellar tendon L3 ! Achiles tendon (S1)
What is a normal finding with a Babinski’s reflex?
! Normal – Toes flexion
! Abnormal – toe extension
Positive resoonse of the SLR dural test is?
When there is pain at the SLR at 45 degrees, ask the patient to flex their neck, or the PT DF the ankle, and if there is pain that is a positive SLR dural test.
How do you teat for the dural of the tibial nerve?
DF and eversion
How do you test for the Dural of the Sural nerve?
DF and Inversion.
Crossover has a high specificity and low sensitivity for
herniated disc,
that if there is, likely there is.
If no crossover, may still have it.
If they have pain and B&B signs, they might be a candidate for surgery.
What procedures are done in theprone position?
AROM/PROM of LE’s and trunk
If there are Red Flags, you would refer out to an MD.
If there is acute issues, you call 911.
If there are no red flags, youncan continue with the orthopedic evaluation.
And you do the joint above and the joint below the area of concern.
,
Pathoanatomical is?
Find the tissue that is damaged • Comparable sign (Produce pain) • Determine irritability
What is PathoMechanical?
Find the cause of thetissue damaged
• The “Cause of the Cause”
What are the components of an Ortho Examination?
Observe, Edema, color changes, asymmetries
Palpation, For Hypertonicity, myofascial assessment, temperaturechanges
AROM/PROM, Determine motion to test, See if it causes pain, Determine cause of limited motion
MMT, Determine motion to test
• See if it causes pain
• Determine cause of limited motion
Accessory Motion, Assessing for joint motion/Joint Mobility
Special Tests (Sometimes done first), Designed specifically to test a tissue
What is one to observe during the objective portion of the orthopedic examination?
Edema, color changes, asymmetries, posture, guarding
What is static vs functional observations?
one is what you see when they are steady and one is what you see when they are performing an action.
Palpation what is it?
For Hypertonicity, myofascialassessment, temperature changes, tenderness, edema
ROM Assessment! Determine
motion to test
ROM Assessment See if it causes
pain, Determine cause of limited motion
Which motions should be assessed?
Some motions already tested in screen!
Check motions that are needed for functional limitations
◦ Based on kinesiology
Does AROM/PROM cause pain?
reproducable
Comparable sign
Note at what point in the ROM pain occurs
If they complain of pain with lifting their arm only.
What shoulder motions?
flexion, extension, IR ER AB/Aductin
If the complaint of pain is only with sit to stand?
What hip motions?Hip extension Neutral, hip flexion to 90.Must check. hip
flexion. they do not need to go to 20 degrees of hip
extension, or 45 degree of rotation.
If they complain of
pain with walking?
• What hip motions?
EXTENSION. Rotation.
If no pain can be produced then:
Test multiple times, tosee if then it could be reproduced. • Check for irritability • Repeat • Sustained holds • Combined movements (functional)
What structures may limit ROM?
Muscles Capsules Nerves Fascia Positional Fault
Muscles as cause of decrease ROM?
Loss of sarcomeres in prolong shortening positions
! Differentiate between 1 vs 2 joint ms
Basic facts of capsule
• Attaches to periosteum •
Reinforced by ligamentous & musculotendinous structures
• checks movement
With injury or lack of motion, there is joint capsule limitation in ROM
Will become fibrotic (Tissue composed of
bundles of collagenous white fibers between which are rows of connective tissue)
How does the dura affect motion?
Remember%dura%is%aZached%t/ Like a giant rubber band, and it
can get stuck at any spot, and theo%the%en*re%system,%from%base%can be injury that will scab and that scab can place pressure on
of%skull%to%the%foot%
• With%injury,%dura%becomes%infl%
and%may%get%scarred%down%
• This%will%limit%ROM
Posi*onal%Fault%(Kaltenborn%76)%
The%joint%is%in%abnormal%posion%%
• Most%of%the%me%due%to%a%hypermobile%joint%
• Therefore%the%axis%of%the%joint%is%affected,%and%thus%will%lead%to%a%loss%of%ROM%
MMT
Determine motion to test
• See if it causes pain
• Determine cause of limited motion
Motor output assessment
Which motions to assess?
Test in wb vs non wb
Pain with motor testing
Determining cause of poor output
Which motor control to assess?
Same ones tested during ROM ◦
Exceptions?
! Functional tasks
Advantage of testing in wb
Functional
• See interaction/
influence of, and on, adjacent structures • See influence of stabilizers
Advantage of testing in non wb
• Test joints in isolation
• See compensations •
IE: Test hip flex, and pt ERs hip
Pain%with%muscle%contrac*on%Pain$can$be:$
Ms%strain%
G %Joint%dysfunc*on%(due%to%compression)
If no muscular pain…
- Repeat%
* Perform%in%outer%range%!%more%tension%on%muscle%and%can%pick%up%more%minor%lesions%(1st%degree)%
Review of normal motor output Signal
starting from CNS to PNS
Antagonist must lengthen/
• Stabilizers (local and global) contract
• Mobilizers contract
Prerequisites for motor output
Full ROM
• Free of inhibition (pain & swelling) Muscle must be intact (no atrophy, no altered length tension relationship, no damage)
• Static stability intact
Possible Causes of Weakness
Cortex not sending signal
! Spinal cord not sending signal
! Peripheral Nerve lesion
! Poor Motor control
! Muscle dysfunction (Atrophy, Strain, altered length-tension relationship)
! Poor stabilization
◦ Dynamic (Ms local or global) or static (bony
configuration or ligamentous)
! Decrease ROM
! Inhibited (all the motor units not firing)
How do you test to see if there is damage to the CNS?
UMN testing, Babinski, Hoffman’s, Clonus, DTR.
Peripheral nerve lesion! Any injury to the peripheral
! Assessment?
NCV, LMN signs, no ms contraction
Poor stabilization
If%the%proximal%bone%is%unable%to%remain%stac%during%stac%MMT%tes*ng,%it%will%lead%to%weakness%
• Pt%appears%to%have%weak%shoulder%flexion,%but%it%is%due%to%weak%upward%rotators%or%weak%RTC%or%poor%
ligamentous%support%
• Assessment?% you can go and supply external stabilization and see if that will assist in lowering the pain or to allow increased ROM.
Dr Rodriguez’s method
provide external stabilization and see if that helps, if it does ask them to do it, if they can so we have motor control, if they cannot, then we are to work on stabilization, but if they cannot lift it with external stabilization, then it could just be atrophy
Muscle%strain% Assessment?
MMT to see if it causes pain. Palpate it tosee if there is pain.
Altered%length%tension%rela*onship%
– Assessment?%
Compare it to the other side.
You will need to assess where in the range it is strong, usually muscles are strong in the mid range, and here it could be that it is weak at it mid range and strong at its end range, the tension curve has shifted, and this will just make it that the person is to have a harder time to perform functional task.
What is poor motor control?
In ability to coordinate all the intricatedetails of a movement
! Assessment? You ask them to maintain a specific position or movement pattern. And see if they can do it.
What%is%accessory%movement?%
Is%movements%within%the%joint%and%surrounding%ssues%that%are%necessary%for%full%ROM%but%cannot%be%performed%acvely%in%isola*on%
Accessory%motions are, ex.
spinning,%rolling%and%gliding%(transla*on)%
Accessory motion is Limited by?
Capsule and ligaments, so if they are lax and they do not provide stability, they will be hyper mobile and they can cause unwanted shifts in the joint and it can cause pain.
And hypomobile joints will cause shifts in other joints, as we had learned in orthosis class.
What%is%the%purpose%of%accessory%tes*ng?%
To%determine%if%pt%has%normal%moons%at%arthrokinemc%level,%needed%for%
osteokinema*c%level%
the joint movement vs. the
individual bone movement.
Grading system
! Variety of grading systems !
Four-point system
◦ 0: No movement / ankylosed ◦
1: Stiff / Hypomobile
◦ 2: Normal
◦ 3: Excessive / hypermobile
Ypu first need to see ________
Then you figure out _______ is ________ the _______
Then you go and ________ the _______
activities the person cannot do, and choose the most important
Then see what actions does not allow the person to participate
Then go and see how you can treat the person so that their activity will not become limited so that hey can return back to their participation
After history and observation, PALPATION, ROM, MMT, FUNCTIONAL ASSESSMENT, AND PREFERENCE what do you do next?
have a problem list, of the participations that they cannot do.
after you have figured out what areas of life they cannot participate, what do you do next?
See which ONE participation is the most important for them. Driving, maybe its their job, walking, maybe they need to go religious services, writing and typing, maybe they …. whatever else.
After you figure out the ONE activity that they want to return to, what do you do next?
You need to figure out which functional limitation does not allow them to do that ONE participation that they want to return to.
After you figure out the functional limitation that is not allowing them to perform the ONE participation that they wish to return to, what do you do next?
you need to go and see which body part is not allowing them to carry out that functional task, which is now impeding their ability to perform that ONE participation which they wish to return to.
How do you determine the cause ofthe pain/problem, that is not allowing the functional task that is getting in their way of the ONE participation which they wish to return to?
! First establish what tissue is damaged
◦ What stage of healing?
◦ The extent of the damage
! Then determine:
◦ Locally (at the joint): do they have stability
“ Dynamic and static
◦ Globally (above and below the joint):
“ Control (dynamic and static)
“ Is there an adjacent decr ROM, causing the joint inquestion to be hypermobile?
You need to consider the joint, area, and the area around it.
For maybe it truly is just that joint, Osteoarthritis for example, there is nothing wrong with the other areas around it, the point of focus is just that one joint, now they cannot perform single leg stands, so they cannot walk up stairs, and so they cannot get to work.
But in addition to the local joint, we must also look at the one joint above and the one joint below, because hypomobile adjacent joints will cause this joint to be hypermobile, and hypermobility is instability, and instability is pain.
What can cause this problem by this other joint that is causing this problem by this joint that is causing the person to not be able to do a functional task, which get int he way of the ONE participation that they wish to return to?
Decreased ROM or Motor control.
By motor control, they just need to be taught how to move the other area so that the forces will be evenly distributed to not make one area sheer and have microtrauma which would result in pain.
When people fall, they are taught how to roll, tuck, bend, and everything else. If they just take all of that force on their legs, depending on the structural soundness of their legs, it might break, and so they are taught to distribute all of that force over their entire body to not bring to one area more force than it can handle.
Does the patient have control ofROM?
! Patient may have the ROM, however can they control that motion
◦ Discrepancy between PROM and AROM
◦ Unable to do the functional motion correctlyin correct alignment
! Lack of control may lead to abnormal forces
Controlling Pain Inflammation &Edema ! PRICE-MEM
Protect ! Rest ! Ice ! Compression ! Elevation ! Manual therapy! Early motion ! Medications
Protection
• Avoid tissue loading of
damaged tissue
• Ie. Assistive device, braceor education
Rest
• Absence from abuse, notabsence from activity
• Prolong rest can be
detrimental
Ice
• Decrease pain, decrease edema
Compression
Very good at the acute stage.
• Reduce edema
Elevation
Reduces edema
Manual therapy
• Reduces pain • Stimulate endorphins • Increase mechanics • Remodeling of local connective tissue• Joint lubrication
Early Motion
- Reduce atrophy (primarily type 1 fibers)
- Maintain joint function
- Prevent ligamentous creeping
- Avoid excessive scarring (arthrofibrosis)
- Enhance cartilage nutrition & vascularization
Medications
• NSAIDS
Affect fibroblast function, but may allow to do PT, which may decr infl
• Scope of practice
Treatment by stage- Proliferation
! Promote Healing, always
! Increase ROM, but…
◦ Not too aggressive, due to new scar
◦ Neuro re ed into new range, to maintain the new range
! Exercise. How?
◦ PROM ~>active ~>assist ~>AROM ~>sub maximal PRE’s
◦ Progression by no pain & good form
Treatment by stage- Maturation
! Increase ROM
◦ More aggressive but don’t restart infl stage ◦ Neuro re ed into new range, to maintain the new ROM
! Exercise
◦ PRE’s, they are strong enough that you start with this.
◦ Specific Adaptation to Imposed Demand
(SAID)
! Promote healing
◦ Not necessary because out of healing stage, unless chronic inflamed
Treatment by stage- Acute
! Promote healing, always ◦ PRICE-MEM ! ROM ◦ Pain free range ! Exercise ◦ Isometrics Almost always safe.
Promote healing
! Respect the healing process ◦ Patient education, not only is the therapist supposed to be careful about the injured tissue, but the patient, who is there with themselves always, is supposed to go and be educated in how to care for their injuries to not increase it. ◦ Proper exercise ! There ex ◦ To increase blood flow ! Modalities ◦ US, E stim, MHP, Laser ! Non PT ◦ Prolotherapy (injections to stimulate healing process)
Restore ROM
! Methods ◦ STM ◦ Stretching ◦ Exercises ◦ Mobilization/Manipulation ! Neuro re ed into new range
Guidelines for increasing ROM (Dutton 301)
! Use post isometric relaxation, first isometrics and then these, because if you increase ROM they may not have the ability to strengthen themselves.
! Heat prior
◦ Ex or modality
! At least 3x week, low force, no pain, for prolonged duration
◦ Cooling in prolonged position
! Reduce spasm if present
Alexander Technique
◦ Breathing and Posture technique
Feldenkrais Method
Move through relaxation and self awareness with minimum effort
Pilates
Core stabilization
Proprioceptive Retraining, why, what, how, gives, ex?
Often is impaired after joint injury
Must retrain afferent pathways
Improved with close chain ex’s
Coordinating muscle strength, endurance, flexibility and neuromuscular control
Ankle sprain there is a lack of propioception loss. Terrible balance on that leg.
Proprioceptive Retraining LE Method
Close chain isometrics, there is no movements, on stable surface
Progress to unstable surface, because we need to make the sensation harder to feel so we will move to an unstable surface, just like we did in THEREX
Transitional stabilization exercises
◦ Conscious control of motion to stimulate dynamic postural response, this is very similar sounding to motor control
◦ Increases muscle stiffness, so that there will be stabilization, because we say that looseness contributes to ROM but is unstable, and tightness is with more stabilization but there is less ROM.
! Dynamic stabilization exercise
◦ Unconscious control and loading of the joint, that is just happens, it is reflexive, it is second nature to the person.
Proprioceptive Retraining UE Method
Leaning on treatment table
Quadruped
Kneeling
◦ 3 point position ! 2 point position ! As above with unstable surface.
I guess these are causing the person to feel more their joint positions and work on themselves so that they will be able to move appropriately.
What may be causing pain?
! Damaged tissue
! Spasm
! Inflammation/Edema
! Improper healed scar! Abnormal Pressure
And all of these can have their own cause, the primary driver, so then as we did say earlier that the therapist must treat the area of functional limitation because that is causing their participation lack, but what really is causing them to have pain their?
It could be a hypomobile adjacent joint, and that hypomobility can be due to stiffness, orthosis, pain, and then that pain might be from another hypomobile joint. ad infinitum?
How do we treat for each source ofpain?
Damaged tissue • Promote healing
Spasm • STM & modalities
Improper healed scar • Exercise, ROM, modalities
Abnormal Pressure • Restore proper mechanics via ROM, Mobs and ex
Inflammation/Edema • PRICE-MEM
