Practicals 2

Question 1

Active Pain-Free mouth Opening

Answer 1

• Ask the individual to open the mouth slowly and as far as possible without pain. Observe the motion for any lateral excursion of the mandible. In normal active movement, no lateral mandibular motion occurs during mandibular depression any lateral excursion of the mandible. In normal active movement, no lateral mandibular motion occurs during mandibular depression.
• Functionally the mandible is able to depress approximately 35 to 50 millimeters so that the individual’s three fingers or two knuckles can be placed between the upper and lower central incisor teeth, although an opening of only 25 to 35 millimeters is needed for normal activities.

Question 2

Active Mouth Opening

Answer 2

• Ask the individual to make an effort to open the mouth as wide as possible even if pain is present
• Functionally the mandible is able to depress approximately 35 to 50 millimeters so that the individual’s three fingers or two knuckles can be placed between the upper and lower central incisor teeth, although an opening of only 25 to 35 millimeters is needed for normal activities.

Question 3

Passive Mouth Opening

Answer 3

• Grasp the mandible so that it fits between the thumb and the index finger and pull the mandible inferiorly. The end of the motion occurs when resistance is felt and attempts to produce additional motion cause the head to nod forward.
• Functionally the mandible is able to depress approximately 35 to 50 millimeters so that the individual’s three fingers or two knuckles can be placed between the upper and lower central incisor teeth, although an opening of only 25 to 35 millimeters is needed for normal activities.

Question 4

Active Protrusion of Mandible

Answer 4

• Have the individual push the lower jaw as far forward as possible without moving the head forward.
• Normally, the
  lower central incisor teeth are able to protrude 6 to 9 millimeters beyond the upper central incisor teeth. However, the normal ROM for adults ranged from 3 millimeters in one study to 10 millimeters in another.

Question 5

Passive Protrusion of Mandible

Answer 5

• Grasp the mandible between the thumb and the fingers from underneath the chin. The individual may assist with the movement by pushing the chin anteriorly as far as possible. The end of the motion occurs when resistance is felt and attempts at additional motion cause anterior motion of the head.
• Normally, the
  lower central incisor teeth are able to protrude 6 to 9 millimeters beyond the upper central incisor teeth. However, the normal ROM for adults ranged from 3 millimeters in one study to 10 millimeters in another.

Question 6

Active Lateral Excursion of Mandible

Answer 6

• Have the individual slide the lower jaw as far to the right as possible. Have the individual move the lower jaw as far to the left as possible.
• The normal ROM is between 8 and 12 millimeters.

Question 7

Passive Lateral Excursion of Mandible

Answer 7

• Grasp the mandible between the fingers and the thumb and move it to the side. The end of the motion occurs when resistance is felt and attempts to produce additional motion cause lateral cervical flexion (be careful to avoid depression, elevation, and protrusion and retrusion during the movement)
• The normal ROM is between 8 and 12 millimeters.

Question 8

Thoracolumbar Lateral Flexion (Fingertip to Thigh)

Answer 8

• Tape measure/Ruler
  Landmarks: where tip of third finger rests on thigh when standing and when bending to the side
• Ages 11-16: 21 cm
  Healthy adults ages 22-55: 21.6 cm
  Blue- and white-collar workers ages 35-59: 19.1 cm

Question 9

Thoracolumbar Rotation (Gonio)

Answer 9

• Fulcrum:
  Over the center of the cranial aspect of the subject’s head.
  Proximal Arm:
  Align parallel to an imaginary line between the two prominent tubercles on the iliac crests.
  Distal Arm:
  Align with an imaginary line between the two acromial processes.
• 45 degrees

Question 10

Thoracolumbar Flexion (Tape Measure)

Answer 10

• Landmark: Spinous process of S2 on a horizontal level with posterior superior iliac spines.
  Identify the spinous process of S1 and observe no motion between S1 and S2.
  Align the tape measure between the two spinous processes and record the distance at the starting of the ROM.
  Hold the tape measure in place as patient performs flexion ROM.
• Average measurement for healthy adults: 4 inches or approximately 10 centimeters

Question 11

Thoracolumbar Extension (Tape Measure)

Answer 11

• Landmark: Spinous process of C7 and S1
  Align the tape measure between the two boney landmarks and record the distance. Make the patient bend backward and record the distance between the two boney landmarks. Calculate the difference between the start and end range position. The Difference is the Range of Motion (ROM) measurement.
• Teens: 4.21 cm
  Healthy adults:
  >2.5 cm

Question 12

Thoracolumbar Extension (Prone Push-Up)

Answer 12

• Landmark: Sternal notch
  Use a tape measure to measure the distance from the sternal notch to the supporting surface. Then, check to make sure the tape is vertical and record the measurement.
• 61 cm

Question 13

Thoracolumbar Lateral Flexion (Gonio)

Answer 13

• Universal Goniometer
  Landmark: Mark the spinous process of T1 and S2 vertebra using a skin marking pencil and center the goniometer over the posterior aspect of spinous process S2
  Proximal arm:
  align the arm so that it’s perpendicular to the ground
  Distal:
  Alin the arms with the posterior aspect of the spinous process of T1
• Young adult female:
• 35 degrees
  Young adult male:
• 38 degrees
  20–29-year-old: - 37.6
  degrees 70–79-year-old:
• 18 degrees

Question 14

Thoracolumbar
Lateral Flexion (Fingertip to floor)

Answer 14

• Tape measure / ruler
  Landmark: Make a mark on the leg level with the tip of the middle finger and the floor
• 21.6 cm

Question 15

Thoracolumbar Flexion (Fingertip to Floor)

Answer 15

• Landmark: Tip of middle finger and the floor
• Healthy females/ mean age of 35: 0.1 cm
  Males and females ages 22-25: 2.2cm

Question 16

Lumbar Flexion (MMST: Tape Measure)

Answer 16

• First mark: at the midline point on the sacrum that is level with the posterior superior iliac spines
  Second mark: 15 cm above the midline sacral mark
• Ages between 15-18:
  Males: 6.7 cm Females: 5.8 cm

Question 17

Lumbar Extension (MMST: Tape Measure)

Answer 17

• First mark: At the midline point of the sacrum that is on a level with the PSIS; this will be over the spinous process of S2
• MALE:
  young adult (15-30 years) : 38 degrees
  middle age (31 to 60 years): 35 degrees
  older than age 60 years: 33 degrees
  FEMALE:
  young adult (15-30 years.): 42 degrees
  middle age (31 to 60 years): 40 degrees
  females older than 60 years: 36 degrees
  the normal ROM for adults is from 20 to 25 degrees

Question 18

Lumbar Spine Extensors

Answer 18

• Prone with hands clasped behind head
• Px extends the lumbar spine until entire trunk is raised from the table (clears umbilicus)
• Raise your head, shoulders and chest off the table. Come up as high as you can.
• Holds like a lock. Can quickly come to the end position and hold without evidence of significant effort.

Question 19

Thoracic Spine Extensors

Answer 19

• Prone with head and upper trunk extending off the table from about the nipple line
• Patient extends thoracic spine to the horizontal.
• Ask the patient to “Raise your head, shoulders, and chest to table level.”
• Patient is able to raise the upper trunk quickly from its forward flexed position to the horizontal with ease and no sign of exertion

Question 20

Lumbar and Thoracic Spine Extensors

Answer 20

• Prone with arms at sides
• Px extends spine raising the body form the table so that the umbilicus clears the table
• “Raise your head, shoulders and chest from the table as high as you can.”
• Fair: Px is able to complete the range of motion

Question 21

Pelvic Elevators

Answer 21

• Supine or prone with hip and lumbar spine in extension. Patient grasps the edges of the table to provide stabilization during resistance.
• Patient hikes the pelvis on one side, thereby approximating the pelvic rim to the inferior margin of the
  rib cage.
• Hike your pelvis to bring it up to your ribs. Hold it. Don’t let me pull your leg down.
• Tolerates a huge amount of resistance that is not readily broken when the muscles are
  involved.

Question 22

Trunk Flexion

Answer 22

• Supine with fingertips lightly touching the back of the head.
• Patient flexes trunk through range of motion, lifting the trunk until scapulae clear table. The neck should not flex.
• “Keep your chin pointed toward the ceiling and lift your head, shoulders and back off the table”
• Grade 5 (Normal); patient completes range of motion until inferior angles of scapulae are off the table (Weight of the arms serves as resistance.)

Question 23

Trunk Rotators

Answer 23

• Supine with hands clasped behind head
• Px. Flexes trunk and rotates to one side. This movement is then repeated on the opposite side so that the muscles on both sides can be examined.
• Lift your head and shoulders from the table, taking your right elbow toward your left knee.” Then, “Lift your head and shoulders from the table, taking your left elbow toward your right knee.”
• Patient is able to raise scapula off the table. The therapist may use one hand to check for scapular clearance

Question 24

Quiet Inspirators – Diaphragm

Answer 24

• supine
• Px. inhales with maximal effort and holds maximal inspiration
• Tell px to “take a deep breath … as much as you can … hold it. Push against my hand. Don’t let me push you down”
• Completes full inspiratory excursion
  Holds against max resistance (range of 100lbs)

Question 25

Capital Extensors
Rectus Capitis Posterior Major/Minor
Longissimus Capitis
Obliquus Capitis Superior/Inferior
Splenius Capitis Semispinalis Capitis Spinalis Capitis

Answer 25

• Prone with head of end of table. Arms at sides.
• Patient extends head by tilting chin upward in a nodding motion. (Cervical spine is not extended)
• Look at the wall. Hold it. Don’t let me tilt your head down.”
• Grade 5 (Normal) patient complete available range of motion without substituting cervical extension. Tolerates maximum resistance.

Question 26

Cervical Extensors

Answer 26

• Prone with head of end of table. Arms at sides.
• Patient extends neck without tilting chin.
• Push up on my hand but keep looking at the floor. Hold it. Don’t let me push it down.
• Grade 5 (Normal): Patient completes full range of motion and holds against maximum resistance. Therapist must use clinical caution because these muscles are not strong, and their maximum effort will not tolerate much resistance.

Question 27

Capital Flexors Rectus capitis anterior Rectus capitis lateralis Longus capitis

Answer 27

• Supine with head on table. Arms at sides.
• Patient tucks chin into neck without raising head from table. No motion should occur at the cervical spine. This is the motion of nodding.
• “Tuck your chin and keep your eyes straight forward. Don’t lift your head from the table. Holt it. Don’t let me lift up your chin.”
• Grade 5 (Normal): Patient holds test position against maximum resistance. These are very strong muscles.

Question 28

Cervical Flexors
Sternocleidomastoid Sternal head Clavicular head
Longus colli Superior oblique head
Vertical intermediate head Inferior oblique head
Scalenus anterior

Answer 28

• Refer to starting position for all flexion tests. Supine with arms at side. Head supported on table.
• Patient flexes neck by lifting head straight up from the table without tucking the chin. This is a weak muscle group
• “Lift your head from the table; keep looking at the ceiling. Do not lift your shoulders off the table. Hold it. Don’t let me push your head down.”
• Patient completes available range of motion against moderate two-finger resistance.

Question 29

Isolated SCM

Answer 29

• Supine with head supported on table and turned to the left (to test right sternocleidomastoid)
• Patient raises head from table.
• “Lift up your head, keeping your head turned.”
• Patient holds test position and tolerates strong resistance. This is usually a very strong muscle.

Question 30

Cervical Rotators

Answer 30

• Supine with cervical spine in neutral. Head supported on table with face turned as far to one side as possible. Sitting is an alternative position for all tests.
• Patient rotates head to neutral against maximum resistance. This is a strong muscle group. Repeat for rotators on the opposite side. Alternatively, have patient rotate from left side of face on table to right side of face on table.
• “Turn your head and face the ceiling. Hold it. Do not let me turn your head back.”
• Patient holds test position with maximum resistance.