Quiz 3 Flashcards
Strength
Force extended by muscle or group of muscles to overcome resistance in one max effort
Power
Work produced per unit of time
Endurance
Ability of muscle to contract repeatedly over time
MMT
Performed to examine capability of muscle or muscle group to function in mvt and ability to provide stability and support when other segments may be moving
Agonist or Prime Mover
Muscle of muscle group that makes major contributions to mvt at joint
Antagonist
Muscle or muscle group that has opposite action to prime mover
Synergist
Muscle that contracts and works along w/ agonist to produce desired mvt
Neutralizing or Counteracting Synergist
Muscles that contract to prevent unwanted mvts produced by prime mover
Ex: hamstrings
Conjoint Synergist
Two or more muscles that work together to produce desired mvt
Stabilizing or Floating Synergist
Muscles that prevent mvt or control mvt at joints proximal to moving jt to provide stable base
Why MMT
Determine relative strength of muscles
Appreciate effect of muscle length imbalances
Determine status of peripheral nerve or spinal root functioning
Differential diagnosis
Examine pt motivation and ability to follow directions
Establish baseline, determine improvement, modify treatment
Precautions
Extreme pain and edema
Extreme weakness
Conditions where MD advises against resistive and/or isometric exercise
Cardiac conditions
Osteoporosis
Limitations in pt’s cognitive or emotional status
Probable Contraindications
Recent unhealed fracture
Serious muscle, tendon, ligament tear
Neoplasm
Pain of unknown etiology
Thrombophlebitis
Tissue inflammation
General Instructions
Intro to pt, explain, and demonstrate
Have pt perform AROM and observe for substitutions
Place pt in recommended test position (if they can’t perform AROM through full range, reposition pt in gravity-eliminated position)
Expose muscle and jt
Optimize body mechanics and stabilize proximal components as necessary
Encourage max effort and apply graded resistance
Check pt status
Record MMT grade
Break Test
After segment has completed its range, resistance is applied near distal end of segment to which muscle attaches
Pt is asked to hold and not allow tester to “break” hold w/ resistance
Commonly used
More objective than active resistive test
Functional muscle strength and fatigue difficult to assess using this method
Active Resistive/Dynamic Testing
Graded manual resistance against direction of mvt (through related ROM)
Difficult to grade, but may be necessary w/ certain medical conditions, such as unstable angina, acute MI
May be more beneficial to asses endurance and patterns of substitution
MMT Grades - 5 (Normal)
Cannot break hold against max resistance
MMT Grades - 4 (Good)
Can tolerate strong resistance
Muscles gives/yields w/ max resistance
MMT Grades - 3+ (Fair Plus)
Holds end position against resistance
MMT Grades - 3 (Fair)
Completes full ROM against gravity
MMT Grades - 3- (Fair Minus)
Does not complete ROM but but greater than half range
MMT Grades - 2+ (Poor Plus)
Initiates mvt against gravity OR in gravity minimized position w/ slight resistance
MMT Grades - 2 (Poor)
Completes full ROM in gravity eliminated position
MMT Grades - 2- (Poor Minus)
Completes partial ROM in gravity eliminated position
MMT Grades - 1 (Trace)
Examiner can detect visually or by palpation some contractile activity, but no mvt of part
MMT Grades - 0 (Zero)
Muscle is completely quiet
To Improve Reliability
Standardize position
Stabilization of proximal body parts
Using grading criteria
Use same examiner
Other Methods of Measuring Strength
Hand-held dynamometry - values vary w/
- Method of applying resistance (make vs. break test)
- Body position in relation to gravity
- Joint angle
- Lever arm
- Stabilization
- Examiner’s strength
Isokinetic dynamometry - can also measure torque, work, endurance
Muscle Weakness
When finding muscle weakness, assess muscle length
Muscle is tight - usually strong
Muscle that is lengthened - harder to produce strength, weaker
Stretch Weakness
From muscles remaining in elongated condition, however, slight beyond neutral physiological rest positions but not beyond normal range of muscle length
Over-Stretch Weakness
From 2-jt or multi-jt muscles, weakness results from repetitive or habitual positions that elongate that muscles beyond normal range of muscle length
Intervention
Lack of use
Overwork/fatigue
Stretch/strain
Neurological impairment
Exercise
Rest
Relieve prior to exercise
Iliopsoas
Hip flexion
Psoas - L2-4
Iliacus - Femoral N L2-3
Fair and above - short sitting
Resistance - pt lifts knee toward ceiling, resisted over distal thigh proximal to knee jt downward toward floor
Below fair - sidelying w/ tested leg uppermost, supported by examiner; lower limb flexed for stability
Sartorius - see ER and abd
TFL - IR and add
Sartorius
Hip flex, abd, ER and knee flex
Femoral nerve L2-4
Fair and above - short sitting
Resistance - pt slides foot up shin, resistance applied at lateral knee to hip flex/abd, above medial ankle to knee flex and hip ER
Below fair - supine, support limb as necessary
Substitutions - iliopsoas or RF - see no abd or ER
Glut Max/Hamstrings
Hip ext
Gmax - inf gluteal nerve L5-S2
Hamstrings - sciatic (tibial) nerve L5-S2
Fair and above - prone
Resistance - pt entire leg, applied on post leg above ankle or post thigh down toward floor; Gmax - flex knee
Below fair - sidelying w/ tested leg uppermost, supported by examiner
Glut Med and Min
Hip abd
Sup glut n L4-S1
Fair and above - sidelying with test leg uppermost, hip slightly extended and pelvis rotated forward, lower leg flexed
Resistance - pt lifts leg toward ceiling, over lateral side of thigh just proximal to knee or at ankle
Below fair - supine, therapist supports at ankle to decrease friction
Substitutions
- Using lateral trunk - see hip hike
- Hip flexors - see ER/pelvic retraction
- TFL - hip flexes or if hip starts in flex
TFL
Hip abd
Inf glut n L4-S1
Fair and above - sidelying with test leg uppermost, hip flexed to 45 degrees
Resistance - pt abducts leg, applied over distal femur toward floor
Below fair - long sitting, backward trunk lean up to 45, hands behind for support, therapist lifts leg to decrease friction
Hip Adductors
Pectineus - femoral nerve - L2-4
All others - obturator nerve - L2-4
Fair and above - sidelying with test leg lowermost, upper limb supported by therapist in slight abd
Resistance - pt adducts lower legs toward ceiling, applied down toward table on medial surface of distal femur
Below fair - supine, therapist supports at ankle to decrease friction
Substitutions
- Hip flex - IR and post pelvic tilt, turn toward spine
- Hamstrings - ER and ant pelvic tilt, turn toward prone
Hip ER
Obturator ext - obturator nerve L3-4
Obt int and sup gem - n to obt int L5-S1
Qfem and inf gem - n to qfem L5-S1
Piriformis - n to piriformis S1-2
Fair and above - short sitting
Resistance - pt rotates hip-foot moves toward other leg, above medial ankle in lateral direction (other hand provides counter pressure over lateral distal thigh in medial direction
Below fair - Supine test limb stats in IR or short sitting w/ sight resistance from IR position
Substitution
- Lifting contralateral hip or trunk leaning
- Knee flex
- Hip abd
Hip IR
Glut min/med, TFL
Fair and above - shorting sitting
Resistance - pt rotates hip-foot moves away from other leg, above lateral ankle in medial direction (other hand provides counter pressure over medial distal thigh in lateral direction
Below fair - Supine test limb stats in ER or short sitting w/ sight resistance from ER position
Substitution
- Lifting ipsilateral hip or trunk leaning
- Knee ext
- Hip add/ext
Hamstrings
Knee flexion
Semis and bicep long head - sciatic (tibial) L5-S2
Biceps short head - sciatic (common peroneal) L5-S2
Fair and above - prone
Resistance
- All flex knee - toward knee ext
- Semis - leg IR (down and out toward knee ext)
- Biceps - leg ER (down and in toward knee ext)
Below fair - sidelying w/ test limb supported by examiner
Substitutions
- Hip flex - see hip flex
- Sartorius - see hip flex, ER
- Gracilis - see hip add
- Gastroc - see ankle DF to stretch gastroc resulting in knee flex
Quads
Knee ext
Femoral n L2-4
Fair and above - short sitting
Resistance - pt extends knee, over anterior distal tibia just above ankle toward knee flexion
Below fair - sidelying w/ test limb supported by examiner
Substitutions - Hip IR allows passive knee ext
Interesting Facts about Pain
Most common reason ppl visit healthcare provides
LBP is second most common
Chronic pain affects more people than DM, heart disease, and cancer combined
Spinal pain, arthritis, and headaches - most common sources of pain
Pain Physiology
Noxius stimuli - mechanical, thermal and/or chemical (transduction or nociception)
Site of stimuli - spinal cord - brain stem - thalamus/cortex and higher levels of brain (transmission or pain cognition)
End result of activity - pain becomes conscious multidimensional experience (perception or suffering and pain behavior)
- Reticular system - action and asses
- Somatosensory cortex - identify signal and relate it to past
- Limbic system - emotions, behavior, processing
Signal can be changed or inhibited (modulation - send more inflammatory markers or signals to heighten pain)
Peripheral and Central Sensitization
Abnormal facilitation of descending modulation of pain
Peripheral - afferent nociceptive input increased (constant, persistent LBP - brain lengthens time, so there is heightened sensitivity, jumpy, tender) - occurs when there is inflammation of either peripheral tissues or neural connective tissue as protective mechanism
Central - increased excitability in dorsal horn and inflammatory chemical mediators up-regulate (occurs in fibromyalgia, myofascial pain syndrome, TMJ disorder, neuropathic pain) - constant, terminal illness, long term pain
Both can persist even when cause has removed
Gait Control Theory
Presynaptic inhibition of transmission cell - preventing pain stimuli from being transmitted to brain
W/ sufficient stimulus of nerve endings, “gate” can be closed (i.e. through massage, TENS, vibration)
Descending inhibition is possible at all levels of the nervous system and is opioid sensitive; however, can also be enhanced thru placebos, antidepressants, and anticonvulsants
Biomedical Model
Health = absence of disease
Every disease can be explained in terms of underlying problem
Focuses on physical and biological factors of disease
Diagnosis, treat, and cure
X-rays, blood work, surgery, chemotherapy, meds, hospitalization
Biopsychosocial Model
Absence of tissue damage/disease DOES NOT always = health (chronic pain)
Physiological and psychological components that are associated w/ chronic illness/pain
Suffering, pain behavior, chronic pain syndrome
Peripheral and central sensitization
Acute Pain
Associated w/ tissue damage or threat of damage
Resolves once healed or threat resolves
Physiological signs - sweating, pallor, nausea, HR or BP changes
Recurrent Pain
Repeated episodes of acute pain
Persistent Pain
Acute pain that continues when cause is not resolved
As long as disease remains, pain remains
Associated w/ chronic diseases such as OA or diabetic peripheral neuropathy
Pain proportional to tissue damage and nociceptive input
Chronic Pain
Pain that persists more than 3 months
Long lasting, persistent, and of sufficient duration and intensity to negatively affect a pt’s well being, function, and QOL
Persists past healing phase w/ impairment greater than anticipated based on physical findings or injury and occurs in absence of observed tissue injury/damage
Treatment of such should address secondary pathology and perpetuating factors than focus on presumed initial insult/injury
Chronic Pain Syndrome
Doctor shopping
Dependency on health care system for multiple medial problems
Preoccupation w/ pain, significant pain behavior
Passive-dependent personality traits
Denial of emotional or family conflicts
Significant disruption in many areas
Feelings of isolation and loneliness
Being demanding, angry, or skeptical
Lack of insight into self-defeating behaviors
Use of pain as symbolic means of communication
Pain Assessment
Pain has no objective or specific measurement tool like ROM or strength
Chronic pain could have acute or subacute conditions in addition to their chronic pain
PRQST, SOCRATES, OLD CARTS
Standard tools for quantifying pain severity: VAS (visual analogue scale) and NRS (numeric rating scale)
Pain questionnaires and outcome measures to measure both nonspecific and disease-specific aspects of pain and can assess special populations
PQRST
Provoking/precipitating factors Quality of pain Region and radiation Severity or associated symptoms Temporal factors/timing
SOCRATES
Site Onset Character Radiation Associations Time Course Exacerbating/relieving Severity
OLD CARTS
Onset - sudden/gradual/insidious, mechanics of injury if trauma, first time/recurrence
Location - where, has it changed, does it change w/ activity/body positions
Duration - how long does it last
Characteristics - type, how sever
Aggravating/Relieving - what makes it change (increase/decrease), red glad is pain doesn’t change even if directed by therapist, pain behavior over last 48 hours
Temporal - when does it occur
Severity - number ranking, adjectives
Pain Assessment - Body Diagrams
Specific anatomical location of pain
Referred pain
Trigger points
Myofascial pain
Pain Assessment - Pain Evaluation
Psychosocial
Physical
Pain Assessment - Patient Interview
For chronic and persistent pain
Pain history
Past treatments, meds, health care provides
Stressors
Perception of cause of continued pain
Ask when pt will know he/she will be better
Complex Regional Pain Syndrome (CRPS)
Type 1 - Reflex Sympathetic Dystrophy (RSD) - occurs after an illness/injury that didn’t directly damage nerves of affected limb
Type 2 - distinct nerve damage
Symptoms vary and change over time and may spread
- Continous burning or throbbing pain
- Sensitivity to touch/cold
- Changes in skin temp, color, texture
- Changes in hair/nail growth
- Jt stiffness, swelling, damage
- Muscle spasms, atrophy
- Decreased ability to move
Central Pain Syndrome
Caused by damage to the CNS (brain, brain stem, spinal cord)
Stroke, PD, MS, epilepsy, SCI
Most common symptom is burning, “pins and needles” and/or pressing, lacerating, aching pain
Physical Exam
Posture
Mvt patterns
AROM/PROM
Muscle strength
Neurological exam
Cyriax Concepts - Active Mvt
Specific soft tissue can’t be incriminated
Provides into about pt’s ability to move, painful range and possible location of originating pain
Cyriax Concepts - Passive Mvt
Tests inert structures (jt capsules, ligament bursa, fascia)
Provides gross assessment of length of extra-articular and periarticular soft tissue
Cyriax Concepts - Active vs. Passive Mvt
If both are restricted and/or painful in same direction, pattern is indicative of a capsular or arthrogenic lesion (capsular pattern - AROM is hard/painful, passive is limited and can’t go further - something wrong in capsule - limited in same direction)
If active/passive actions are restricted and/or painful in opposite directions, it’s indicative of contractile lesion
Cyriax Concepts - Resistive Motion
Isolation of contractile tissue (muscle, tendon, bony insertion) by isometric contraction in midrange of jt motion
Exceptions - fracture close to muscle insertion causing shifting of fractured ends OR inflamed structure underlying muscle
Cyriax Concepts - Resisted Isometric Testing
Strong and painless - WNL or referred pain from another area
Strong and painful - minor lesion of tested muscle or tendon
Weak and painless - disorder of NS or neuromuscular junction, total rupture of tested muscle/tendons, disuse atrophy
Weak and painful - major lesion such as fx and neoplasm, acute inflammation inhibiting muscle contraction, partial rupture of tested muscle or tendon
Painful Arc Test
Test for subacromial impingement syndrome
Pain w/ active shoulder abd 60-120 degrees
Referred Pain
Trigger pts - refers to pain when pressure is applied or when irritable
Pathology - heart attack, appendicitis, gall bladder attack
Nerve root impingement - dermatomal distribution
Pain w/ Repetitive Mvts
Intermittment claudication - most commonly in distal 1/3 of leg when walking
Painful Joint Position
Assumption of resting position
Results in least amt of pain
Typically where jt capsule is laxest
Shoulder - scapular plane abd 55 deg, IR, and 30 deg add
Hip - 30 deg abd, 30 deg flex, slight ER
Knee - 25 deg flex
Ankle - 10 deg PF
Waddell’s Test for LBP
Type 1 - tenderness - superficial/non-anatomic (doesn’t correspond to dermatome pattern, referred pattern, very superficial, skin discomfort on light palpation or tenderness)
Type 2 - simulations - axial loading/rotation (press thru head, pain increases; rotation - turn whole body - feel pain - positive)
Type 3 - distraction - SLR (shooting pain down when lying down, but no pain when sitting and extending knee - positive)
Type 4 - regional disturbances - weakness/sensory (numbness, weakness, can’t move limb
Type 5 - overreaction - exaggerated painful response to stimulus that is not reproduced when same stimulus is given later
Screening for nonorganic, psych, and social elements to client’s pain syndrome
Does not signifying malingering
Score >3 indicative only of symptom magnification or possible illness behavior
Pain Assessment in Nonverbal Patient
Position statement w/ clinical practice recommendations (hierarchy)
Self report
Search for potential causes of pain
Observe patient behaviors
Surrogate reporting
Attempt analgesic trial
Appropriate Ages for Pain Scales
18-24 months - locate and identify that there is pain
3 years - intensity (no pain, little pain, lot of pain)
4-7 years - concrete measures such as Poker Chips = pieces of hurt
5-7 years - VAS esp color versions
10-12 years - verbal scales and affect
Pain Scales for Children
Could be used w/ pts w/ cognitive deficits - must consider cognitive abilities (need to know how to count by rote AND ability to estimate quantities using #s)
Faces pain rating scale
Behavioral scale
- CHEOPS pain scale (>1 yr)
- FLACC (face, legs, activity, cry, consolability) scale (0-3 yrs of age or non-verbal pts)
- Non-communicating children’s pain checklist (NCCPC) - vocal, social, facial, activity, body and limbs, physiological
VAS/NRS
Developed to provide simple way to record subjective estimates of pain intensity
Can be used for acute/chronic pain (esp when attempting to determine changes in pain due to position, wt bearing, mvt, activity)
Must give consistent anchors for ends (0 and max number)
PAINE - Pain Assessment in Noncommunicative Elderly Persons
4 sections - 7 levels - motor, vocal, and unusual behaviors, activity involvement
1 section - yes/no/don’t know/NA - physical signs such as falls, swelling, changes in vital signs
NCCPC - Non-Communication Children’s Pain Checklist
Designed for children 3-18 years who are unable to speak b/c of cognitive impairments or disabilities
Post-operative version for pain after surgery or procedures done in hospital
Categories: vocal, social, facial, activity, body and limbs, physiological, eating/sleeping
MPQ - McGill Pain Questionnaire
Developed to provide quantitative profile of person’s perception of pain
Categories - sensory, affection, evaluations descriptors
Includes body diagram and VAS scale
MSPQ - Modified Somatic Perception Questionnaire
1-2 minutes
Developed to measure somatic and automatic perceptions (stomach churning, legs feel weak)
Higher score - worse pain
Pain Catastrophizing Scale
Thoughts and feelings that pt has when they are in pain
Higher numbers in women vs men
Chronic pain
RMDQ - Roland-Morris Disability Questionnaire
24 item self-report questionnaire
How LBP affects functional activities
PDI - Pain Disability Index
5 mins to administer
Designed to measure pain related disability
ADLS/IADLs - home, recreation, social work, sexual, self care and support (eating, breathing, sleeping)
Higher score - more disability
Revised Oswestry Disability Index
1-2 minutes
Measures how pain has affected ability to manage daily life
10 sections - pain intensity, personal care, lifting, walking, sitting, standing, sleeping, social life, traveling, changing degree of pain
Higher score, greater disability
FABQ - Fear-Avoidance Beliefs Questionnaire
Cognitive beliefs about role of pain on ability to perform physical and work activities
