Rehab Flashcards
Physiatrist or Rehab Physician
specialize in FUNCTION
practical approach to patient care
Common Physiatric subspecialities
acquired brain injury spinal cord injury sport's medicine pain management pediatric physiatry palliative care
Spinal cord injury -> paraplegia
not necessarily restoring function
but improve function within his or her limitations or restrictions
Goals of Rehab
- Function (FIM)
- Independence (Oswestry Disability Index)
- Quality of Life (SF-36)
Acute Rehab facility
must show how much progress patients made
FIM score
Functional Independence Measurement
- used to measure progress of functional skills
- can be used for outcome predictor: 1. LOS 2. prognosis 3. discharge destination
- Rehab dependent of many subjective, non-measurable factors
FIM Score interpretation
over 90 - patient goes home
below 40 - go to nursing home
ADLs
Dressing
Eating
Ambulating - must ambulate otherwise will lead to DVTs, osteoporosis, etc.
Toileting/Transfers
Hygiene - leads to skin breakdown, cellulitis
ask at bedside !!!
Loss of independence
Impairment - any loss of abnormality of physiologic, psychological, or anatomic structure or function
Disability - restriction due to impairment in the ability to perform an activity within the range of what is considered “able bodied”
Handicap-???
radial nerve palsy
disease
impairment for RNP
wrist drop
disability for RNP
inability of the work as surgeon
handicap for RNP
job loss
60/40 rule
average of 60% its admitted to acute inpatient rehab needed one of the impairment categories per Medicare
Functional deficits
2/2 pain, immobility, cognitive dysfunction, communication disorder, motor deficit
NOT SAFE TO RETURN TO PREVIOUS LIVING ARRANGEMENT
Medical necessity
controversial
functional improvement
for > 3 wks
Dx
Premorbid status
ability to tolerate/particopate 3hr/daily, 5 days/weekly
Members of the Rehab team
Physiatrist PT OT Speech therapy neuropsych Rehab nursing social worker patient/social supports MOST IMPORTANT IS COMMUNICATION!!!
Normal gait patterns
focus on one leg
5 parts of the stance phase
3 parts of the swing phase
Gait cycle
stride
functional unit of gait
step length
distance b/n both heels
stride length
distance b/n heel of same foot after two steps
gait analysis
faster the walk, the 80% (single limb support) goes up to 100% (person is running, jogging)
speed for gait
length per time
most energy efficient and comfortable
walking speed = 3 mph
Stance phase
I Like My Tea Presweetened Initial contact Loading response Midstance terminal stance preswing
Eccentric contraction
muscle tenses while it lengthens
Length-tension relationship
reason for sprains for runners
Heel strike - hamstrings max contracts while greatest length
if not trained, will get sprains
Swing phase
In My Teapot
Initial swing
mid swing
terminal swing
8 most common gait dysfunctions
Antalgic Trendelenburg Steppage vaulting circumduction genu recurvatum ataxic festinating
Antalgic gait
stance phase abnormally shortened relative to the swing phase
shortened the amount of time on the leg that hurts
circumduction is possible
Bilateral tendelenburg gait (uncompensated)
myopathic gait
=result in waddling type gait
compensated trendelenburg gait
patient leans the trunk on the side that hurts
so that contralateral pelvis does not drop
=pts with osteoporosis
Proximal (pelvis) problem!!!
Foot drop
fibular head fx can result in common fibular n. dysfunction
Foot slap
tibalis ant. has mild strength deficit
steppage gait
uses proximal m. to hip hike
hip flexes to clear the foot with the foot drop
vaulting
good leg is excessively plantar flexing to allow toes of swing leg to clear the ground
circumduction
swing leg excessively hip abducts so that the toes of swing leg can clear the ground
WIDE ARCH is seen
can also circumduct in antalgic gait
genu recurvatum
weak quads or limited ankle dorsiflexion/excessive plantar flexion
BACKABENDING OF KNEE CAUSING EXCESSIVE EXTENTION AT THE TIBIOFEMORAL JOINT
dorsiflexion stretched gastrocnemius causing knee flexion movement at knee???
ataxic gait - DRUNKEN APPEARANCE
seems like don’t know where in space
unsteady, uncoordinated walk, employing a wide base and the feet thrown out. seen with cerebellar pathology
Festinating gait
Parkinson’s patient
Involuntary advancement of legs with short, accelerating steps often on tiptoes (shuffling)
Limb innervation
PROXIMAL TO DISTAL GRADIENT INN: brachial plexus - C5-6 : shoulder girdle
C8-T1 - hand
OVERLAPPING: Elbow flexion - C5-6 (even some C7)
patellar MSR - L4 (some L3)
Limb=extremity = arm/leg
Manual muscle testing
LMN and UMN
LMN
anterior horn cell -> root-> plexus-> branch ->NMJ -> muscle
UMN
corticospinal tract -> anterior horn of spinal cord
Key dermatomes
UL : C5-T1
LL: L2-S1
Manual muscle testing grading scale
Dont confuse this with true neurological deficits
5/5, 4/5, 3/5, 2/5, 1/5, 0/5
e.g. neck and back pain radiates to the limbs -> pain inhibition function (not a true weakness of the muscle)
MMT UL and LL
C5 C6 C7 C8 T1 L2 L3 L4 L5 S1
Muscle stretch reflexes
muscle spindle (sensory reflexes) in skeletal muscles are stimulated by stretch, causing a nonosynaptc reflex contraction of that same muscle
Grading reflexes
indicative of hyperreflexia when other tendons are active when only one tendon is strikened
reflex will be 3 = hyperactive without clonus
Clonus
rapid alternating contractions and relaxations of muscle after forced stretch
UL reflexes
biceps
brachioradialis tendon
triceps tendon
LL reflexes
patellar tendon medial hamstring (unreliable)* - pt with ipsilateral below-knee amputation (no L5 dermatome test) = will work for asymmetry when one hamstring is missing? archilles tendon
Sensation testing: light touch
wisp of cotton, gauze, fingers
sensation testing: pain
differentiating sharp and blunt ends of safety pin
dermatome deficit
side to side demarcation
sclerotome (cervical)
regional area of pain
cervical spine disc herniation
C6 impingement
foraminal, posterolateral, and central
lumber spine disc herniation
L5-S1 - L5 root emerges but only forminal herniation will affect it Posteriolateral herniation (lateral recess?) and central herniation - S1 root and/or below
posterolateral disc herniation
can result in herniate into the subarticular zone or lateral recess
3 reasons why posterolateral herniations are common
- lack PLL
- posterior annulus is thinner than the anterior portion due to nucleolus pulpous being located posterior
- flexion is the predominant motion of the lumber spine resulting in the posterior annulus receiving most repetitive tensile and shear stresses
disc herniation into the thecal sac
no spinal cord below L2-L3
only spinal cords are impinged
Pathological tests
Babinski
Oppenheim
Chaddock
Hoffman
Brabinski
lateral plantar aspect of foot is stroked with blunt object causing dorsiflexion of great toe and fanning of other toes
Oppenheim
downward pressure on tibia causing great toe dorsiflexion
Chaddock
stroking lateral foot causing great toe dorsiflexion
Hoffman
hand pronated with passive D3 MCP hyperextension
DIP is passively flexed and suddenly released, causing thumb flex/add. and flexion of other fingers.
Most meaningful when correlated with MMT
Low back pain
recurrent for life
self-limiting
Proper Dx
nonspecific diagnoses -> nonspecific treatments-> nonspecific outcomes
must do Hx first
then Dx
Lumbago (LBP)
is a symptom not a Dx
Facet joints
1/3 of the pain generator
DDx
Mechanical discogenic SIJ mediated Facet joint fracture infection cancerous medical causes piriformis syndrome spinal stenosis Somatic dysfunction (TART is the criteria) - overlap with primary pain generators
Mechanical low back pain
axial and multifactorial nature
RESULT FROM POSTURE/EXERCISE
MOST OF THE TIME IT IS THE JOINT , NOT NECESSARILY A MUSCLE
acute back pain
MAY NOT HAVE NO LONG TERM CONSEQUENCES
Discogenic
don’t need to have disc herniation
long lasting dull and vague pain morning stiffness axial unloading - lean off to the side (weight off the disc) better with laying down relieved with walking
straight leg raise
dural tension sign
sciatic n.
SI mediated
pain over PSIS = Fortin Finger sign
iliolumber ligament is important
Iliolumber ligament
MAINTAIN SI JOINT
MOST RESTRICTING MOVEMENT
attach to the transverse processes of L4-L5?
Fortin sign test
more reliable than faber test, yeoman’s test
no tenderness = not the source of pain
posterior pelvic pain provocation test
highest sensitivity
start with this in PE
assess the SI joint dysfunction or sacroiliolitis
pain over PSIS reproduced = POSITIVE TEST
Decision tree
copy from lecture
Facet joint mediated
TTP over transverse processes to rarely below the knee; never goes below the knee
sclerotomal referred pain
pain with extension and rotation
Medial branches of the dorsal rami
medial branches of L4 = inferior portion of the facet joint
medial branch of L5 = superior portion of the face joint
every medial branch innervate corresponding facet joint
e.g. L4-5 facet joints are inn. by L3 and L5?
Spinal stenosis
dont rely on imaging
go in order: Hx -> PE -> imaging
not necessarily back pain
spondylosis
Fx - pars articularis
translation of the bodies
step-off sign - spinal processes will dip off
low back pain is present
L4/L5 facet fx
L5 is affected
Tx of LBP
specific dx -> specific tx -> specific outcomes
Global finding
- neck and low back - if there is one area of the spinal stenosis from disc herniation
- dont do HVLA
progressive neurological deficit
get imaging
infection and malignancy
low back pain at night
pain and problem urinating
prostate cancer
PT
if patient will be more compliant
OR discogenic herniation
multimodal
low back pain
tx with many different modalities synergistically
Epidural injections
- transforminal - through the nerve sheet - goes to the PLL and posterior annulus
- interlaminar
- caudal
