Week 3 Flashcards
Where does the objective exam fall in the 5 elements of patient management?
Evaluation and examination
The subjective exam is equal to what kind of hypothesis?
Hypothesis generation
The objective exam is equal to what kind of hypothesis?
Hypothesis refinement
What are the goals of the objective exam?
- Look for patterns of movement & restrictions
- Reproduce symptoms or produce comparable sign(s)
- Systematic approach to confirm or rule out your working hypothesis and differentials
Things to consider during an objective exam?
• Get baseline symptoms
• Look for two sets of data:
- What the patient feels (subjective asterisks)
- Key comparable signs (objective asterisks)
• Do painful movements & tests last if possible
What is the layout of an objective exam?
- Collect / Test / Measure Objective Data
- Analyze Data / Establish Working Diagnosis
- Determine Prognosis
- Formulate a Plan of Treatment
What are the 3 components of motion testing?
- Active ROM (Physiologic) motion testing
- Passive ROM (Physiologic) motion testing
- Joint Play (Accessory) motion testing
What are the 3 essential assessment for diagnosis?
• Quality of the movement
- Movement pattern, asymmetry, end-feel
• Quantity of movement
• Symptom response
Definition of AROM
The patient’s ability to actively move on their own
_____ are applied to normal ROM to reproduce symptoms when necessary
Progressions
During PROM, examiner takes joint through ROM with patient ____
relaxed
Each movement in PROM is compared with ___
opposite side (preferred) or accepted norms
PROM is used when…?
AROM is altered or painful
Motion testing helps us determine whether to move to ___ or move to __
Pain
• Pain is the dominant factor in patient’s disorder
• Range to first onset of pain (and just beyond)
Resistance
• Assess for stiffness/ hypomobility
• Apply overpressure to assess end-feel and symptom
response
What does PROM help understand?
Helps understand if there’s any limitations in the ROM (hypomobility) or if the patient has an excessive amount of ROM (hypermobility)
What are the 2 instruments for measuring ROM?
- Goniometer
- Bubble inclinometer
What is a goniometer?
Protractor with movable arms
and comes in various sizes. Used for extremities
What is a bubble inclinometer?
360° rotating dial with fluid indicator. Commonly used for spinal movement
What are the ROM general procedures?
• Assess range of motion bilaterally (unaffected side first)
• Recommend two repetitions for each movement
• First repetition: Visually assess movement quality,
quantity, and symptom response
• Second Repetition: Joint measurement as needed
What are the ROM specific procedures?
Patient in base position
• Locate pertinent bony landmarks
• Place goniometer axis of motion at the approximate axis of joint motion
• Align stationary and moving arms along the appropriate body parts and in line with identified bony landmarks
• Move the joint through it’s active or passive ROM
• Read the goniometer at appropriate ranges of motion
Things to record when documenting a ROM measurement
- The type of ROM: AROM or PROM
- Right or left extremity
- The joint and the direction of motion
- The quantity of motion achieved
- Symptom changes
Things to keep ROM measurement in check
- Goniometer measurement error +/- 5 degrees
- Reliability varies widely
- Intra-rater generally better than inter-rater reliability
- Reliability can be enhanced
When is reliability enhanced?
- When we use a standardized test position
- When we use the correct goniometer size
- When the same person evaluates each measurement
What is accessory joint mobility/motion?
The ability to passively move a joint through arthrokinematic (accessory) motion that make up a gross osteokinematic (physiologic) motion
How is accessory joint motion assessed?
Passively by the examiner, but cannot be performed actively by the patient
What is osteokinematics?
Directions the bones move when motion occurs. AKA: “physiologic motions”
Osteokinematics is characterized by ___ motion during ___ movement
Visible motion during voluntary movement
Osteokinematics is typically described as ..
movement around a specific joint axis and within a particular joint plane
What are physiologic motions?
Movement in one of the 3 cardinal planes occurs at right
angles to the joint axis
What are the physiologic joint motions?
- Flexion and Extension
- Abduction and Adduction
- Internal and External Rotation, - Horizontal ABD/ADD
What are the joint planes?
- Sagittal
- Frontal (Coronal)
- Transverse (Horizontal)
What are the joint axes?
- Frontal
- Sagittal
- Longitudinal (Vertical)
What is arthrokinematics?
motion between the joint surfaces during
movement.
AKA: “ accessory motions or joint play”
Arthrokinematics is described as motion that should occur _____
within the joint to allow normal
range of motion (osteokinematic) to occur
Arthrokinematics is characterized as being ___ and ____
Invisible and involuntary
What are types of accessory motions?
- Roll
- Slide (glide)
- Spin
Accessory motion: Roll
Various points on one surface contact many points on another surface
Accessory motion: Slide (glide)
One point of one surface in contact with many points on another surface
Accessory motion: Spin
One point of one surface in contact with one point on another surface.
What are the two types of Concave-Convex “Rule”
Convex on Concave and Concave on Convex
What is Convex on Concave?
Convex surface moving on fixed concave surface
In Convex on Concave, Roll and Glide accessory motions occur in the _____ directions.
OPPOSITE
In Convex on Concave, Movement of bone is in ____ direction to movement of joint (glide).
OPPOSITE
What is Concave on Convex?
Concave surface moving on fixed convex surface
In Concave on Convex, Roll and Glide accessory motions
occur in the_____ direction.
SAME
In Concave on Convex, Movement of the bone is in ___ direction as movement of joint surface.
SAME
What are the two types of joint positions?
- Open-Packed (Loose)
- Close-Packed
Characteristics of Open-packed (Loose)
• Ligaments and capsule in
position of greatest laxity
• Joint surfaces are maximally
separated
• Minimal congruency between joint surfaces
• Proper position to assess joint play and to mobilize!
Characteristics of Close-packed
• Ligaments and capsule are taut
• Joint surfaces are maximally
contacted
• Maximal congruency between joint surfaces
• Position of maximal stability
• POOR position to assess joint play or to mobilize!
What is end- feel?
The sensation you “feel” in the joint as it reaches the end of the range of motion
What does end-feel do?
- Assesses the quality of motion
* Assists in identifying pathology
Normal end- feels: bone to bone
– hard, unyielding sensation; painless
• Example: elbow extension
Normal end- feels: Soft-Tissue approximation
– soft, yielding compression
• Example: muscle contact with elbow or knee flexion
Normal end- feels: Tissue Stretch
– hard or firm (springy) type of movement with a slight give
• Feeling of springy or elastic resistance
• Example: shoulder rotation, knee extension
Abnormal end-feels: Capsular
– similar to tissue stretch, but occurs early in motion. Two
subdivisions: Hard capsular and Soft capsular
What is hard capsular abnormal end feel?
Hard or firm end feel, thicker feeling than normal tissue
stretch
• Abrupt onset after smooth, friction-free movement
• Seen in chronic conditions
What is soft capsular abnormal end feel?
– Boggy, very soft, mushy end feel typically accompanied joint
effusion
• Stiffness early in range and increases until end range
• Seen in acute conditions
Abnormal end feel: Muscle spasm
sudden and hard end feel; dramatic arrest in movement accompanied with pain; usually due to subconscious effort to protect an injured joint or structure
Abnormal end feel: Bone to Bone
hard, unyielding sensation similar to normal bone to bone
• Restriction occurs before normal end range is expected
• Example: osteophyte formation
Abnormal end feel: Springy Block
also a firm end feel, similar to tissue stretch
• Restriction occurs before normal end range is expected
• Usually has a rebound effect indicating internal derangement in the joint (i.e., meniscal tear)
Abnormal end feel: Empty
no mechanical resistance, but considerable pain is produced by movement
What is capsular pattern?
Characteristic pattern of motion restriction when joint capsule is involved (contracted)
There are ___ pattern for each joint
Unique
Capsular patterns are often ___
inconsistent, but may be helpful
Examples of capsular pattern
- Glenohumeral joint – ER limited more than ABD, limited more than IR
- Hip – FLEX limited more than ABD, limited more than IR
What is a fulcrum of a goniometer?
The circular part of a goniometer
What is the proximal arm of a goniometer
The one that is attached to the fulcrum. This is in reference to where it’ll be facing on the body
What is the distal arm of the goniometer?
The one not attached to the fulcrum
All hip motion end feel are ____ due to ____, with the exception of ___
Firm due to muscle tension, joint capsule or ligaments.
Exception is flexion of the hip
Flexion of the hip end feel is ___, due to
Soft due to muscle bulk
Normal end feel of hip joint extension
- Firm due to muscle tension, anterior joint capsule, or ligaments
Avoid hip joint extension if patient complains of…
low back (lumber) pain in extension
Normal end feel of hip abduction
Firm due to medial joint capsule, muscle tension, or ligaments
Normal end feel of hip adduction
Firm due to lateral joint capsule, muscle tension, or ligaments
Normal end feel of hip internal rotation seated and prone
Firm due to posterior joint capsule, muscle tension, or ligaments
Normal end feel of hip external rotation prone
Firm due to posterior joint capsule, muscle tension, or ligaments
Normal knee flexion end feel is …
- Soft due to muscle bulk
- Firm due to tight muscle/capsular tension
Normal knee extension end feel is …
- Firm due to muscle tension, posterior joint capsule and ligaments
Normal ankle dorsiflexion end-feel
Firm due to posterior joint capsule, muscle tension or ligaments
Normal ankle plantarflexion end-feel
Firm due to anterior joint capsule, muscle tension or ligaments
Normal ankle inversion end-feel
Firm due to joint capsule, muscle tension, ligaments
Normal ankle eversion end-feel
Firm due to joint capsule, muscle tension, ligaments
Normal metatarsophalangeal (MTP) flexion end-feel
Firm due to dorsal joint capsule, muscle tension or ligaments
Normal metatarsophalangeal (MTP) extension end-feel
Firm due to plantar joint capsule, muscle tension or ligaments
Normal metatarsophalangeal (MTP) abduction end-feel
Firm due to joint capsule, muscle tension, ligaments or web space fascia
Normal metatarsophalangeal (MTP) adduction end-feel
Firm due to joint capsule, muscle tension, ligaments or web space fascia
Normal interphalangeal (IP) flexion end-feel
Firm due to dorsal joint capsule or ligaments
Soft due to soft tissue bulk
Normal interphalangeal (IP) extension end-feel
Firm due to medial joint capsule, muscle tension or ligaments
What are the two components of muscle testing?
- Muscle length testing (flexibility test)
- Muscle strength testing (manual muscle testing MMT & resisted isometric test)
What is the purpose of muscle length test (flexibility tests)?
To determine if range of muscle length is normal, limited, or excessive
What is the most common form of muscle strength testing?
Manual muscle testing (MMT)
What is the purpose of muscle strength test?
Helps us to find and measure muscle strength to determine the person’s ability to voluntarily contract a muscle or muscle group using gravity or applied manual assistance
The manual muscle test helps…
determine the degree of muscle weakness from either disease, injury or atrophy that may have occurred for a patient
Indications for Muscle Strength Testing
- Diagnosis of peripheral nerve injury or nerve root injuries
- Effects of spinal cord injury & potential recovery
- Basis for treatment planning and prognosis
- Provide measure for treatment progress
- Basis for supportive devices/orthoses
MMT General Procedures
- Position patient
- Explanation / PROM
- Screen Test / AROM
- Palpate
- Apply resistance
- Grade
Grading of MMT characeristics
- Attempt to express strength objectively
- Consider age, gender differences
- Name and number grades
- Gravity lessened
- Against gravity
In the muscle grading system, a 3- or above allow _____ gravity going through ___ ROM
- vertical motion against gravity
- going through full ROM
In the muscle grading system, a 2+ or below allow _____ gravity going through ___ ROM
Allow supported horizontal motion: gravity is lessened
Factors Reducing Grading Accuracy
- Pain
- Limited Joint ROM
- Muscle Hypertonicity/Spasticity
- Others: Fatigue, cognition, cultural/social norms
What are the limitations of MMT?
- Hard to determine which muscle is being tested
- Different physical shapes patients
- Inter rater ability
A normal (5) is described as:
Holds test position against strong to maximum resistance.
Good + (4+) is described as
Holds test position against moderate to strong resistance.
A good (4) is described as:
Holds test position with moderate resistance
A good- (4-) is described as:
Holds test position against slight to moderate resistance.
A fair + (3+) is described as:
FullROM against gravity; able to hold end ROM against slight resistance
A fair (3) is described as:
FullROM against gravity; able to hold end ROM without added resistance
A fair - (3-) is described as:
FullROM against gravity; unable to hold end ROM (gradual release occurs)
A poor + (2+) is described as:
Completes partial(< ½) ROM against gravity or slight resistance in gravity minimized position
A poor (2) is described as:
Completes full ROM in a gravity minimized position
A poor- (2-) is described as:
Completes partial ROMin a gravity minimized position
A trace (1) is described as:
Slight, palpable contraction; no joint movement
A zero (0) is described as:
No palpable evidence of muscle contraction
For muscle grading from 4- to 5, the patient should be positioned ____
To allow VERTICAL MOTION against gravity
For muscle grading from 2+ to 3+, patients should be positioned _____
To allow VERTICAL MOTION against gravity
For muscle grading from 2 to 2-, patients should be positioned _____
To allow supported HORIZONTAL MOTION; gravity lessened
For muscle grading from 0 to 1, patients should be positioned _____
To allow palpation of muscle with NO MOTION
What movement happens in the frontal plane?
Abduction and adduction
What movement happens in the sagittal plane?
Flexion and extension
What movement happens in the transverse plane?
Internal and external rotation
