Download Physical Therapy Examination

Physical Therapy Examination
PTP 565: Fundamentals of Tests and
Measures
1
Physical Therapy Examination
• Examination: gathering of data: history,
systems review, selecting and administering
tests and measures. Comprehensive
screening and specific testing process. Leads
to a diagnostic classification.
• APTA Guide to Physical Therapy Practice
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PHYSICAL THERAPY EXAMINATION
• Important to develop a system for
examination
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Organizational Structure of an
Orthopedic Exam
I.
History
II.
Systems Review
III. Scanning Exam
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IV. Tests and Measures
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Observation/Posture/Gait
Active ROM
Passive ROM
Resisted movements
Neuro Screen
Functional Assessment
Special Tests
Joint Play
Palpation
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I. History
Benefits from obtaining a history:
1. report from the patient of their condition
2. assists in formulating a working
hypothesis for differential diagnosis
3. gives clinical signs and symptoms
4. assists with formulating an examination plan.
5. assists in setting functional goals for the patient
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• General Demographics
– Gender/Age/Height/Weight
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Social History
Occupation, Employment, Work
Functional Status, Activity Level
Growth and Development
Living Environment
Red Flags
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Other Significant Information
• Past Medical History
• Past Surgical History
• Medication
• Review of Systems: Questionnaire
information about Heart, Lungs, Other organs.
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Red Flags
• Definition:
• Constitutional Signs and Symptoms
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Fevers, chills, night sweats
Malaise or Fatigue
Unexplained Nausea or vomiting
Recent unexplained weight changes
Unilateral, bilateral or quadrilateral paresis or paresthesia
Shortness of breath
Bowel or bladder dysfunction
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Red Flags: continued
• Insidious onset of pain
• Multiple levels of neurological symptoms
• Pain at night
• Increase in pain intensity over time
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Red Flags:
• No Red Flags? Continue with the Exam
• Red Flags exist: Clinical Decision
• What do you do with the patient?
– Refer
– Consult
– Send to the ER
– Call an ambulance
– Make an appointment for the Primary Physician
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Pain
• Onset
– Sudden
– After 24 hours
– Gradual or insidious onset
• Intensity
– Visual Analog Scale
– Verbal Analog Scale
– McGill-Melzack pain
questionnaire
– Thermometer Pain Rating
Scale
• Pain Perception
– Acute
– Subacute
– Chronic
• Pain Progression
– Better
– Worse
– No Difference
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• Quality of Symptoms
– Location of Symptoms
– Aggravating Factors
– Easing Factors
• Pain Descriptors
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Sharp
Shooting pain
Aching
Burning
Pins and Needles
Numbness
Stiffness
Twinges
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How Acute is the injury?
• In terms of pain
• Time since onset of symptoms
• Length of Time pain lasts
• Acute
• Sub-acute
• Chronic
• Other Symptoms
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Signs/symptoms of acute conditions
• Inability to maintain any position for any length of
time.
• Verbal and nonverbal expressions of pain while
moving, slow guarded movements,
• Pain Scale that is very high 9-10 on a scale of 1-10
• Recent injury like within 1-2 days
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Examination for acute conditions: Key
Points
Don’t try and complete the examination
Move into an intervention designed to relieve acute
symptoms
Re-examine at a later date when the individual is able
to tolerate the activity
Goal: interrupt the pain cycle
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Injury not in acute phase:
• Continue with the
examination process.
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II. Systems Review
• Cardiovascular System
• Integumentary System
• Musculoskeletal System
• Neuromuscular System
• Psychological Status
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III. Screening Examination
• Purpose: decide area of
involvement so that the
examination can be
directed to the
appropriate area
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Scanning exam is especially helpful
when:
• No history of trauma
• Radicular signs are present: referred pain
along a specific spinal nerve root distribution
(dermatome)
• History of trauma along with radicular signs
are present
• Patient reports pins and needles sensation
(paraesthesia) or complete numbness
(anesthesia) in the region.
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• “long track” signs (spinal cord or UMN lesions)
are present (flaccidity or spasticity)
• patients signs and symptoms don’t reveal any
clear pattern
• ? psychological factors, secondary gain or
patient is a poor historian
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Scanning Exam: Upper Quadrant
• Upper Quadrant: areas to scan include the joints
above or below the patient’s dysfunction.
• Cervical spine: must screen the thoracic spine, TMJ,
and shoulder
• Shoulder: must screen the cervical spine, thoracic
spine, elbow and hand
• Elbow: must screen the shoulder, thoracic spine,
hand
• Hand: must screen shoulder and elbow
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Thoracic Spine Scan
• Thoracic Spine: in particular must be aware of
the systemic dysfunctions which show up as
thoracic pain, rib pain, and or/shoulder pain
• Upper: cervical spine, shoulder, ribs
• Lower: lumbar spine, ribs
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Lower Quadrant:
• Lumbar spine: must screen the thoracic spine,
ribs, sacroiliac joint, hip, sometimes knee and
feet
• Sacroiliac joint: lumbar spine, hip, knee, ankle
• Hip: lumbar spine, SI, knee, ankle
• Knee: lumbar spine, hip, ankle
• Ankle/Foot: lumbar spine, knee
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What do you check during a scanning
exam?
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Observation/Posture
Active ROM
Passive ROM with Overpressure
Muscle Strength
Sensory: myotome, dermatome and reflexes
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After the Screening Exam
Clinical Decision
Keep
Refer
Keep and Refer
(Consult)
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Keep/Refer/Consult
• Keep: Patient is appropriate for Physical
Therapy
• Refer: Patient’s signs and symptoms do not
have a musculoskeletal origin
• Consult: Patient can be treated by physical
therapy but also needs another medical
professional for assistance
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Specific Joint Examination
• Investigative hat
• Ruling out or confirming
hypothesis for the
dysfunction
• Determining the facts:
muscle weakness, loss
of range etc.
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Observation:
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Done before any hands on activities.
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Looking phase of exam
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Observe/Inspect for Visible defects,
dysfunctions, alignment abnormalities
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Observation
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Gait: quick observation noted while the patient is
walking from the waiting room to the examination
room.
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–
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Will note gait deviations that are really obvious like an
antalgic pattern.
Can also get an idea of balance by looking at base of
support, position of arms, waddling gait
Assistive devices used by patient
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Transitional movements
• Sit to stand, walking, back to sitting
• Guarded movements, stiffness, willingness to
move
• Ability to maintain a position like sitting or
standing
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•
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Facial expression during history taking, affect
of patient – anxious, flat etc.
Patient’s willingness to move, substitute
movements noted
Medicated? Too much or too little?
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•
Posture: review
standard
alignment; sagittal
and A/P views, look
at symmetry and
determine if the
findings are related
to the dysfunction.
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• UE: head, shoulder
position in relation
to acromian, thoracic
spine position, Q
angle of elbows,
previous fractures
for example a
clavicular fracture,
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• Obvious deformities are
noted during the posture
exam such as scoliosis, or
presence of bony
abnormalities in the LE
• LE – may observe patella
positioning in relation to
the LE alignment, Varus or
valgus position of knees,
genu recurvatum
• Ankle position
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Other Observations:
• Muscle wasting
• Scars and color of scars. If red
these are recent, pale, they are
old and well healed.
• Note any joint noise such as
crepitus, snapping or grinding
sounds made with movement
• Skin changes, nail changes can be
observed
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Purpose of HANDS ON examination:
• To rule out or confirm a hypothesis developed
by the therapist during the history and
observation as to the patient’s cause of pain.
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Active ROM
• AROM
– Patient’s willingness to move
– Joint mobility/limitations
– Muscle control
– Muscle power
– Movements which cause pain
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AROM: What to observe
• When/where pain occurs during movement
• Does the movement increase the intensity of the
pain
• Reaction of the patient to pain
• Amount of observable restriction/limitation
• Pattern of movement
• Willingness of the patient to move the limb
• Quality of movement
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2. Passive movement:
•
This is done with overpressure after the patient has
moved through their available range.
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Determines end feel at that particular joint with
that physiological movement.
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End feel: quality of resistance to movement at the
end of a physiological movement
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Normal end feels
• Hard: Bone to bone
• Firm: Capsular end-feel, Tissue Stretch
• Soft: Soft tissue approximation
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Abnormal end feels
• Muscle spasm: Sudden and abrupt stop to
movement
• Capsular: similar to tissue stretch, it doesn’t occur at
end range
• Bone to bone: similar to the normal bony end feel
but the restriction in range occurs earlier than it
should in the normal range.
• Empty: pain is produced with movement
• Springy Block: elastic resistance to further movement
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Definitions:
• Gonia: Angle
• Metron: Measure
• Definition: Measurement of the angles
created by rotary motion of two bones around
a joint
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Goniometry Purposes:
1. Joint Position
2. ROM
 Active ROM
 Passive ROM
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Other Aspects
1. Only motions occurring in a single
plane are measured with few
exceptions.
2. Measures osteokinematic motion
NOT arthrokinematic motion
3. Flexibility Measurement
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4. Degrees of freedom: freedom of
movement around a plane of
motion
– Motion occurs around one plane – one degree of
freedom
– Motion occurs around two planes – two degrees
of freedom
– Motion occurs around three planes – three
degrees of freedom
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Purposes of Joint ROM Examination
1. Database:
 Establish the existing ROM available in the joint
 Compare this with the normal ranges given in
the literature
 Compare with the other side.
 Beginning data base for treatment
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2. Aids in diagnosing and determining joint function
a. Hypomobility: less than normal ROM
when compared to established norms
or the patients other side.
b. Hypermobility: greater than normal
ROM when compared to established
norms or the patients other side.
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C. Capsular Pattern:
– Cyriax: pattern of limitation in range of motion at a joint
which predictably occurs when the capsule of the joint is
tight due to capsular fibrosis or extended due to swelling.
– Fixed proportional loss of range of motion, it is not all
inclusive as he never considered flex/extension when
determining the shoulder’s capsular pattern.
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D. Orthotic fabrication: Many splints and
orthotics rely on goniometric measurement to
fabricate the devices
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3. Reassessment:
4. Acts as a motivational tool:
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5. Document results from treatment regimes
6. Research
– Validity
•
Evidence that a test will measure what it is suppose
to measure
– Reliability
•
How reproducible are the results? Is the
measurement consistent and free from error?
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Validity of Joint Angle Measurements
• Validity: Evidence that a test measures what it
is suppose to measure
• Goniometric Measurements
– Content Validity:
– Criterion Validity: Gold Standard
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Reliability of Joint Angle
Measurements
• Degree of consistency between goniometric
measurements
• Intratester reliability is better than Intertester
reliability, generally there is about a 5dg
measurement difference between testers.
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• Universal goniometer is the most reliable of
joint measurement tools
• Good to excellent reliability found in the
numerous studies.
• UE measurement is more reliable than LE
measurement
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• No real difference in reliability between using
the mean of several measurements and one
measurement once you are experienced in
goniometry
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Factors which improve reliability in
goniometric measurement
1. Consistent test position: if done antigravity
position, should always be tested in the
antigravity position
2. Consistent anatomical landmarks for
movement and stationary arm alignment
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3. Consistent testing situation: if always
evaluate in the morning, should continue in
this manner.
4. Inexperienced PT’s may want to take the
mean of several measurements while
experienced PT’s will be reliable with only
one measurement
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5. Same amount of manual force applied to the
joint when measuring PROM
6. Consistent Tester: Due to intertester
reliability (5 Dg difference between testers)
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Factors influencing Joint ROM
1. Age
2. Gender
3. Occupation or pattern of activity:
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4. Joint Structures:
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Anatomical Variance
Disease Processes
Posture
Genetics
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5. Hand Dominance:
6. Types of Motion:
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PROCEDURE
1. Knowledge required to be competent in
goniometry
a. Optimal testing position
b. Alternative Testing Positions
c. Stabilization required for
measurement
d. Joint structure and function
e. Normal end feels
f. Anatomical bony landmarks
g. Instrument alignment
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2. Skills required to be competent in goniometry
a. position patient and stabilize correctly
b. move a body part through an appropriate
ROM
c. determine the end feel of the joint range
d. palpate appropriate landmarks
e. align measuring instrument with landmarks
f. read measuring instrument
g. record measurements correctly
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Positioning for joint measurement
1. The muscles surrounding the joint must be
as relaxed as possible to get a true joint
measurement
2. Position must place the joint in the starting
position of 0
3. Position must permit complete ROM
4. Provide stabilization for the proximal
joint segment
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Alternative testing positions:
• Need to accurately describe the position in
records so that the same position is used in
subsequent measurements.
• Reliability issue
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Stabilization:
1. Stabilize the proximal segment
2. Substitute Movements
3. Force of stabilization
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4. End Feel: Noted at end of the PROM
– Quality of resistance to movement at the end
of a physiological movement
– Normal End Feels
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•
•
Soft: Soft tissue approximation
Firm: Capsular end-feel, Tissue Stretch
Hard: Bone to bone
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MEASUREMENT TOOLS:
• Visualization:
– Very subjective, not the best method to use.
– Can be used for a quick reference but not for
objective measurements needed in charts.
– Unreliable
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Electrogoniometer:
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Dynamic joint measurement used in research.
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Developed in 1959,
The two arms of the goniometer are attached to a
potentiometer which is attached to an EMG machine.
The change is joint position will cause resistance in the
potentiometer which is then recorded as the amount of
joint motion.
Problem: time consuming
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Inclinometers: 2 types
1. Gravity dependent inclinometer: pendulum
2. Fluid or “bubble” goniometer: carpenter’s level,
360 dg scale, relies on gravity
–
Has proven most effective in spinal mobilization so far
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Other Types of Measurement Tools
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Tape Measures/Rulers
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Primarily used for trunk and scapular mobility
Radiographs
Tracings
Motion Analysis with videotaping
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markers are placed over bony landmarks and then the
angles are drawn
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Universal Goniometer:
•
•
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Gold Standard for joint measurement
outside of radiographs
Most commonly used, versatile
Measures joint position/range at nearly all
joints of the body, most effective in the
extremities
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Basic Design:
•
Protractor: full or half circle, center of which is the fulcrum,
placed over the approximate location of the axis of motion
of the joint being measured, axis will move during motion
so must be adjusted at end range
•
Stationary Arm: aligned parallel to the longitudinal axis of
the proximal segment of the joint
•
Moving arm: aligned parallel to the longitudinal axis of the
distal segment of the joint
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Principle of Concurrent Lines
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Principle of Parallel Lines
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Sources of Error in reading a
goniometer
1. Distortion of the scale as the examiner is not
at eye level
2. Reading the wrong scale: 0 – 180 or 180 –
0
3. Misinterpreting the intervals on the
scale
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NOTATION SYSTEMS
1. Anatomical position is the reference or 0
position for all movements EXCEPT
• Supination/pronation of the forearm
• Glenohumeral joint internal/external
rotation
• Thumb movements
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Recording in the patient’s chart:
1. ROM: number of degrees at beginning and
at end of the motion
2. Passive or active ROM
3. Subjective information
4. Objective information
5. Position of patient is not in the
recommended position
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RECORDING SYSTEMS
1. 0-180 dg. System is most widely used.
Method of the American Academy of
Orthopedic Surgeons
• Describes one specific motion, arc of motion
is based on 180 dg. Numbers are all
positive.
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2. 180 dg to 0 dg
– System is used but is more difficult to interpret.
– 180 dg is the reference or starting point for
measurement, measurement moves toward 0 dg
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3. 360 dg system
– Anatomical position is 180 dg
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(+) and (-) numbers:
• Used to indicate hyper and hypo mobility of
the joint, can also create confusion
1. Works well when: there is no motion past 0
dg. A minus number would indicate that the 0
position was not reached
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2. Confusion exists when the movement is past
0 dg
3. Creates problems when dealing with soft
tissue approximation
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3. Isometric Resistive
Movements
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Spine first than the extremities
Movement strength exam, not a specific manual
muscle test
Break Test
Myotomal distributions: 5 Second holds for
endurance/fatigue
Myotome: muscle innervated by a particular nerve
root, pattern of weakness if nerve root is
entrapped
Shoulder abduction: C5 cervical nerve root
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Muscle Strength Testing
• Only one factor in determining muscle
function
• MMT is only one form of strength testing
• Consider factors of velocity of contraction,
power, endurance
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Principle of MMT
• Muscle strength required to hold a test
position must be equivalent to the muscle
strength required to complete the test
movement (Kendall)
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Measurement Purposes
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•
•
•
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Diagnostic – Cyriax Exam
Patient Improvement or Patient Worsening
Predictive Capabilities
Functional Loss
Outcome Measures
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Definitions: Muscle Performance
• Capacity of a muscle to do work. Incorporates
the properties of strength, power and
endurance
• W=FxD
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Muscle Strength
• Measurable force exerted by a muscle or
group of muscles to overcome a resistance.
Occurs with one maximal effort
• F
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Power
• Work produced per unit of time, Rate of work
• P=FxD
T
• One isometric contraction, maximal resistance
with movement occurring throughout the
range
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Endurance
• Ability of muscle to contract repeatedly over a
period of time
• FxDxT
• Number of repetitions a muscle can perform
before fatigue sets in
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Fatigue
• Inability to maintain torque over a period of
time or a set number of muscle contractions
• Describes the amount of power maintained
over time
• Fatigue is a loss of power and less range noted
during a muscle contraction
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Types of Muscle Contraction
• Isometric
• Isotonic
– Concentric
– Eccentric
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Factors influencing Contractile Force
1. Size of muscle – length and cross sectional
area
2. Muscle type – slow twitch, fast twitch
3. Cyto-architectural factors
 Arrangement of muscle fibers
 Angle and pull of the muscle
4. Muscle Vascularization
5. Muscle Innervations
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6. Recruitment Order: controlled by the motor
unit
–
–
–
–
Recruited from weakest to strongest
Slow fatigue resistant fibers are recruited first
Fast fatigue resistant
Fast fatigue fibers recruited last
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Factors Influencing Power
1.
2.
3.
4.
5.
6.
Neurological stimulation
Fuel storage
Fuel delivery
Balance
Timing
Recruitment order
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Factors influencing muscle endurance
1. Cytoarchitectural factors
– Muscle mass
– Capillary density
– Percent of slow resistant fibers
2. Recruitment of muscle mass within a muscle
3. Recruitment of other muscles
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Biomechanical Factors Influencing
Muscle Strength
1. Cytoarchitectural Factors
– Pennate versus parallel muscles
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– Muscle fibers arranged in
series (pennate) rather than
parallel
– Pennate muscles have larger
physiologic cross sectional
area (and muscle force) but
smaller length and shortening
velocity than parallel muscle
fibers
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Cytoarchitectural factors cont.
2. Aponeurosis and tendons: Have a series
elastic component
3. Passive tension of muscle
4. Elastic Energy
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Specific Tests and Measures: Mechanical
Means
• Weights: lift or move a
specific weight and
maintain this against
gravity
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Springs
• Compress or pull out on
a spring, force will vary
in the range
• Not very accurate at
end range
• Inexpensive
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Air Cylinders
• Compress air and force
• Equal pressure on all
sides
• Read the pressure
guage to determine the
force
• Myometers
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Hydraulics
• Pressure on a gauge
• Hand grip dynanometer
• tensiometer
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Strain Gauge or Force Plates
• Electronic ways of reading contractility
• Research approach
106
Isokinetic testing
• Dynamic muscle strength
through range
• Constant velocity with
variable resistance
• Advantage: can reproduce
results, reliable
• Disadvantage: big piece of
equipment, costly, tests in
open chain
107
Manual Muscle Test
• Developed over 80 years ago by Dr. Lovett
• Measure of impairment not function
108
Fundamental Aspects
• Muscle has a specific Action on a joint
• Patient is positioned in such a way that one muscle
or group of muscles are primarily responsible for
active movement
• Grading is based on
– an arc of movement produced by the muscle and
– the amount of external resistance to motion
109
Grading System
Numerical Score
Qualitative Score
5
Normal
N
4
Good
G
3
Fair
F
2
Poor
P
1
Trace
T
0
Zero, no activity 0
110
+ and – in MMT
• + and – are unreliable above a 3+
• In MMT, + and – are discouraged except for
– 3+
– 2+
– 2-
111
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Test Procedures: Break Test
• Manual resistance applied at end range or mid
range of muscle
• Patient holds position
• Therapist gives resistance and assigns strength
grade
113
Active Resistance test
• Application of manual resistance against a
contracting muscle
• Resistance increased during the range until it
reaches maximal level and motion ceases
114
Measurement Principles
1. Reliability: changes when the muscle grades
are above fair
2. Sources of variability within the muscle test
– Measurement device
– Intertester versus intratester
– subject
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3. Functional Threshold
 UE:
 LE:
116
Issues and Concerns
1. Single muscle, group of muscles, movement
testing
2. Prime movers and Accessory movers
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3. Factors which limit motion
4. Fixation
5. Stabilization
6. Substitution
118
7. Muscle Imbalances
8. Point of Application
 Break test
 One joint muscles
 Two joint muscles
119
9. Demographic Factors
 Age
 Gender
10. Pain
 Inhibitory muscles
 Excitatory muscles
120
Examination
• TEST THE NORMAL (UNINVOLVED) SIDE FIRST
1. Establishes a base line for comparison
2. Allows the patient to know what you are
going to do to the involved side before
touching that side. Helps to decrease the
patient’s apprehension
121
EXAMINATION
• ACTIVE MOVEMENTS ARE TESTED BEFORE
PASSIVE MOVEMENTS THEN FOLLOWED BY
RESISTED MOVEMENTS.
122
EXAMINATION
• PAINFUL MOVEMENTS ARE DONE LAST – TO
HELP PREVENT OVERFLOW OF PAIN INTO THE
NEXT MOVEMENT.
123
EXAMINATION
• IF ACTIVE RANGE OF MOTION IS NOT FULL,
OVERPRESSURE IS STILL APPLIED TO
DETERMINE END FEEL.
• MUST BE CAREFUL AS THIS WILL / MAY CAUSE
AN INCREASE IN THE PATIENTS SYMPTOMS.
124
EXAMINATION
• WHEN OVERPRESSURE IS APPLIED, YOU ARE
ESSENTIALLY DOING PASSIVE RANGE OF
MOTION AT THE END RANGE. A MORE
FORMAL PASSIVE RANGE OF MOTION TESTING
IS NOT NEEDED.
125
Examination
• Repeat each active, passive or resisted
isometric movement test several times or hold
for a certain amount of time
• Results: symptoms increase,
– Decrease
– change pattern of movement
– increase in weakness
– or if there is possible vascular insufficiency
126
Examination
• Resisted isometric tests are done with the
joint in a neutral or resting position so that
stress on the inert tissues is minimal
127
Examination
• For passive ROM or ligamentous tests, it is the
degree AND the quality of end feel that is
important.
128
Examination
• When testing the ligaments, apply stress
gently and repeat several times.
• Stress is up to but not beyond the point of
pain.
• Stress joint to the maximum but avoid muscle
spasm.
129
Evaluation Process: (after the exam)
• Dynamic Process
• Clinical judgments based on data gathered during the
exam
• May identify possible problems requiring
consultation with another health care provider.
• APTA Guide to Practice
130
Capsular Patterns
• Pattern of limitation or restriction of
movement noted during range of motion
testing. Specific for each joint.
131
Non-Capsular patterns:
• There can be limitations or restrictions to
movement caused by structures other than
the capsule.
• 3 types of non-capsular patterns
– 1. ligament adhesion
– 2. internal derangement
– 3. Extra-articular lesion
132
Inert structures
• Non-contractile structures: ligaments, nerves,
blood vessels
• Within the body are evaluated by the degree
of pain which occurs, and the type of
limitation that occurs in the body.
• Cyriax : four classic patterns
133
1. Normal:
•
•
•
•
ROM is full
no pain
no lesion in the inert tissue tested
may be a lesion elsewhere
134
2. Abnormal
• Limited PROM in some directions
• painful with an abnormal end feel
• Movements that stretch or move the affected
structure cause pain.
• Could indicate a first or second degree strain
of the ligament, local adhesion, internal
derangement, extra-articular limitation
135
3. Abnormal
•
•
•
•
•
Limited PROM, pain free
abnormal end feel
end feel is generally bone to bone
Indicates symptomless OA
Don’t treat unless painful as it could cause
more of a problem.
136
4. Abnormal
•
•
•
•
•
Limited PROM
pain in all directions
abnormal end feel
Entire joint is affected
Capsular pattern is present and in correct
proportions.
137
Contractile tissue:
• Musculotendinous tissue
• Active contraction of muscle is painful
• passive stretch of the muscle will also be
painful.
138
• Only one resisted test will cause pain unless:
– 1. psychogenic component, emotional
hypersensitivity or problems
– 2. Acute lesion where everything is painful
– 3. fatigue
• 4 classic patterns
139
1. Strong and painfree:
• no lesion of muscles being tested
140
2. Strong and painful:
• local lesion of muscle or tendon
• 1st or 2nd degree strain
• no primary limitation of PROM but can
develop secondary joint stiffness
141
3. Weak and painful:
• severe lesion around the joint
• weakness or reflex inhibition of the muscles
around the joint
• ? fracture
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4. Weak and pain free:
• rupture of the muscle/ third degree strain
• involvement of the nerve supplying the
muscle
143
References
• Norkin CC, White DJ. Measurement of Joint Motion:
A Guide to Goniometry, 2nd ed. 1995
• Greene WB, Heckman JD. The Clinical Measurement
of Joint Motion. American Academy of Orthopaedic
Surgeons, 1994.
• Dutton M. Orthopaedic Examination, Evaluation,
and Intervention. 2004
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