Stanbridge - T4 - TMT - W1 - Intro & Cervical Spine

Introduction to TMT PTA 1008: Course Goals

• Course goals include describing and identifying:
  • Positional terminology
  • Anatomical planes of motion.
  • Goniometry terms and concepts
  • Principles of range of motion (ROM) like types, end-feels, and capsular versus noncapsular patterns.
  • Principles of muscle testing (MMT).

Objectives

• Students will review the anatomy of the spine, specifically the cervical spine.
• Students will learn various methods to measure the active range of motion of the cervical spine.
• Students will learn different tests to assess the strength of the cervical musculature.
• Students will discuss the importance of range of motion and strength during functional activities, especially pertaining to the cervical spine.

General Guidelines for Therapeutic Measurement and Testing

• Adhere to doctor's orders, physical therapy plan of care, licensure regulations and consider patient precautions and contraindications.
• Follow appropriateness principles for treatments based on injury stage, protocol, and systemic/immune considerations.
• Do no harm; when in doubt, refrain from performing the procedure.
• Ensure the stability and integrity of bones, joints, and muscles involved in measurements, considering the suitability and tolerance of testing positions.
• Listen to and observe the patient, and discuss concerns with the primary physical therapist if changes in status are noted.

Introduction to Therapeutic Measurement and Testing

• Specific universal terminology is needed to accurately describe body positions.
• Understanding hand placement with MMT and goniometry, as the body changes position, so does the relationship of body parts to each other
• Understanding correct positional terminology critical for physical therapist assistants to:
  • Accurately collect and document objective data.
  • Communicate effectively with other health care professionals.

Range of Motion (ROM) Assessment Goals

• Assess the excursion (range of motion) for each joint, to find R2.
• Assess the end feel, which reflects joint integrity by identifying which structure limits the motion, if any.

Goniometry: Terms and Concepts

• The size of the goniometer used should match that of the joint being measured for the most accurate results.
• There are many types of goniometers, and they may be scaled differently.
• Knowing how to read the goniometer is important before taking measurements.
• A ROM visual estimate is always a good idea as a double check to avoid getting extreme errors.

Visual Estimate of Goniometry

• Visual estimation is useful in the learning process before goniometric measurements to reduce errors of incorrect reading of the goniometer.
• Visual estimation will also prepares students to anticipate what to expect during measuring.

Class Activity - Practice on Paper

• Useful when practicing measuring various angles on paper
• Helps get familiar with matching appropriate goniometers are best to choose different size segments
• Useful in checking are angles looking greater or less that 90, 45, 135 etc

Goniometry Documentation

• Documentation needs to include:
  • What you do
  • Patient response
• At a minimum, documentation must include:
  • The specific body part and motion being measured
  • Full available ROM with starting and ending measurements.
  • Patient response to testing, including pain or tightness.
  • Pertinent objective information, like end feels and joint sounds.
  • Signature, credentials, and date.

Goniometry Numerical Documentation

• The American Medical Association (AMA) uses a plus sign (+) to describe hyperextension.
  • "L elbow extension PROM +10 deg" is used if the measurement is beyond zero (hyperextension) at 10 degrees while measuring elbow extension
• The American Medical Association (AMA) uses a minus sign (-) to describe when the zero starting position cannot be attained.
  • “L elbow extension PROM -5 deg" is used if the patient unable to get to full elbow extension by 5 degrees from zero while measuring elbow extension.

Anatomy and Osteokinematics of the Cervical Spine

• Cervical Vertebra: 7
• Cervical Nerves: 8
• Atlanto-Occipital Joint: Occiput on C1 (Atlas)
  • Condylar synovial joint
• Atlanto-axial Joint: C1 (Atlas) on C2 (Axis)
  • Consists of 3 separate articulations: median atlanto-axial and two lateral joints

Cervical ROM and Strength Testing

• Use caution when performing cervical ROM and Strength Testing.
• Only active cervical spine range of motion (ROM) will be measured.

Goniometry of Cervical Flexion

• The mean range of cervical flexion: 0-45 degrees
• Position of patient: Seated with neutral cervical rotation/side bending.
• Position of therapist: Standing along side of patient
• Position of goniometer:
  • Fulcrum: external auditory meatus
  • Stationary arm: perpendicular to the floor
  • Movable arm: base of the nares (nose)

Cervical Spine AROM Flexion

• Starting position is at 90 deg (in the left picture)
• Ending position – is at 130 deg on the goniometer
• 130°-90° = 40 deg
• Result being compared to normal (5 degrees less than normal cervical flexion ROM)

Other Ways to Measure Cervical Flexion

• Other ways to measure cervical flexion are by using:
  • Single inclinometer (top left)
  • Tape measure (top and bottom right)
  • Cervical range of motion (CROM) device (bottom left)

Goniometry of the Neck

• Cervical extension: 0-45 degrees
• Position of patient: Seated neutral cervical rotation/side bending
• Position of therapist: Standing along side of patient
• Position of goniometer:
  • Fulcrum: external auditory meatus
  • Stationary arm: perpendicular to the floor
  • Movable arm: base of the nares (nose)

Cervical Lateral Flexion

• Normal range is 0-45 degrees.
• Procedure:
  • Position the patient seated.
  • Position the therapist behind the patient.
  • Place the fulcrum of the goniometer on the C7 spinous process.
  • Align stationary arm with the thoracic spinous processes (perpendicular to the ground)
  • Align the movable arm with the occiptal protuberance (dorsal midline of the head)

Goniometry of Cervical Rotation

• Normal range is 0-60 degrees.
• Have the patient seated.
• Position the therapist behind the patient.
• Goniometer Placement:
  • Fulcrum: center of the cranium,
  • Stationary arm: parallel to the two acromial processes,
  • Movable arm: tip of the nose.

Therapeutic application of Neck ROM

• Bennett, Schenk and Simmons conducted a study using a CROM for performance measurement:
  • Star gazing requires near full cervical extension.
  • Backing up a car requires 93% of cervical rotation.
  • Drinking require more cervical extension than eating
  • Deficits lead to body compensation using surrounding joints or altered position of joints.

Principles of Manual Muscle Testing

• MMT is a data collection skill integral to physical exams.
• MMT Provides information useful in differential diagnosis, prognosis, and treatment of neuromuscular/musculoskeletal disorders.
• MMT Collects objective data related to muscle strength during motion.
• Key principle is to test strength of muscles through objective data collection

Why Test Muscle Strength?

• Muscle capability determination for movement, stability and support
• To address cause of weakness through therapeutic exercise/neurological interventions

How Muscles Function

• Each muscle acts as a prime mover for specific actions.
• No two muscles serve the same function.
• If one muscle becomes paralyzed, part stability is compromised or movement loss occurs.

Positioning for MMT

• Stabilize body part adjacent to being tested.For example, stabilize pelvis when testing hip movement
• Find the pain-free range of motion and apply pressure

Terms Explained in Relation to Gravity:

• AGANIST GRAVITY: gravity resisted
• ACROSS GRAVITY: in the horizontal plane
• WITH GRAVITY: gravity assisted

General Procedure of MMT

The procedure for MMT includes the following steps:

1. Passively position the person for the test (start with the uninolved side)
2. Have the patient demonstrate their ability achieve specified test position
3. Give the patient a break
4. If moved then add pressure, and if cannot move the eliminate gravity

MMT Step 5 – Applying Resistance

• Determine where to apply resistance and how to provide stabilization to proximal joint
• Follow Kendall MMT positions
• If the resistance crosses an additional joint, check the primary PT's documentation to verify stability; then, confirm this information with the PT.
• Do NOT perform MMT if patient cannot tolerate the MMT position.

MMT Application

• Apply force gradually up to maximum applied.
• Force should be applied in the opposite direction to the body part's movement.:
  • While testing shoulder flexor strength, force is pushing into shoulder extension
• Explain the test to patient, instructing to hold position against attempt to move them and continue to cue the hold..
• Apply pressure that doesn't exceed strength of resistance. Stop pressure once test position breaks or strong resistance is shown

MMT Across Gravity Positioning

• Support part to test using surface minimizing movement resistance in horizontal plane
• Hand replacement same for applying resistance in across gravity position
• Steps 5-7 follow across gravity positioning:
  • Ask if patient can move into across gravity test position
  • If patient can add resistance in the same manner as slide 42-43 if fully moved
  • If fully moved then palpate muscles belly while watching how far they move.

MMT Proper Resistance

• Application proper at the distale axis without not over intervening joint
• Must apply pressure away from muscle
• Strength tested
• Test can repeat if trial isn't correct.

Principles of Manual Muscle Testing (MMT) Grades

• Zero measures 0/5, Trace measures 1/5, Poor measures 2/5, Fair measures 3/5, Good measures 4/5 and Normal measures 5/5 strength.

Zero

• Can't be felt when grading

Trace

• Felt with no movement

Supporting the Patient

• Movement through partial range measures Poor
• Complete range test is Poor
• If slight pressure then, Poor

Testing against Gravity

• Gradual release = Fair
• Holds in position = Fair
• Only slight pressure = Fair +
• Has moderate pressure and force = Good
• Resistance in high force = Normal

MMT Grades Detailed

• Zero: No palpable muscle contraction
• Trace: Palpable muscle contraction, or tendon prominent, No joint movement
• Poor Minus: partial muscle ROM Across Gravity
• Poor: complete ROM of muscle being tested, Across Gravity
• Poor Plus: complete Across Gravity movement against slight resistance, OR partial ROM Against Gravity
• Fair Minus: gradual release from the test
• Fair: holds test position Against gravity
• Fair Plus: able to hold test position Against Gravity with slight pressure
• Good Minus: hold test position Against Gravity with slight-moderate pressure
• Good: hold test position Against Gravity with moderate pressure
• Good Plus: hold test position Against Gravity, moderate-strong pressure
• Normal: holds test position Against gravity with strong pressure

Calculation of the Final Grade

• One test determines patient strength.
• First result isn't final from not stabilizing from PT or misunderstanding and the test will then rerun.
• Rest will be permitted for each trial
• Some cause need more than one trial

Key Components of Manual Muscle Grading

• FOR ACROSS GRAVITY: To provide a firm, smooth surface to reduce movement resistance
• A 2+/Poor results mean a part can be moved/held when testing at a greatest strength.
• In key, the highest the test movement grade in across gravity is also Poor

Documentation MMT Documentation should include:

• MMT results are in documentation
• MMT's body test
• If tested, it is placed out of position
• PT response
• Info
• Signature is present
• There is the right upper trapezius when reduced

Subjective Documention:

• Document all symptoms including pain, fatigue, etc
• Include location, intensity, and type of the symptoms
• Address all concerns with the patients

Objective Documentation:

• Objective findings show testing to perform a test and compare results.

Documentation Plan

• Will add all the steps to add in POC

Upper Trapezius MMT

Action: contralateral cervical rotation, ipsilateral side bending, shoulder elevation. If patient cant reach a part it is consider too week Testing: The patient isn't usually weak

Cranio-Cervical Flexion Test (CCFT):

• Test on deep flexor muscles when there is loss of motion.
• Pressure is taken from an outside source in Chattanooga Group, South Pacific
• Blood cuff simulates this test.
• Caution; If there is pain from a cuff do not continue

CCFT Positions

• Lay on back so neck can be stabilized before pillow.
• Pressure is applied and is set 20mmHg ( to fill in empty space)
• Head movement then increases the pressure.

More CCFT's

• increase by 2mm hg by bobbing head
• hold max contract for 10 secs
• SCM won't move
• repeat
• keep to 30mm hg to be max before stopping
• pause when done

###Signs to stop a CCFT

• If there is retraction
• Overly used muscles in the face
• Head raise
• Quick jerk motion
• Drop in BP
• Head/breath is always in proper placement

Action score of CCFT

• Pressure held in check
• Form in use by SCM to proper form
• PT can hold 24 mm hg
• Exits SCN used by patient

Deep Neck Flexor Endurance Test-

Action: Tuck the Chin, lift head up and hold If the muscles tire 1.Skin starts to crease in the neck. 2.Head starts to drop 3.Headtouching fingers 4. No head rise.

End Test

Time- ends and test is terminated, when 1 occurs- Skin folds at ant. neck separate second- Subject head will be resting on fingers (folded) more than 1 third- head lifted not in contract w/ tester fingers- tester end it Lastly- The person doesn't wanna go on.

Normative Values

In men Time values- 40 secs. In women Time values- 30 secs.

Deep Neck Extensor

• The neck bends slightly. Normal hold: should be no more than 2 mins max to fully hold. (79= normal)