PNF Review PDF

Neuro 2 PNF Review UE Patterns D1 Flexion D1 Extension D2 Flexion D2 Extension “Grab your “reach and get “Reach for your “Click in your seatbelt” something ou...

Neuro 2 PNF Review UE Patterns D1 Flexion D1 Extension D2 Flexion D2 Extension “Grab your “reach and get “Reach for your “Click in your seatbelt” something out of seatbelt” seatbelt” the backseat” Scapula Anterior Posterior Posterior Anterior Elevation Depression Elevation Depression Shoulder - Flexion - Extension - Flexion - Extension - Adduction - Abduction - Adduction - Adduction - ER - IR - ER - IR Elbow Extension Extension Extension Extension Radioulnar Supination Pronation Supination Pronation Wrist - Flexion - Extension - Extension - Flexion - Radial Dev - Ulnar Dev - Radial Dev - Ulnar Dev Finger Flexion Extension Extension Flexion LE Patterns D1 Flexion D1 Extension D2 Flexion D2 Extension “CROSSING “STANCE “FIRE “SOCCER KICK” LEGS” PHASE OF HYDRANT” GAIT” Pelvis Anterior Posterior Posterior Anterior Elevation Depression Elevation Depression Hip - Flexion - Extension - Flexion - Extension - Adduction - Abduction - Abduction - Adduction - ER - IR - IR - ER Knee Flexion Extension Flexion Extension Ankle/ - Dorsiflexion - Plantarflexion - Dorsiflexion - Plantarflexion Foot - Inversion - Eversion - Eversion - Inversion Feature Scale Score “responses” “notation” Eye Opening - Spontaneous - 4 - To speech - 3 - To pain - 2  - None - 1 Verbal Responses - Oriented - 5 - Conversation confused - 4 - Use of inappropriate words - 3 - Incomprehensible sounds - 2 - No response - 1 Motor Response - Obeys verbal command - 6 - Localized - 5 - Withdraws to pain - 4 - Decorticate posturing - 3 - Decerebrate posturing - 2 - No response - 1 - Mild = >13 - Moderate = 9-12 - Severe = 3-8 Rancho Level COGNITIVE LEVEL I Cognitive Training for Rancho Levels NO RESPONSE 1-2: - 1. Keep the room calm and quiet A person at this level will: - 2. Keep the comments and - Not respond to sounds, sights, touch, or questions to the patient short and movement simple - Not respond to painful stimuli - 3. Explain what is about to be - Need total cognitive and physical done using a “calm” tone of voice assistance COGNITIVE LEVEL II GENERALIZED RESPONSE A person at this level will: - Respond to external stimuli with physiologic changes generalized, gross body movements, and/or non-purposeful vocalization - Have responses that may be significantly delayed - Demonstrate generalized reflex response to painful stimuli - Respond to repeated auditory stimuli with increased or decreased activity - Need total cognitive and physical assistance COGNITIVE LEVEL III Cognitive Training for Rancho Level 3: LOCALIZED RESPONSE - 1. Limit visitors to 2-3 people at a time A person at this level will: - 2. Allow the person extra time to - Respond directly related to the type of respond, don’t expect correct stimulus (specific response) responses - Withdrawal or vocalizing in response to - 3. Give the person rest periods painful stimuli - 4. Remind the person who they - Turn toward or away from auditory stimuli are, who you are, why they are in - Blink when strong light crosses the visual the hospital, and what day it is field - 5. Bring in favorite belongings and - Follow a moving object in the visual field pictures of family members - Respond to discomfort by pulling tubes or - 6. Engage the person in familiar restraints activities such as listening to their - Respond inconsistently to simple favorite music, reading out loud to commands the person, familiar ADLs - May respond to some people (family/friends) but not others COGNITIVE LEVEL IV Cognitive Training for Rancho Level 4: CONFUSED AND AGITATED - 1. Allow the person as much movement as is safe A person at this level may: - 2. Allow the person to choose - Be alert and in a heightened state of activities within safety limits activity - 3. Give the person breaks and - May perform motor activities (sitting, change activities frequently reaching, walking, but without any - 4. Keep the room calm and quiet apparent purpose or upon another’s (turn off tv and radio) request) - 5. Limit visitors to 2-3 people at a - Brief and non-purposeful movements time - Absent short-term memory - 6. Find familiar and calming - May cry out or scream out of proportion to activities stimulus even after its removal - 7. Bring in pictures of family and - Aggressive or flight behavior friends, personal items - Mood swings from euphoric to hostile with - 8. Tell the person where they are no apparent relationship to environmental and reassure the person that they events are safe - Unable to cooperate with treatment efforts - 9. Take the person for rides, if the - Incoherent and/or inappropriate person uses a wheelchair. If they verbalization in relation to activity or are walking, take them for short environment walks in a safe environment COGNITIVE LEVEL V Cognitive Training for Rancho Level 5: CONFUSED AND INAPPROPRIATE - 1. Repeat questions or comments as needed. Don’t assume they will A person at this level may: remember what you have told - Be alert and non-agitated them. - Wander randomly or with the vague - 2. Tell the person the day, date, intention of going home name, and location of the hospital - Become agitated in response to external and why they are in the hospital stimulation and/or lack of environmental - 3. Keep a calendar and list of  structure visitors available - Not oriented to person, place or time - 4. Keep comments and questions - Frequent, brief periods of short and simple non-purposeful sustained attention - 5. Limit visitors to 2-3 people at a - Severely impaired recent memory time - Absent problem-solving, self-monitoring - 6. Help the person organize and behavior get started on an activity - Demonstrates inappropriate use of - 7. Give the person frequent rest objects without external direction breaks when they have problems - Perform previously learned tasks when paying attention structured and cues provided - 8. Limit the number of questions - Unable to learn new information you ask. Try not to “test” the - Be able to respond appropriately to patient by asking a lot of simple commands, fairly consistently with questions. external structure and cues - 9. Help the person connect what - Responses to simple commands without they remember with what is external structure are random and currently going on with their family non-purposeful in relation to command and favorite activities - Converse on a social, automatic level for - 10. Bring in family pictures and brief periods of time with external personal items from home structure and cues - Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided COGNITIVE LEVEL VI Cognitive Training for Rancho Level 6: CONFUSED AND APPROPRIATE - 1. Repeat things. Discuss things that have happened during the day A person at this level may: to help the person improve their - Be able to attend to highly familiar tasks ability to recall what they have in a non-distracting environment for 30 been doing and learning minutes with moderate redirection - 2. Encourage the person to repeat - Remote memory has more depth and information that they need or want detail than recent memory to remember - Vague recognition of some staff - 3. Provide cues to help the person - Able to use assistive memory aid with start and continue activities maximal assistance - 4. Encourage the person to use - Emerging awareness of appropriate familiar visual and written response to self, family, and basic needs information to help with their - Moderate assistance to problem-solving memory (ex. Calendar) barriers to task completion - 5. Encourage the person to - Supervised for old learning (ie self-care) participate in all therapies. They - Shows carryover for relearned familiar will not fully understand the extent tasks of their problems and the benefits - Max assist for new learning with little or of therapy. no carryover -Unaware of impairments, - 6. Encourage the person to write disabilities, and safety risks down something about what they - Consistently follows simple directions have done each day. - Verbal expressions are appropriate in  highly familiar and structured situations COGNITIVE LEVEL VII Cognitive Training for Rancho Level AUTOMATIC AND APPROPRIATE 7-8: - 1. Treat the person as an adult A person at this level may: while still providing guidance and - Consistently oriented to person and place assistance in decision-making. within highly familiar environments Their opinions should be - Moderate assistance for orientation to respected, and their feelings time should be validated. - Able to attend to highly familiar tasks in a - 2. Use a natural and respectful non-distracting environment for at tone of voice and attitude. You least 30 minutes with minimal assist may need to limit the amount of - Minimal supervision for new learning information or the complexity of - Demonstrates carryover of new learning the vocabulary but do not talk - Initiates and carries out steps to complete down to the person. familiar personal and household routines - 3. Be careful when joking or using but has a shallow recall of what he/she slang, because the person may has been doing take things literally and - Able to monitor accuracy and misunderstand the meaning. Also, completeness of each step in routine be careful about teasing the personal and household ADLs and modify person. plans with minimal assist - 4. Be sure to check with the - Have superficial awareness of his/her physicians on the person’s condition but unaware of specific restrictions concerning driving, impairments and disabilities and the limits working, and other activities. Do they place on his/her ability to safely, not rely only on the person with accurately, and completely carry out the brain injury for information, his/her household, community work, and since they may feel that they are leisure ADLs ready to go back to their previous - Minimal supervision for safety in routine lifestyle right away. home and community activities - 5. Help the person participate in - Unrealistic planning for the future family activities. As the person - Unable to think about the consequences begins to see some of the of a decision or action problems they have in thinking, - Overestimates abilities problem-solving, and memory, talk - Unaware of others’ needs and feelings with the person about how to deal - Oppositional/uncooperative with these problems without - Unable to recognize inappropriate social criticizing the person. Reassure interaction behavior the person that their problems are caused by the brain injury COGNITIVE LEVEL VIII PURPOSEFUL AND APPROPRIATE A person at this level may: - Consistently oriented to person, place, and time - Independently attends to and completes familiar tasks for 1 hour in distracting environments  - Able to recall and integrate past and recent events - Use assistive memory devices to recall daily schedules and record critical info for later use with stand-by assist - Initiates and carries out steps to complete familiar personal, household, community, and work routines with stand-by assistance and can modify the plan when needed with min assist - Requires no assistance once new tasks are learned - Aware of and acknowledge impairments and disabilities when they interfere with task completion but need stand-by assistance to take appropriate corrective action - Thinks about the consequences of an action with min assist - Overestimates or underestimates abilities - Acknowledges others’ needs and feelings and responds appropriately with min assist - Depressed - Irritable - Low frustration tolerance/easily angered - Argumentative - Self-centered - Uncharacteristically dependent/independent - Able to recognize and acknowledge inappropriate social behavior while it's occurring and take corrective action with minimal assist COGNITIVE LEVEL IX Cognitive Training for Rancho Level PURPOSEFUL AND APPROPRIATE 9-10: - 1. Discourage the person from SBA when requested for cognition drinking or using drugs, due to - Independently shifts between tasks medical complications. and completes them accurately for at - 2. Encourage the person to use least two consecutive hours note-taking as a way to help with - Uses memory devices to recall daily their remaining learning problems. schedule and record information for later - 3. Encourage the person to do use with assistance when requested their self-care and other daily - Initiates and carries out steps to complete activities as independently as familiar personal, household, work, and possible. leisure tasks independently and unfamiliar - 4. Discuss what kinds of situations personal, household, work, and leisure make the person angry and what tasks with assistance when requested they can do in these situations.  - Aware of an acknowledges impairments - 5. Talk with the person about their and disabilities when they interfere with feelings. task completion and takes appropriate - 6. Help the person think about corrective action but requires stand-by what they are going to do before assistance to anticipate a problem before they actually do it. Afterward, talk it occurs and take action to avoid it about how it went and what might - Able to think about consequences of work better next time. actions with assistance when requested - 7. Consult with social work and - Accurately estimates abilities but requires psychology to help family stand-by assistance to adjust to task members learn to adjust to living demands together after brain injury. - Acknowledges others’ needs and feelings and responds appropriately with stand-by assistance - Depression may continue - May be easily irritable - May have low frustration tolerance - Able to self-monitor appropriateness of social interaction with stand-by assist COGNITIVE LEVEL X PURPOSEFUL AND APPROPRIATE Modified Independent cognitively - Able to handle multiple tasks simultaneously in all environments but may require periodic breaks - Able to independently procure, create, and maintain own assistive memory device - Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, and work tasks but may require more than the usual amount of time or compensatory strategies - Able to independently think about consequences of decisions or actions but may require more than the usual amount of time and compensatory strategies to select the appropriate decision or action - Accurately estimates abilities and independently adjusts to task demands - Able to recognize the needs and feelings of others and automatically respond in an appropriate manner - Periodic periods of depression may occur - Irritability and low frustration tolerance when sick, fatigued and under emotional  stress - Social interaction behavior is consistently appropriate SCI Review Level ASIA Key Muscles Most Independent Type of Transfer C5 Elbow flexion Mod A for bed mobility C6 Wrist extension Potential Indep for SB and Pressure Relief C7 Elbow extension Maybe indep with all transfer C8 Finger flexion Maybe indep with all transfer plus wheelies T1 Finger Abduction Floor from W/C L2 Hip flexion House ambul w/ orthosis + AD L3 Knee Extension Maybe indep w/ comm ambul + ortho AD L4 Ankle DF Comm ambu w/ AD + Ortho (AFO) L5 Big Toe Ext Comm ambu w/ AD + Ortho (AFO) S1 Ankle PF Ambu w/ or w/o AD + Orth SCI Terminology Zone of Preservation Brown-Sequard - Results from half of the spinal cord being injured Syndrome - (when one-half of the spinal cord is injured from a mechanism like a stab wound) - Loss of motor function, proprioception, and vibration = same side - Loss of pain and temperature = opposite side - Good prognosis - Potential for independence with ADLs and continent with bowel and bladder Anterior Cord - Results from a flexion injury to the cervical spine Syndrome - Loss of motor, pain, and temperature = bilaterally - Position sense and vibration remain intact below the level of the injury - The prognosis is poor  - (still have proprioception, vibration, and deep touch) Central Cord - The most common incomplete injury Syndrome - Results from progressive stenosis or compression as a result of a hyperextension injury, bleeding into the central gray matter - UEs are more affected than the LE’s - Motor impairment - Sensory more variable - Bowel, bladder, and sexual function are preserved if the sacral portions are spared - Functional independence depends on the amount of UE innervation the patient regains Posterior - Rare incomplete injury Cord/Dorsal - Results from damage to the posterior spinal artery by a Column Syndrome tumor or vascular infarct - Loss of ability to perceive proprioception and vibration - The ability to move and perceive pain remains intact - (good prognosis) (have balance issues) Cauda Equina - Results from direct trauma from a fracture dislocation below L1 Injury - Results in an incomplete lower motor neuron (LMN) injury - Flaccidity, areflexia, loss of bowel and bladder - * Regeneration of the involved peripheral nerve root is possible, depending on the extent of initial damage. Conus Medularis - Flaccid paralysis - Areflexic bowel and bladder - Sometimes sacral reflexes are present Autonomic Dysreflexia Cerebral Vascular Accidents Vertebrobasilar ▪ Supplies the cerebellum, medulla, pons, and CVA internal ear ▪ Complete occlusion results in death ▪ Incomplete occlusion results in: Diplopia = double vision Dysphagia = difficulty with swallowing (UMN) Dysarthria = difficulty forming words (LMN) secondary to weakness in tongue and facial m’s Deafness = inability to hear Vertigo = spinning/dizziness Headaches Ataxia = uncoordinated movements Disequilibrium  Locked-in syndrome = unable to move or speak but alert/oriented. Able to move eyes only Posterior Cerebral ▪ Supplies the occipital lobe, temporal lobe, upper brainstem, Artery CVA thalamus ▪ Occlusion results in: Contralateral sensory loss Thalamic pain syndrome Homonymous hemianopia (could only see through one eye) Visual agnosia – cannot recognize objects or people Cortical blindness – cannot process incoming visual information (completely blind, problem in the brain) Memory deficits Pusher Syndrome ▪ Occurs following a stroke in the posterolateral thalamus ▪ Characterized by: Individuals using their nonparetic limb to push themselves toward their paretic side Efforts to passively correct are met with resistance Thalamic Pain Syndrome Hemineglect - Often caused by right-sided CVA (left side is neglected) Wallenberg ▪ Infarct of the posterior inferior cerebellar artery which supplies the Syndrome cerebellum and medulla ▪ Occlusion results in: Loss of pain and temperature on the contralateral side of the body and ipsilateral face Dizziness and vertigo Ataxia Diplopia Dysphagia Dysarthria Horner’s syndrome: miosis (pupil constriction), ptosis (eyelid droop)(its a problem because it can cause dry eyes), decreased sweating (can't regulate temperature) Lateral Pontine ▪ Infarct of the anterior inferior cerebellar artery which supplies the Syndrome cerebellum and CN VII and VIII ▪ Occlusion results in: Ipsilateral ataxia Contralateral weakness Contralateral loss of pain and temperature Dizziness and vertigo Parkinson’s Disease 4 Clinical Features Tremor - Often the first sign of primary PD (begins unilaterally, and progresses bilaterally) - Resting tremor described as “pill-rolling” in the hand (4-7 beats per second) - Can also be in the postural muscles in the head, neck, trunk, and face - Rarely interfere with ADL’s Rigidity Resistance to passive movement regardless of speed - Trunk rigidity impairs breathing and phonation by restricting chest wall motion - Increases energy expenditure and fatigue - Trunk and extremities i.e. first sign is limited arm swing with walking - 2 types: - 1. Lead-pipe = constant resistance to passive movement in any direction regardless of speed - 2. Cogwheel = jerky, ratchet-like, tense & let go (combination of lead-pipe and tremor) Bradykinesia Decreased amplitude of movement - Slow oral movements = poor speech, inadequate breath support - Impaired swallowing - Micrographia = small handwriting - Akinesia = inability to initiate movement i.e. standing up, crossing legs, turning in bed - Forward flexed posture develops Postural Instability - Loss of postural extension - Inability to respond to postural disturbances - High fall risk - Fall risk increases the longer the person has the disease - Visuospatial deficits and slow processing of sensory information contribute to this Gait - Festinating gait = short steps with increased speed to try and “catch up” - Speed is slow - Narrow BOS - Freezing episodes – triggered by environmental situations (doorway, change of surface, speaking, blinking) - Decreased arm swing & trunk rotation = bradykinesia & rigidity - Trunk flexion increases over time - LE ROM restricted through walking - Heel strike and toe-off are both lost = decreased foot clearance - Gait is even more difficult when trying to add a complex task (i.e.  carrying a laundry basket while walking) Hoehn and Yahr Scale Stage Progression of Symptoms 0 No signs of disease 1 Unilateral symptoms only 1.5 Unilateral and axial involvement 2 Bilateral symptoms, no impairment of balance 2.5 Mild bilateral disease with recovery on pull test 3 Balance impairment, mild to moderate disease, physically independent 4 Severe disability, but still able to walk or stand unassisted 5 Needing a wheelchair or bedridden unless assisted Treatment Based HY 2-4 on Hoehn and Yahr Stage Treatment Goal: Intervention: - Prevent falling - Active and functional-task - Reduce limitations on core exercises (at home) using areas: - General strategies - Transfers - PD specific strategies - Posture - Cognitive - Reaching and movement Grasping strategies - Balance - Cueing strategies - Gait - Reduce multitasking HY 5 Treatment Goal: Intervention: - Maintain vital functions - Postural adjustments in - Prevent pressure sores bed or wheelchair - Prevent contractures - Assisted active exercise - Supply information to prevent pressure sores and contractures Medical *E = Early = Eldepryl Management - This medication is given early on in the disease course. - It helps enhance the levels of dopamine in the brain by enhancing the uptake of what the body is already producing. SSR = “Symptoms Significantly Reduced” = Sinemet, Symmetrical, Requip - These meds are given to reduce the major symptoms of PD. These are also meds that contain levodopa and cabodopa. - These are the meds that will wear off after 4-6 years of use AP = “Advanced Parkinsons” = Artance and Palodel - These are meds that are added to the patient’s med list once the SSR drugs start wearing off - These meds reduce some of the wearing-off symptoms - One of these symptoms is dystonia = torsion or twisting of the body caused by prolonged involuntary contraction. Also seen as a person twisting their facial muscles and sticking out their tongue. Anticholinergics = decrease resting tremor by blocking the increase in acetylcholine Multiple Sclerosis 4 Types: Clinically Isolated The first episode of neurologic symptoms lasts Syndrome (CIS) for 24 hours; not everyone who experiences CIS will go on to develop MS Relapsing-remitting Definable exacerbations and remissions (most common) Primary – Relentless progression without relapses (10% progressive of cases) Secondary-progres Begins with relapsing and remissions and then sive becomes progressive with only occasional relapses and minor remissions Interventions - 1. Strength Training in Moderation - 2. Spasticity Management - 3. Ataxia Management - 4. Cardiorespiratory training - 5. Fatigue Management Post-Polio Syndrome 5 Clinical Features: - 1. Fatigue - 2. New weakness - 3. Pain - 4. Losing muscle tissue (atrophy) Other Symptoms - Cold Intolerance - Decreased Function Non-fatiguing Aerobic Non-fatiguing Interval Training Strengthening Exercise Resistance Target heart 60–80% of one rate—low range, repetition maximum 60–70% Frequency 3 times per week 3–5 times per week Repetitions N/A Goal of 5–10 Duration 15–30 minutes N/A Contract time/rest N/A 5 seconds/10 time seconds Intervals Start: 2- or 3-min ex. N/A bouts interspersed with 1-minute rest for a session of 15 minutes; when able to do this comfortably for a total of 20 min for 2 weeks, increase each ex. bout by 1 min. Goal: 4 min each ex. bout, 1 min rest interval, total session 30 min total of ex. bouts Kinds of exercise Walking, swimming, Concentric pool walking, stationary bicycling, and arm ergometer— the selection is based on the strongest muscle group to  achieve heart rate goals and avoid joint trauma. Guillan-Barre Syndrome Pathology - Myelin is destroyed and accompanied by inflammation - Lesions are present within several days of the onset of symptoms - Nerve conduction is slowed and may be blocked completely - Schwann cells were destroyed but axons were left intact - In most cases, 2-3 weeks after onset, Schwann cells proliferate, and remyelination begins 3 Phases of Recovery Acute Hospitalization Phase (1-4 PT Goals are: weeks) - Minimize acute signs/ symptoms - Support pulmonary function (percussion and vibration, postural drainage) - Prevent skin breakdown - Prevent contracture formation - Manage pain Interventions include: - PROM – at least 2x/day (contracture management) - Positioning - Postural drainage and percussion - STM and TENS for pain control Plateau Once stabilization of respiratory and autonomic Phase (3-4 functions occurs, then the treatments in the weeks after plateau phase can begin onset) PT Goals are: - Acclimation to an upright position (go slowly sit up, if not then orthostatic hypo happens) - Maintenance of ROM - Improve pulmonary function - Prevent fatigue and overexertion Interventions include: - Functional training to acclimate upright position - PROM - Positioning to decrease contractures  Recovery Can last up to one year Phase PT Goals are: - Strengthening (using the non-fatiguing protocol) (show signs of improvement before strengthening) - Maximizing functional abilities - Carryover of goals from previous phases Interventions include: - Short periods of non-fatiguing exercise matched to patient’s strength - Exercises should be matched at increasing function rather than solely on strength - Low repetitions and short, frequent bouts of exercise - Gravity eliminated exercises - Gait training and ambulation once muscle grade is 3/5 in LEs - Adaptive equipment that allows for more independence as the patient recovers - Lightweight Orthotics - Endurance training CIDP Similarities to GBS: - Symmetrical loss of motor function - Myelin sheath compromised Differences from - Chronic GBS: - At least 2 months for diagnosis - Slower onset - GBS onset within a day Huntington’s Disease Early - Individuals are largely functional - May continue to work, go to school, live independently - Symptoms may include mild chorea, mild loss of coordination, difficulty thinking through complex problems, may have depression, irritability, or disinhibition Middle - Individuals will lose the ability to work or drive, may not be able to manage their finances, and perform ADLs without assistance - Chorea is more prominent - May have dysphagia, impaired balance, falls, and weight loss Late - Individuals will require assistance with all ADLs - Often nonverbal and bedbound in late stages, but may retain some comprehension - Chorea is most severe at this stage, but rigidity, dystonia, and bradykinesia will be present Cranial Nerve Testing Cranial Nerve Test Cranial Nerve I – - The patient is blindfolded or eyes closed Olfactory Nerve - A familiar item placed under the nose - The patient asked to ID odor Cranial Nerve II – - The patient stands a selected distance away from the chart Optic Nerve - Read eye charts or ID pictures Cranial Nerve III – - Patient sitting Oculomotor Nerve - Asked to track an object (pen or pencil) - Track vertically, horizontally, and diagonally - Not allowed to rotate the head Cranial Nerve IV – - Patient sitting Trochlear Nerve - Tack pen with eyes - Move inferiorly - Not allowed to move/rotate head Cranial Nerve V – Test (Sensory) Trigeminal Nerve - The patient sitting, eyes closed - Cotton ball, safety pin - Alternate at random, touch the patient’s face - Ask the patient to clarify whether sharp or dull Test (Motor) - The mandibular protrusion, retraction, lateral deviation - Ask the patient to clench their teeth and the therapist attempts to push down on the lower jaw to open the mouth Cranial Nerve VI – - Patient sitting Abducens Nerve - Ask the patient to abduct their eyes without rotating the head - One side at a time (it’s ok if the other eye moves too) Cranial Nerve VII – Test (sensory): Facial Nerve - The patient sitting, eyes closed - Distinguish between sweet and salty substances - Place on the anterior tongue Test (motor): - The patient was asked to mimic facial expressions (close eyes tightly, smile and show teeth, whistle and puff cheeks) Cranial Nerve VIII – - Patient in a quiet location Vestibulocochlear - The therapist is behind the patient on one side; the patient’s Nerve eyes closed - Slowly bring the ticking watch/finger rub toward the patient’s ear and record when the patient can hear the ticking/rubbing - Record the distance between the watch and the patient’s ear Cranial Nerve IX – Test (sensory): Glossopharyngeal - Place salty, sweet, or bitter/sour items on the posterior 1/3 of the Nerve tongue. - Pt’s eyes closed - Patient states what they taste Test (motor): - Patient sitting - The therapist uses a tongue depressor to press down on the tongue and touch the pharynx Cranial Nerve X – - Same test as CN 9 for motor (gag reflex) Vagus Nerve - Ask the patient to swallow - Ask the patient to say “Ahh” Cranial Nerve XI – - Patient sitting with arms rested at sides Accessory Nerve - Patient shrugs their shoulders and holds the position - The therapist applies resistance through the shoulders in the direction of shoulder depression Cranial Nerve XII – - Patient sitting Hypoglossal Nerve - The therapist asks the patient to protrude the tongue Vestibular System Adaptation - Adaptation exercises facilitate central adaptation in which the Exercises brain relearns and adapts to the impaired vestibular neural inputs (impaired VOR) - Involves head movement which patients with vestibular dysfunction typically avoid Adaptation exercises target the VOR - X1 viewing - involves keeping the eyes fixed on a stationary visual target while the subject moves the head side to side, or up and down (Fig. 13-7, A) - X2 viewing - involves maintaining visual fixation on a visual target when the head and target move in the same or opposite directions (Fig. 13-7, B) - Using exercise, create a controlled Retinal Slip with HEAD  MOVEMENT - Results in the creation of ERROR SIGNAL - The brain makes long-term changes in response - Retinal slip decreases and there is DECREASED dizziness Substitution - If the vestibular system is absent or severely impaired affecting Exercises gaze stability and/or postural control, compensate by using another system other than the vestibular - For gaze stability: use cervico-ocular reflex (COR) at low frequency head movement, smooth pursuit, or saccades - Specific substitution exercises for gaze stability: Target on Target, Target to Target - For disequilibrium: sensory organization training to increase the use of other visual and somatosensory feedback for postural control Habituation - Repeated motion exercises to decrease the patient’s symptoms Exercises by systematically provoking symptoms - Provoke symptoms up to a moderate level (5/10) to a specific motion - GOAL: Patient habituates to that motion - PATIENT EDUCATION IS KEY! - Use the Motion Sensitivity Test to identify provoking motion Pt performs motion > Symptoms may go up to 5/10 > Allow symptoms to return to baseline and repeat Cerebral Palsy Review Early: Handling and Positioning - The supine position should promote orientation with the head in midline and symmetry of extremities - Objects should be within infants' grasp to promote reaching - Active head lifting in a prone using bright-colored or noise-making toys - Carry child in prone to increased tolerance to position Therapeutic Exercise - Gentle ROM - Education to parents/caregivers on ROM Functional Postures - Focused on sitting and standing - When motor control does not allow for independent standing, a standing program can be implemented on a stander - Programs begin at 12-16 months of age - 60 minutes of standing 4-5 times a week is recommended Independent Mobility  - Rolling - Sitting - Creeping - Upright ambulation Preschool: Gait - May be possible in patients with spastic quadriplegia if the motor involvement is not severe - Spastic diplegia (both LE is spastic) - Decreased single-limb and increased double-limb time - Trouble disassociating one leg from the other and from the trunk and over-stabilization with adductors - Practice coming to stand over a bolster deters adductors while strengthening and weight-bearing - Lateral trunk postural reactions - As double limb stance time decreases, activities to improve single limb support should begin ( i.e. stepping over an object) Orthoses - The most frequent orthotic used in CP children who are ambulating is an AFO - PT should establish a wearing schedule for the child - Hinged AFOs offer more normal motion in the foot - Ground AFOs have been recommended for spastic CP patients to decrease knee flexion - Foot orthoses can help control pronation in children who don’t need ankle stabilization - SMOs (supra malleolar orthosis) provide medial-lateral stability for the child with unstable ankles School/Adolescenc Independence e: - 1. Strength - Studies show that adolescents with CP can increase strength when engaged in a program of isokinetic resistance - 2. Fitness - Students with CP often are unable to participate in a PE program unless adaptations are made - Recreational programs are important to the student with recent attention to Martial Arts and Aquatic program - 3. Community Integration - Efforts to support student driving are important for social interaction and should be a goal if possible Adulthood: - 1. Independence in mobility and ADL’s - 2. A healthy lifestyle - 3. Community participation - 4. Independent living - 5. A vocation  Ortho 2 Motion Innominate Sacrum Hip flexion (OKC) Posterior rotation IL rot + nutation Hip extension (OKC) Anterior rotation CL rot + counternutation Trunk extension (CKC) Posterior rotation Nutation Trunk flexion (CKC) Anterior rotation Nutation +slight counternutation at end of motion R) Trunk side bend (OCK + R) Anterior rotation R) IL SB, R) counternutation, CKC) L) posterior rotation L) nutation R) Trunk rotation (OCK + R) Posterior rotation R) Nutation, L) CKC) L) Anterior rotation Counternutation (sacrum stays still relative to moving innominate bones) Mobilizations Lumbar Spine Lumbar Spine Prone PA - Performed to increase extension, or when extension reduces symptoms - Prone REIL with over-pressure - Performed when the patient is responding to lumbar extension and to progress load - Prone REIL with hips to the side (side-glide) - Performed when patient symptoms are unilateral and patient progress is limited with extension, Lumbar Spine RFIL with therapist over-pressure - Performed when the patient is responding to lumbar flexion, and to progress load Cervical Cervical Up glides (PA glide) - To improve C/S flexion, contralateral rotation, contralateral side bending Cervical Down glides (AP glide)  - To improve C/S extension, ipsilateral rotation, ipsilateral side bending Thoracic Seated Thoracic Rotation with Therapist Over Pressure - Performed when the patient needs increased thoracic rotation Seated Thoracic Extension With Therapist Overpressure - Performed when the patient is responding to TS extension, to correct kyphosis, and to progress load C/S Test VBI - Passively place the patient in combined cervical extension and rotation to test the contralateral artery - The vertebral artery on the side to which the head is rotated will be “kinked” or compressed. Symptoms are caused by insufficient blood flow of the “unkinked” vertebral artery opposite to the side to which the head is rotated to make up for the loss on the opposite side. - Example: With C/S R rotation, the R vertebral artery will be compressed. A healthy L vertebral artery will be able to make up for the loss on the R. A positive test indicates the L side cannot make up for this lack of blood flow causing sxs. Alar Ligament - Patient lies supine - The examiner stabilizes the axis with a wide pinch grip around the spinous process and the lamina - The examiner attempts to side-bend the head and axis - A strong capsular end feel should be felt - Positive test = poor capsular end feel with excessive motion Spurling - Stage 1: Compression on the head in neutral - Stage 2: Compression on head in extension - Stage 3 Compression on the head in extension and rotation to the side of the complaint - Positive test = patient reports pain radiating into the arm toward which side the head is bent Sharp-Purser test - Subluxation of the atlas on the axis - The patient is sitting, feet on the floor - Place hands over patient’s forehead while thumb and 1st IP of the index finger of other hand is placed over the SP of the axis to stabilize it - Positive test = head slides backward during the movement, patient may feel a lump in the throat or a ‘clunk’ sensation  - The patient is asked to slowly flex head while the examiner presses backward with palm (not too hard or fast) Distraction Test - Nerve root alleviation test - Gently pull the patient’s head superiorly (majority of pulling force is on the occiput) - Positive test= Pain or sxs are relieved with pulling force Zygopopheseal Jt - Extension and rotation “most common compression” Coupled Motions - Segmental side bending: extension (downglide) of the ipsilateral joint and flexion (upglide) of the contralateral joint - Ipsilateral rotation coupled with side bending involves extension of the ipsilateral joint and flexion of the contralateral joint - Coupling: Two or more individual motions occurring simultaneously at the segment (e.g. rotation + sidebend) - Coupled motions - Rotation and side bending are opposite (in neutral); they are the same once the spine is outside of neutral (i.e. flexed or extended before the other motions occur) SIJ SI joint Test Leg length screening: Both PGP and LBP This is important because asymmetry and asymmetric loading increase incidence of LBP and PGP Limb length determined by - A-P radiograph of pelvis in standing- Gold standard - Bilateral measurement of limb in supine - ASIS → tip of medial malleolus - >1 cm difference is considered a significant discrepancy Measuring alignment: compare ASIS position symptomatic vs asymptomatic sides ASIS is lower and PSIS higher on the symptomatic side= Anterior rotation - Associated with a “longer” leg - Intervention: Use hip extensors (MET) to facilitate posterior rotation to correct an anterior rotation ASIS is higher and PSIS lower on the symptomatic side= Posterior rotation - Associated with a “shorter” leg  Intervention: Use hip flexors (MET) to facilitate anterior rotation to correct a posterior rotation ASIS Closer to midline using the umbilicus as reference n symptomatic side = inflare ASIS further from the midline on the symptomatic side = outflare MET Technique Shotgun Technique - Supine hook lying position - Resisted bilateral abduction then adduction (2-5 second hold, 5-10 times each direction) - This technique is also performed after any MET for the SI joint To Correct an Anteriorly Rotated Ilium (MET) - Patient in supine - Passively flex the hip until the point of pain or restriction - The patient creates submaximal hip ext contraction in this position - Resist the motion 2 seconds, 5-10 reps, 1-3 sets - Finish with shotgun technique To Correct a Posteriorly Rotated Ilium (MET) - Patient in prone - Passively extend the hip until the point of restriction - Patient creates submaximal hip flexion contraction in this position - Finish with shotgun technique To Correct an Inflare (MET) - The patient lies supine at the edge of the table with legs extended - The therapist stands next to the patient - The therapist passively flexes the L hip and knee to 90° with slight ER and abduction - The therapist applies a gentle force against the leg into Adduction which fires the gluteus minimus To Correct an Outflare (MET) - The patient lies supine at the L edge of the table with legs extended - Therapist stands next to the patient - The therapist passively flexes the hip to 45° (pictured here at 90 degrees), internally rotates and adducts the thigh to get the greater trochanter medial to the ilium - The therapist applies a force into Extension and ABDuction to fire the iliacus, Sartorius, and rectus femoris “Outer unit” SIJ 1. Posterior oblique system: Latissimus dorsi, Gluteus maximus with muscles thoracodorsal fascia - approximates the posterior aspects of the innominate bones  - Provides rotational stability with gait 2. Deep longitudinal system: Erector spinae, thoracolumbar fascia, sacrotuberous ligament, biceps femoris - Facilitates compression of SIJs, counteracts shear forces 3. Anterior oblique system: External and Internal obliques, contralateral adductors, anterior abdominal fascia - Initiates movements and is involved with all movements of the body 4, Lateral system: Gluteus medius, gluteus minimus, and contralateral adductors - Stabilizes pelvic girdle on the femoral head during gait Guy-wires muscles 1) Quadratus Lumborum 2) Erector spinae 3) Psoas Dynamic stability Anterior Muscle System muscles - Rectus abdominis - External obliques - Internal obliques - Transverse abdominis Function of Pelvis - Primary stabilizer for maintaining static and dynamic stability of the body Hip Special test Thomas Test Ober Ely Prone Knee Bent cemented vs - WBAT is typical for cemented joint replacements non-cemented - TTWB to PWB is typical for cementless joint replacements THA most common indications include: - 1. Pain (movement and rest) - 2. Functional limitations - 3. Loss of mobility - 4. Post-hip fracture (when risk of AVN is high) - 5. Radiographic indications of intra-articular disease  Patients are discharged from the hospital when they can: - Transfer in and out of a bed from standing - Rise from a chair to standing and sit from standing - Ambulate 100 ft independently - Ascend and descend stairs independently Assistive devices used to avoid dislocation for a posterior approach: - High toilet seat - A reacher or grabber - Abduction pillow - High seat chair Precautions Posterior/Posterolateral Approaches ROM - Avoid hip flexion > 90 deg adduction and internal rotation beyond neutral ADL - Use a raised toilet seat - using a shower chair in the bathtub - Sleep in a supine position with an abduction pillow; avoid sleeping or resting in a side-lying position Anterior/Anterolateral and Direct Lateral Approaches ROM - Avoid hip flexion > 90 deg - Avoid hip extension, adduction, and external rotation past neutral - Avoid the combined motion of hip flexion, abduction, and external rotation Transgluteal Approach (Trochanteric Osteotomy) ROM - Avoid hip adduction past neutral - No active, antigravity hip abduction for at least 6 to 8 weeks or until approved by the surgeon - No exercises that involve weight bearing on the operated leg Shoulder Force Couples Deltoid-rotator cuff - During elevation, the deltoid creates an upward and outward force on the humerus - The infraspinatus, subscapularis, and teres minor create a medial and inward force - Direct compression towards the glenoid fossa created by the supraspinatus - Pressure from the humeral head on the coracoacromial arch increases by 60% when the rotator cuff is not working properly  - Clinical implication: Increases stability during functional activities; Deltoid overpowering RC muscles can cause an excessive elevation of the humerus Upper and lower trapezius and serratus anterior Creates upward rotation of the scapula during elevation 4 crucial functions - 1. Rotation of scapula; maintains glenoid surface in optimal position - 2. Maintains length tension for deltoid - 3. Prevents impingement of the rotator cuff from subacromial structures - 4. Stable scapular base for scapulohumeral muscles - Clinical Implication: UT muscle often overpowers LT and Serratus muscles causing excessive elevation of shoulder girdle during overhead activities Anterior-posterior rotator cuff Subscapularis vs Infraspinatus and Teres minor - Provide a stable fulcrum to allow for rotation of the humeral head on the glenoid - These muscles are mostly active midrange of shoulder elevation - Depress and compress the humeral head into the glenoid - Many problems with force couple due to over-developed subscapularis (IR) vs infraspinatus and teres minor (ER) - Clinical implication: Often the subscapularis overpowers the infraspinatus and teres minor causing an anterior shift in the humerus and contributing to forward shoulder posture Motion and Scapulothoracic Joint Elevators Muscles - Upper trapezius (UT) - Levator scapulae - Rhomboids (assist) - Weakness and paralysis of the UT will cause a depressed and downward rotated scapula - Levator scapulae dysfunction occurs with forward head posture Scapulothoracic Depressors - Lower trapezius - Latissimus dorsi - Pectoralis minor - Subclavius - Latissimus dorsi and lower trapezius elevate the trunk when using crutches or FWW, sit to stand, and with transferring to a bed or wheelchair Upward rotators - First 30° of upward rotation- the upper and lower divisions of trapezius m. and serratus anterior m. - Signs of Weakness: scapular depression and downward rotation  Protractors - Serratus anterior - Signs of Weakness: winging of the medial border of the scapula with resistance to shoulder abduction, with a push-up, or eccentrically lowering the arm Downward rotators - Levator scapulae - Rhomboids - Pectoralis minor - Latissimus dorsi (assist) Retractors - Rhomboids - Middle trapezius - Upper and lower trapezius (assist) 3 Types of - Type I- prominence of the inferior medial border Scapular - Type II- entire medial border is protruding Dyskinesis - Type III- superior translation of the entire scapula and prominence of the superior medial border Glenohumeral General Exercise Progression Instability - During immobilization - Submaximal isometrics, rhythmic stabilization - PROM, AAROM - Core stability After sling removal (immobilization period) progress to: - Isotonic and resistive exercises - PNF - Prone scapular exercises - Plyometrics and eccentric exercises Adhesive Capsulitis Stiffness and pain in a shoulder from synovial inflammation and reactive fibrosis Primary/Idiopathic Adhesive Capsulitis - Mechanism: Chronic inflammation of the musculotendinous or synovial tissue. Condition Characteristics: - Ages 40-60 - Progressive and painful loss of PROM and AROM, especially ER - Pain eventually leaves and a stiff shoulder remains Secondary Adhesive Capsulitis: - Restriction of both AROM and PROM that occurs due to a previous pathology such as a systemic condition (diabetes, thyroid disease), intrinsic shoulder condition (previous RC tear/repair) or extrinsic condition (CVA, MI) 3 Phases:  - Freezing: A capsular pattern of motion. Lasts 10-36 weeks (3-9 months) - Frozen: Pain has resolved, but stiffness remains. There may be atrophy of surrounding muscle. Lasts 4-12 months (9-15 months) - Thawing: Slow steady recovery of lost ROM due to capsular remodeling. (15-24 months or greater) Dislocation Anterior and Anterior-inferior traumatic dislocations assoc. Injuries - Bankart Lesion: Avulsion of the anterior, inferior labrum from the glenoid rim. - Hill-Sachs Lesion: Compression fracture of the humeral head at the site where the humeral head impacted the inferior glenoid rim. Capsular Pattern ER>ABD>IR Total Shoulder AC Sprain - Types I- Injury w/o tearing - Type II- Incomplete - AC capsule and ligament are torn but no injury to coracoclavicular(CC) ligaments - Clavicle may sublux up to 50% - Type III- Complete rupture of AC and CC ligaments - Visual “step off deformity” due to depression of acromion - Types I-III and V- Inferior displacement of the acromion vs. the clavicle - Types III and IV- Involve a dislocation and a distal clavicle fracture (Type IV is posterior displacement of the clavicle). - Type VI- Clavicle is inferiorly displaced. Special test Neer Impingement test - The clinician forcibly elevates the patient’s arm into flexion “jamming” the greater tuberosity of the humerus into the anteroinferior border of the acromion. - +test: Pain/Reproduction of Sxs - *May indicate subacromial impingement Hawkins-Kennedy Impingement Test: - The clinician flexes the patient’s arm to 90o and then internally rotates the arm. This pushes the supraspinatus tendon against the coracoacromial ligament and coracoid process. - + test: Pt’s usual pain in or around AC joint region - *May indicate subacromial impingement Gerber Lift -off (Subscap lift-off) test:  - Patient IRs arm and places the hand over the back pocket (small of back if possible) and attempts to actively lift the back of the hand off the back. The clinician applies moderate force in an anterior direction, pushing the hand toward the spine. - + test: unable to lift the back the handoff of the back or patient unable to hold against resistance - *May indicate subscapularis tear Empty Can (Supraspinatus/Jobe) test: - Patient lifts arm in scaption to 90° elevation and internally rotates the arm (thumbs down). The therapist adds resistance to the arm in a downward direction. - + test: Weakness And/ or pain - *May indicate supraspinatus tendinopathy or tea Painful Arc test: - The patient is sitting or standing, and they abduct the arm as far as they can overhead. The therapist observes and the patient is to report any symptoms they feel throughout the arc. Observing for pt’s usual pain between 60°-120° of abduction. - +Test: Symptoms of catching or Pain within the arc - *May indicate subacromial impingement Drop Arm Test - The therapist abducts the patient’s shoulder to 90° and then asks the patient to actively, slowly lower the arm back to their side. - +Test: If the patient is unable to control the descent of the arm and/or has severe pain with performing this activity - *May indicate RTC(supraspinatus) tear Scapular Mobilization Diagnosis associated with surgery Elbow Open Pack Humeroulnar Joint - 70˚ flexion and 10˚ supination Humeroradial Joint - Full ext and Supination - Concave radial head + Convex distal humerus (capitellum) Proximal radio-ulnar joint - 70˚flexion and 35˚ of supination  - The proximal radioulnar joint formed by the convex radial head and the concave radial notch of the ulna Distal Radioulnar Joint - 10˚ supination - distal end of the convex ulna, concave radius, Diagnosis Bicipital Tendonosis - due to repetitive hyperextension of the elbow with pronation or repetitive flexion with stressful pronation-supination - Pain with palpation of the distal biceps belly, musculotendinous portion of the biceps, or bicipital insertion of the radial tuberosity - Pain with resisted elbow flexion and supination (pain with contraction) - Pain with passive shoulder and elbow extension (pain with stretch) Triceps Tendonosis - Due to repetitive extension - Tender to palpation over the distal triceps insertion. Increased pain and weakness with a triceps extension. - Focus on the shoulder, scapular strength, and closed chain exercises once appropriate Olecranon Bursitis - Caused by direct trauma or repetitive weight bearing or grazing of that area. Median nerve - Pronator teres - motor distal to pronator teres and sensory changes - Anterior interosseus n- -motor changes only (FPL, FDP) Ulnar nerve: - Cubital tunnel and/or between the heads of the FCU- weakness in FCU, FDP III and IV, and hypothenar muscles, sensory changes Radial Nerve: - Posterior interosseous nerve through arcade or canal of Frohse- can cause functional wrist drop, no sensory changes Different positions Biceps for the forearm to - supinating bias different flexors Brachioradialis - Pronating Brachialis - Neutral Medial/lateral Lateral Elbow Tendinopathy epicondylitis - Mechanism of injury- Overuse or trauma, repetitive grasping with elbow in extension  - Symptoms: Achiness, morning stiffness, dropping objects - Patient examination: Pain with palpation of the ECRB and ECRL, pain and weakness resisted wrist extension and radial deviation - Counterforce bracing- limits the expansion of the muscle and therefore decreases the contribution force proximal to the band Medial Elbow Tendinopathy - Mechanism of Injury: Forceful work or overuse of the flexor-pronator group. Eg. Tennis serve, baseball pitch, FOOSH (can be associated with a fracture of the radial head, olecranon, or medial humeral epicondyle - Patient Examination- Tenderness with placing the pronators and wrist flexors on stretch, grip strength testing What takes the most weight-bearing Hand Tunnel - Tunnel 3 - EPL - Tunnel 4 - extensor digitorum, extensor indicis Nerve Impingement Carpal Tunnel Syndrome - compression on median nerve Pronator Teres Syndrome: - Same symptoms as carpal tunnel plus forearm and volar wrist numbness Anterior Interosseous Syndrome - Purely motor loss; no sensory change - Innervates FPL, FDP (1 and 2) and pronator quadratus m. - No OK sign - Decreased pinch grip strength Tunnel of Guyon - Superficial to the flexor retinaculum between hook of hamate and pisiform bones, entrapment site for the ulnar n - Partial Claw hand (4th and 5th digits) De Quervain’s - The patient describes the gradual insidious onset of symptoms Tenosynovitis - Dull ache over the radial aspect of the wrist - Pain with turning doorknobs or keys - Swelling and tenderness in the region of the radial styloid process - Test: Finklestein test - Tuck thumb into a fist and ulnar deviate the wrist - + Test if reproduction of pain CMC - Distal Concave Radius and Ulna articulates with the TFCC- Convex articular surfaces of the scaphoid and lunate tendon gliding - Full extension of hand- MP an IP Joint extension - Hook fist- lumbrical extensibility and maximal differential gliding between FDP and FDS - Straight fist- maximum gliding of FDS tendon - Full composite fist- maximum gliding of FDP tendon Knee Ligament Medial Collateral Ligament - Special test: Valgus Stress Test Lateral Collateral Ligament - Special test: Varus Stress Test Anterior Crucial Ligament - Special Tests: Anterior drawer test, Lachman test, Pivot shift test Posterior Cruciate Ligament - Special Test: Posterior sag sign Q Angle Increases from - External tibial torsion - Internal rotation of the femur - Dynamic (functional) knee valgus - Wide pelvis Patella Increase due to: - Acuity of Q-angle - Angle of knee flexion - Location of patella contact - Surface area of contact Patella Compression - Superior: 90 deg - lateral: 135 deg - Inferior: 20 deg - Middle: 45 deg Joint Mobilizations - Patellar - The posterior glide of the tibia on the femur - The anterior glide of the tibia on femur - Distraction of tibiofemoral joint Gait Deviations Limited knee flexion:  - WA (Weight acceptance) and SLS (single limb stance): Decreases shock absorption, decreases forward momentum of the tibia, potential injury to posterior capsule of the knee (also true for hyperextension or extension thrust) - SLA (Swing limb advancement): Interferes with foot clearance (ISw), Decreased knee flexion in PSw usually creates decreased knee flexion in ISw, Increases energy cost - Knee hyperextension or extension thrust in SLA may assist in achieving maximum knee extension Excess Knee flexion (ie. not enough extension) - WA: Increased demand on the plantar flexors, quadriceps and hip flexors. Decreases limb stability (decreases ability to get to closed packed position) - SLA: Decreases step length of reference limb, Interferes with heel first contact Varus/Valgus - SLS: decreases limb stability, necessitates compensation proximal or distal to the knee, may result in knee pain Excess contralateral flexion: - SLA: relatively lengthens the reference swing limb and interferes with foot clearance and limb advancement Surgery Precaution Meniscus Tears Surgical Intervention - Partial menisectomy vs. a repair - Meniscus repair requires ~4-6 weeks non weight bearing (NWB) - ROM, strength and edema control are addressed first - CKC exercises are typically not introduced for 8 weeks Articular Cartilage Repair - Autologous chondrocyte implantation Ankle Open Pack - Talocrural: PF 10° - Subtalar: neutral between inversion and eversion Capsular-pattern - PF>DF, Subtalar Inv (varus)> Ev (valgus) Talocrural Most stable: max dorsiflexion Grades of Strain - Grade I- ATFL - Grade II- ATFL + CFL - Grade III- ATFL + CFL + PTFL High Ankle Sprain - forceful over dorsiflexion injury to the interosseous membrane Foot Diagnosis Flatfoot (pes planus) - Constant little or no longitudinal arch in weight bearing - Flexible flatfoot (15% of population): Arch can be recreated when person stands on their tip toes - Rigid flatfoot (rare): Calcaneus is in a valgus position, midtarsal region in pronation, displaced navicular (posterior) and talus faces medially and inferiorly Stiff Foot/high arch (pes cavus) - Characterized by a high arch, increased external rotation of the tibia, forefoot varus and an inability to pronate during the stance phase of gait - Loss of shock absorption ability - Creates increased pressure on the heel and the metatarsal heads Adult-acquired flatfoot deformity (AAFD) - Physiological and structural change that causes deformity in the foot that was structurally normal at one time - Mismatch between active and passive arch stabilizers is most likely the cause - Posterior tibial and spring-ligament complex and talo-calcaneal interosseous ligament Tendon Tear PTA Practice 2 Cardiopulmonary According to the Borg RPE scale, if a patient 15= hard (heavy) reports they feel the work is hard or heavy, that will equate it to what number?6-20 scale What are normal vital responses to - A decrease in HR greater than 20-30 exercise? bpm is an abnormal response. - First, the PTA should stop ambulating and sit the patient down. - Then re-assess vitals. - After the PTA should document this and report it to the supervising PT. What is respiratory failure caused by? It is caused by an impairment of gas exchange between the air and circulating blood. It can be due to reduced intrapulmonary gas  exchange or reduced movement of gases in and out of the lungs. Compromised flow rates are typically Obstructive lung diseases associated with which lung diseases? Compromised lung volumes and capacities Restrictive lung diseases are typically associated with which lung diseases? What is tested with an ABG test? Arterial blood gasses (ABGs) measure the partial pressures of PaO2, PaCO2, and bicarbonate HCO3 in arterial blood to determine if blood is too acidic or too alkaline. What is the most optimal V:Q ratio? Give an - Measures the movement of the volume example of what may cause the V:Q ratio to of air into and out of the lungs to be < 1. assess ventilation status - 1:1; V:Q < 1 likely d/t atelectasis, build up of secretions, trapped air - In general, a V:Q mismatch results in reduced gas exchange and limited respiratory function obstructive vs restrictive OBSTRUCTIVE - (COPD-emphysema, asthma, chronic bronchitis, CF, bronchiectasis) - Compromised flow rates - A common abnormal I:E ratio for someone with COPD is 1:4 or 1:5 (normal is 1:2) - Hyperinflation with barrel chest deformity - Rounded shoulders with tight pec muscles, kyphosis - Increased use of accessory breathing muscles (SCM and Scalenes) - Flattened diaphragm - Increased pulmonary artery pressure - Persistent cough and wheezing - Mucus build-up in airways resulting in airway clearance disorders RESTRICTIVE - (pneumothorax, PE, PNA, TB, ARDS, asbestosis, pulm edema from CHF, paralysis) - Compromised lung volumes and capacities  - Loss in compliance with lungs and chest wall - Impairment in lung expansion due to restrictions (i.e., tumor, scarring, fibrosis, respiratory muscle weakness, chest wall stiffness, structural abnormality) - Shallow rapid breathing pattern - Increase in WOB (work of breathing) - Significant hypoxemia - Rapid oxygen desaturation on exertion Airway Clearance and Breathing Strategies Manual techniques and Examples - Postural drainage with percussion and vibration - Assisted cough with compression in epigastric area above umbilicus, below xyphoid - Segmental breathing: utilized to improve localized chest expansion for patient s/p surgery and will be best for minimizing risk of atelectasis (collapsed lung) Mechanical Techniques - High-frequency chest wall oscillation vest - Postural drainage with percussion and vibration - Vibratory positive expiratory pressure Breathing strategies - Forced expiratory (huff) technique (FET) - Large inspiration followed by short expiratory efforts like fogging glasses - ACBT - Unsticking phase - Diaphragmatic (especially in people with COPD to improve the function of the diaphragm and decrease the use of accessory mm)/PLB - Positioning: Standing or seated with forward lean produces a significant increase in max inspiratory pressures which help to relieve the sensation of dyspnea and couple with PLB. Supine lying flat can make it more difficult to breathe for patients with dyspnea. What is IMT intervention and what type of Inspiratory muscle training patient is it commonly associated with? How is CHF classified? Systolic vs Diastolic; - Systolic – ischemic, - Systolic- non-ischemic List and describe the