Eval Final Exam

Purposes of MMT

Assist in determining/quantifying extend of muscle weakness/dysfunction

Assist in establishing:
-differential Diagnosis
-Goals
-Intervention Plan

Establish baseline to determine
-response to intervention
progression or deterioration of condition

Factors that affect strength (Person)

Age
- force production decrease with increase aging

Gender
-Men are typically stronger/bigger than women

35-40 years old --> start the decline of muscle

Factors that affect strength (physiologically)

Motor unit recruitment
-Motor unit --> alpha motor neuron and all muscle fibers it innervates
- increase frequency and # of motor units firing at the same time
- recruit larger MU's

Muscle size/type
-fiber arrangement
(fusiform -all fibers pulling in line of pull)
(pennate) - feather; pull is oblique to tendon

-cross sectional area- tension produced increases and size increases

Factors Affecting Strength (Position)

Joint position + angle of pull

Length-tension - max isometric tension at optimal sarcomere length
(when length of muscle is increases or decreased from optimal length --> tension produced decreases)

Moment arm of muscle: increased MA = increased Torque

Factors affecting strength (contraction)

eccentric >isometric> concentric

As speed increases in concentric force produced decreases

as speed increases in eccentric force production increases then plateaus

Passive insufficiency

Insufficient length of a 2 joint muscle to elongate over both joints at the same time

Active insufficiency

Decreased ability for a muscle to produce tension because of excess shortening over two joints

wrist flexion vs. wrist flexion and making a fist

MMT Position

Apply resistance at mid range

Patient position for MMT

Comfort/supportive surface
Expose area/associated areas
Start against gravity

Therapist position for MMT

Close to patient --> easier to generate force
Use body weight - GOOD BIOMECHANICS

Instructions/sequencing for MMT

Explain text, purpose, expectations (explain what and why of the test)
Patient actively moves through full ROM
Patient assumes test position --> then apply force

Joint position for MMT

One-Joint: end range
Two-Joint: mid range

Stabilization for MMT

Stabilize the proximal segment
Utilize table/body weight as able

Resistance for MMT

Apply at distal end of moving segment
Gradual buildup- hold- slow release
BREAK TEST
2-3 repetitions
Hold for 5 seconds

Documentation for MMT

1. Side/joint/motion(muscle group)
2. Report score out of total possibly (e.g. 3/5)

"MMT: (R) hip flexion 4/5; (L) elbow flexion(biceps): 5/5"

- Note position of the patient if they are not in the standardized position

"MMT: (R) knee extension: 3+/5 (tested supine with over 6" bolster)"

Grading for MMT (Full AROM against gravity)

3/5 (Fair)
- unable to hold against MINIMAL resistance, but can go through full active range of motion

3+/5 (Fair+)
- Full AROM; can hold very minimal resistance

4-/5 (Good-)
-Able to hold against minimal-moderate resistance

4/5 (Good)
-Able to hold against moderate resistance

4+/5 (Good+)
-Able to hold against moderate/almost maximal resistance

5/5 (Normal)
-Able to hold against maximum resistance

Grading for MMT (Can not complete full AROM against gravity)

2+/5 (Poor +)
- Full AROM in grav. minimized position with resistance or partial range in anti-gravity

2/5 (Poor)
- Full AROM in gravity minimized position

2-/5 (Poor-)
-Partial AROM in gravity minimized positon

1/5 (Trace)
-Palpable contraction but no visible movement

0/5 (Zero)
- No palpable contraction

MMT Limitations

Pain during testing
-CANNOT assign a grade
-Useful information for differential diagnosis

Doesn't assess all aspects of muscle strength
-Power
-Endurance
-Quality

A grade of 4/5 (Good) isn't always the best for function

Use with caution for patients with upper motor neuron lesions/disorders

Vital Signs

Useful for many aspects of evaluation and treatment
-provide info on physiological state
-reflect organ function (heart, lungs, vascular systems, etc)

Provide information and feedback for clinical judgement
- help determine diagnosis + prognosis
-identify plan or care (goals, outcomes, treatment selection)
-evaluate effectiveness of treatment in achieving outcomes

Normal vs Abnormal Vital Signs

Values may depend on individual and circumstances
- time of day
-patient state
- individual variation

Most useful when performed serially and periodically

Individual Variation for Vital signs

Some people have "abnormal" vital signs

factors affecting vitals:
-age
-gender
-people with chronic HTN
-chronic hyper- and hypothyroidism
-individuals taking meds

Normative vital signs - New Born

Temp (deg F): 98.6-99.8

Pulse (bpm): 100-140

Respiratory Rate (Brpm): 30-40

BP S/D (mmHg): 50-52 / 25-30

**higher values because smaller body**

Normative Vital Signs - 3 year old

Temp (deg F): 98.5 - 99.5

Pulse (bpm): 80-125

Respiratory Rate (Brpm): 20-30

BP S/D (mmHg): 78-114 / 46-78

Normative Vital Signs - 10 year old

Temp (deg F): 97.5-98.6

Pulse (bpm): 70-110

Respiratory Rate (Brpm): 16-22

BP S/D (mmHg): 90-120 / 56-84

Normative Vital Signs - 16 year old

Temp (deg F): 97.6-98.8

Pulse (bpm): 55-100

Respiratory Rate (Brpm): 15-20

BP S/D (mmHg): 104-120 / 60-84

Normative Vital Signs - Adult

Temp (deg F): 96.8-99.5

Pulse (bpm): 60-100

Respiratory Rate (Brpm): 12-18

BP S/D (mmHg): 95-119 / 60-79

Normative Vital Signs - Older Adult

Temp (deg F): 96.5-97.5

Pulse (bpm): 60-100

Respiratory Rate (Brpm): 15-25

BP S/D (mmHg): 90-140 / 60-90

Vital signs changing with Age

Pulse gradually decreases until ~ 16 years old
increases and levels out to adult and older adult

Respiratory rate gradually decreases from New born to adult, increases in older adult

BP gradually increases until ~ 16 years old(peak at puberty) decreases going to adult and Increases to older adult

Makes sense why they all increase in older adult --> vessels aren't as compliant:(
Pulse increases
RR increases
BP increases

Patient observation for Vital Signs

Signs of distress
Nutritional Status (obese, malnutrition)
Skin/appendage color and appearance
Diaphoresis (excessive sweating - may indicate hypotension)
Posture

Pulse for vital signs

Pulse rate= measures peripheral arterial wave propagation generated by hearts contraction

Pressure wave of blood in the peripheral arteries
Systole: highest point of arterial pressure
Diastole: lowest point in arterial pressure

Pulse is palpable on any superficial artery over a bony prominence

Factors affecting pulse for vital signs

Age:
Fetal: 120-160 bpm
New born: 100-140
Adult(Normal): 60-100

Gender: Male
Emotion: grief, fear, anxiety, and pain increase pulse rate (White coat syndrome)

Systemic or local heat:
-fever increases pulse rate
-hot packs, diathermy, warm whirlpool increase pulse rate

Exercise and Heart Rate - Vital Signs

True Heart rate: requires auscultation or ECG recording of electrical impulses of the heart

There is a linear relationship between HR and Exercise intensity (as intensity increases, HR increases)

HR during exercise is a good indicator of a persons physiological response to stress --> level of fitness can effect HR

**** HR/Pulse rate should be routinely monitored in ALL patients with cardiovascular disorders

Procedure for taking Vital Signs

1. Wash Hands
2. Assemble equipment: clock or watch
3. Explain to patient what you're about to do (What and why)
4. Select location:Left radial pulse is optimal
5. Place first 2-3 fingers over site
-apply firm, but not excessive pressure

How to count Pulse Rate

Count pulse for 30 seconds and multiply by 2
- If irregularities noticed --> recount for full 60 seconds

Note the rhythm and volume/quality of pulse
Record results

Factors Affecting Respiration

Metabolic state: fever, hyperthyroidism, burn, infection increase demands for oxygen = increase RR

Age:
Gradual decrease in RR
Increase TV with age up through 5th-6th decade, then RR increase and TV decreases

Body size, stature, adiposity

Gender: Males have a lower RR and higher TV compared to females

Assessment of Respiration - Vital Signs

Respiratory Rate (RR): #breaths/min

Count # of inspirations OR expirations for 30 seconds, multiply by 2
-if irregularities show, recount for full 60 seconds

Depth: observe chest movement
Rhythm: regularity of respirations
Character: normally respiration is quite and effortless

Procedure for Respiration - Vital Signs

1. Explain procedure to patient (what and why)
2. Expose chest is possible
3. Observe depth, rhythm, character and pattern
4. Record results

Blood Pressure - Vital Signs

BP: force blood exerts against vascular walls

Systolic Pressure: BP at time of contraction of left ventricle

Diastolic Pressure: BP at time of rest period of the heart

Factors affecting BP (Physiological) - Vital Signs

Blood Volume - hemorrhage decreases BP
Diameter and Elasticity of arteries
Cardiac Output: increase CO = increase Sys + Dia BP
HR/Pulse rate: lower rate typical results in lower BP

Factors affecting BP (Physical) - Vital Signs

Exercise: SBP linear with exercise; DBP remains constant or slightly decreased

Age: BP rises gradually with age, peaking at puberty; typically levels off

Arm position: up to +/- 20mmHg due to different arm position


**For consistency: check BP with L arm at heart level

Measuring BP - Vital Signs

Listen carefully to korotkoff's sounds
Phase 1: first clear, paint rhythmic tapping, gradually rises in intensity (point at which blood flows through artery)
Phase 2: -4 ....
Phase 5: Sound disappears- second diastolic BP

Proper recording of BP, Pulse and RR - Vital Signs

Examples

"BP at rest, sitting, L UE = 120/80mmHg"

"Pulse at rest, sitting L UE = 60bpm"

"RR at rest, sitting = 16 Brpm"

Blood pressure categories - Vital Signs

Normal
Elevated
Stage I HTN
Stage II HTN

Normal Blood Pressure

Less than 120/80 mmHg

Elevated Blood Pressure

Systolic: between 120-129 mmHg

*******AND*******

Diastolic: less than 80 mmHg

Stage I HTN

Systolic: between 130-139 mmHg

********OR*******

Diastolic: between 80-90mmHg

If Stage I or II HTN detected
-recheck in 5-10 min
-tell patient findings
-inform primary caregiver


OR in both Stage I and Stage II HTN

Stage II HTN

Systolic: at least 140

********OR*******

Diastolic: at least 90 mmHg

If Stage I or II HTN detected
-recheck in 5-10 min
-tell patient findings
-inform primary caregiver

OR in both Stage I and Stage II HTN

Hypertensive Crisis

Systolic: over 190

********AND/OR******

Diastolic over 120 mmHg

recheck after 5-10 minutes
-if still very high --> patient needs immediate medical attention

Summary: "Normal" values for adults

BP: less than 120/80 mmHg
Pulse Rate: 60 bpm
RR: 12-18 breaths per minute

What is Goniometry used to measure

Active and passive arc of motion
Abnormal fixed position of joint
Muscle length

Purposes of taking Goni measurements

1. Determine presense or absence of dysfunction
2. Documentation of impairment
3. Differential diagnosis
4. Evaluate progress or lack there of
5. Motivate client
6. Baseline for development of specific intervention plans
7. Research - effectiveness of specific therapeutic techniques
8. Fabrication of orthoses + adaptive equipment

Athrokinematics

Movement of joint surfaces
Glides, Spins and Rolls
Occur in combinations (Roll + Glide)
Results in movement of shafts of the bones

Osteokinematics

Movement of the shaft of the bones
Goni measures OSTEOkinematic motion

Sagittal Plane

Divides body into left and right
Movement in Frontal Plane
Flexion and Extension

Frontal Plane

Divides body into front and back
Movement in Sagittal Plane
Abduction and Adduction

Transverse Plane

Divides body into top and bottom
Movement in longitudinal axis
Rotation

Degrees of Freedom

1 degree of freedom: motion in only one plane
E.g.: humeroulnar joint, interphalangeal joint

movements in multiple planes = more degrees of freedom
E.g.: Radiocarpal (2): F/E; radial and ulnar deviation
E.g.: Shoulder (3): F/E; ABD/ADD; internal and external rotation

AROM

Unassisted Voluntary Movement

Pain with AROM
-contractile tissue (contracting or stretching)
-Non-contractile tissue(stretching or pinching)

PROM

PT is doing the motion
Typically greater than AROM

Pain with PROM
-Non-contractile (moving, stretching, or pinching)
-Contractile(Stretching at end ranges)

End-Feel

Performed Passively
Stops movement at end range

Helps identify limiting structures (if patient is having pain, then the end feel may be painful)

Types of End Feels

Hard: Bone-Bone
Firm: Capsule, ligament, muscle
Soft: soft tissue approximation

Abnormal Types of End Feels: Spasm

Muscle contraction stops movement

Abnormal Types of End Feels: Boggy

"Mushy" - it is expected to be firm but is "Mushy" due to some swelling

Abnormal Types of End Feels: Springy

"Rubbery" - likely seen with meniscus tear at the knee

Abnormal Types of End Feels: Empty

No resistance - NO endfeel; patent won't let you go through ROM

Abnormal Types of End Feels: Bony Block

No give; unexpected point in ROM

Abnormal Types of End Feels: Capsular/ firm

Leathery; unexpected point in ROM - if too early = abnormal

Abnormal Types of End Feels: Laxity

Excessive motion; will have endfeel but there more motion than needed

Interpretation ROM Findings: Full AROM, Full PROM

ROM is Normal, probably okay

Interpretation ROM Findings: Limited AROM, Full PROM

May be contractile, continue with testing

Interpretation ROM Findings: Limited AROM, Limited PROM

Capsule, ligament, muscle - can't rule much out

Goniometric Sequnce

AROM
PROM
End-Feel

Measure AROM, PROM or both with Goni depending on what is deficient

Assessing Flexibility with Goniometer

Performed of 2+ joint muscles
Performed PASSIVELY
Sequence of A/P/End-feel not needed - would have been done on joints involved during ROM assessment
Normal joint ROM is necessary to fully lengthen muscle
NO starting position measurement

Documentation of Goniometric Measurements

Side
Joint tested
Type of Motion (AROM or PROM)
Direction of Motion
Start and End degrees of ROM (End degrees only for muscle length)
End Feel (PROM only)
Reproduction or symptoms


E.G.:

(R) Shoulder AROM Flexion 0-175 deg, No Pain
(L) Knee AROM Flexion 15-80 deg, anterior pain at end range flexion
(L) Ankle PROM DF 0-10 deg firm end-feel, no pain
(L) Gastroc Muscle length 3 deg. of DF
(R) elbor AROM Flexion 5-0-140 deg., no pain

Potential errors for Goni measurements

Position of Patient
Effort of patient with AROM
Pressure provided by PT with PROM
Alignment of goniometer
Joint characteristics - DOF = more potential for error
Stabilization

Contractile Tissue

Contractile Unit: ability to contract or is attached to a tissue that's able to contract

Tissue is loaded by stretch (Tensile) forces or muscle force production

Examples: Muscle belly, tendon, bony insertion

Inert Tissue

No ability to contract

Example: joint capsule, ligament, fascia, blood vessels, articular cartilage, bone, meniscus, and "bursa"

Interpretation of Inert tissue Patterns

PROM full and no pain
-no lesion

Pain and limitation in majority of directions
- capsular lesion

Pain and limited or excessive motion in one (or two) directions
-ligaments, joint lesions

Limited movement, may be pain free
bone-bone OA

Purpose of Resisted testing

Load "contractile" tissue without loading non-contractile tissue

Position: Mid Range
MAKE TEST

Interpretation of Resisted Testing

Strong and Painless
-normal contractile tissue

Strong and Painful
-minor contractile lesion

Weak and Painful
-moderate or major contractile lesion

Weak and painless
-total rupture

Purpose of Selective Tissue examination

1. identify type of tissue (contractile/inert)
2. Contribute to generating prognosis
3. contribute to decision-making regarding tolerance to examination and intervention procedures

Purpose of Problem list

1. Organize information gathered from examinatin
2. Contribute to determining diagnosis and prognosis
3. Prioritize impairments --> development of goals and intervention plan

Problem List Identification

History (gives hints to ones below)
System Reviews
Tests/measures

Impairments included in Problem List

Within PT scope of Practice
impairments/problems written as deficits (what is NOT working properly)
Be relatively specific (category, side, joint, NO measurements)
Link problems to functional limitations

Prioritization guidelines

- #1 most significant impact on condition (if I can only do ONE thing, what can I do to help the most)
- Highest priority related to functional limitations/disability
- Minor problems have less functional impact
- Pain is typically not highest priority - if focusing on underlying causes of pain, it will decrease their pain
- typically will see multiple impairments per diagnosis

If present, what should be top of the prioritized problem list

Edema/swelling/inflammation

if we can control the swelling, we can get to the problem

Posture is a high second typically

Key Characteristics: Strength Screen tests

Screen general function (rarely use, unless straight out of surgery, etc)

Purpose: do they have the strength to participate
Hold Time: 5 Seconds
Position(s): of convenience (laying, short sitting)
MAKE test

UE can test bilaterally
LE harder to test bilaterally, resort to unilaterally

Key Characteristics: Resisted Testing

Selective Tissue Testing (90% of outpatient patient screenings)

Purpose: stress contractile tissue without stressing non-contractile tissue
Hold time: 5 seconds
Position(s): mid joint range --> minimizes stress on joint capsules, ligaments and tendons
MAKE test

Not bilaterally --> need stabilization

Key Characteristics: Manual Muscle Testing

Purpose: quantify strength of a muscle(s)
Hold time: 5 seconds of MAX force
Position(s): against gravity
(grade 3 full range against gravity)
BREAK test (only one)

2 repetitions for good measure

Key Characteristics: Neurologic Screening Muscle Performances: Nerve Root Test

Myotomes!

Purpose: testing the muscles supplies by ONE specific nerve root
Hold Time: 10 Seconds --> looking for fading
Position(s): of convenience --> most likely short-sitting + looking forward
MAKE test

PROXIMAL TO DISTAL

Unilaterally --> compare 1-1 directly
measure C5 L shoulder abduction --> measure C5 R shoulder abduction
... then move on to C6, each side, C7 each side etc.
2 above + 2 below

Key Characteristics: Neurologic Screening Muscle Performance: Peripheral Nerve

Purpose: Testing muscles supplied by peripheral nerves
Hold Time: 10 Seconds --> fundamental function
Position(s): Most often MMT position (doesn't have to be against gravity)
MAKE test

PROXIMAL TO DISTAL

Unilaterally --> compare 1-1 directly
Compare axillary on L and then right, move onto musculocutaneous on L then right

When to do a Neurological Screening examination

-Radiating pain
-History of Stoke
-Numbness and Tingling
-Parkinsons
-Unexplained Muscle Atrophy
diabetes
-Spinal Cord Injuries
-Discs on nerves
-Injuries to peripheral nerves (carpal tunnel)
-Burns

Components of Neuro Screen: Sensory examination

Dermatomes
Peripheral nerve distributions

Other distributions:
-Diabetic neuropathy
-central nervous system lesion

Components of Neuro Screen: Muscle Performance

Myotomes
-very similar to gross muscle testing

Components of Neuro Screen: Reflexes

Testing Afferent and Efferent pathways to the brain

Upper Motor Neuron Lesion (UMNL)

Damage to corticospinal or pyramidal tract in brain or spinal cord

Can result in: hemiplegia, paraplegia, quadriplegia

Signs of Upper Motor Neuron Lesion (UMNL)

Loss in voluntary movement, Muscle spasms(spasticity), Sensory loss, hyperreflexia, hyporeflexia, and pathological reflexes (bouncing )

Lower Motor Neuron Lesion (LMNL)

Injury to anterior horn cells, nerve root cells, or PNS

Signs of Lower Motor Neuron Lesion (LMNL)

Diminished reflexes
Weakness or flaccid paralysis
Atrophy

Dermatomes

Sensory distribution of a single nerve root