Outcome measures/ special scales

Ottawa knee rules

• A knee x-ray is indicated if there is pain over the patella or fibular head with any of these findings

  • Pt. is >/= 55 y/o

  • Isolated tenderness of the patella

  • Tenderness at the head of the fibula

  • Inability to flex the knee to 90 degrees

  • Inability to WB for at least 4 steps both immediately after injury and at the time of the eval

Ottawa Ankle rules

• An ankle x-ray should be performed if there is pain in the malleolar region with any of the following

  • Bone tenderness at the posterior edge of the distal 6 cm or the tip of the lateral malleolus

  • Bone tenderness at the posterior edge of the distal 6 cm or the tip of the medial malleolus

  • Inability w/ weight bearing for at least 4 steps both immediately after injury and at time of eval

Ottawa Ankle rules: foot

• A foot x-ray should be performed if there is pain in the midfoot region with any one of the following

  • Bone tenderness at the navicular bone

  • Bone tenderness at the base of the 5th metatarsal

  • Inability with WB for at least 4 steps, both immediately after injury and at time of eval

Ranchos Los Amigos (RLA) levels → First 3 R = response

• 1 → No Response- Coma

• 2 → Generalized Response- non-purposeful, whole body, vocal, inconsistent

• 3 → Local Response- Purposeful, local, and specific, inconsistent

  • Follows simple commands: close/ open eyes, squeeze hand

Ranchos Los Amigos (RLA) levels → Next 3 (RCA) C= confused

• 4 → Confused and Agitated

  • Behavior: heightened activity, aggressive, confabulation, does not cooperate, verbalizes, but is incoherent → Establish routine, do not confront (closed environment), orient patient, give options

  • Attention: non-selective

  • Memory: no short-term or long-term

• 5 → Confused Inappropriate

  • Behavior: responds consistently to simple commands, responds inconsistently to complex commands, with structure able to socialize for short periods

  • Memory: impaired, inappropriate use of objects → can’t learn new task

• 6 → Confused Appropriate

  • Behavior: follows simple instructions consistently, goal-oriented behavior with external input

  • Memory: carryover of previous skills present (self- care)

Ranchos Los Amigos (RLA) levels → Next 2 (RCA) A= Appropriate

• 7 → Automatic Appropriate

  • Oriented in home/ hospital

  • Daily routine- automatic but robot-like

  • Judgment impaired

  • Able to initiate social or recreational activity w/ structure

• 8 → Purposeful Appropriate

  • Carryover of new skills present

  • Impaired judgment in an emergency situation, abstract reasoning, and reduced tolerance for stress

Brunnstrom stages of stroke recovery

• Stage 1: Flaccidity (cerebral shock)

  • No active limb movement

• Stage 2: beginning of minimal voluntary mvmt

  • in synergy, with associated reactions

  • increase tone

• Stage 3: voluntary control of mvmt synergy (spasticity at peak)

  • Further increase tone to peak level

• Stage 4: movement outside of synergy

  • Decrease tone

• Stage 5: increase complex mvmt, greater independence from limb synergies

• Stage 6: Individual joint movement, coordinated mvmt

• Stage 7: Normal fxn

MMT Grading

• 0 → no contraction

• 1 → Palpable contraction

• 1+ → Gravity eliminated < 50% ROM

• 2- → Gravity eliminated, 50% ROM

• 2 → Gravity eliminated, full ROM

• 2+ → Gravity eliminated, full ROM, minimal resistance

• 3- → Gravity, 50% ROM no resistance

• 3 → Gravity, full ROM

• 3+ → Gravity, full ROM, slight resistance

• 4- → Gravity, full ROM, nearly moderate resistance

• 4 → Gravity, full ROM, moderate resistance

• 4+ → Gravity, full ROM, nearly full resistance

• 5 → Gravity, full ROM, full resistance

DTR- reflex grading

• 0- Absent

• 1+ Decreased

• 2+ normal

• 3+ Hyperactive

• 4+ Hyperactive with clonus

Modified Ashworth Scale

• 0: no increase in muscle tone

• 1: slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the motion when the affected parts are moved in extension (catch and release)

• 1+: slight increase in muscle tone, manifested by catch, followed by minimal resistance throughout (less than half) of ROM (does not fully go away)

• 2: more marked increase in muscle tone through most of ROM, but affected portion is easily moved

• 3: Considerable increase in muscle tone, passive movement difficult

• 4: Affected parts rigid in flexion or extension

ABI Range

• > 1.2- falsely elevated, arterial disease, diabetes

• 1.19-.95- normal

• .94-.75- mild arterial disease, intermittent claudication

• .74-.5- moderate arterial disease, rest pain

• <.5- severe arterial disease

UE Myotomes

• C1/C2: cervical flexion

• C3: Cervical side flexion

• C4: scapular elevation

• C5: shoulder abduction

• C6: elbow flexion and wrist extension

• C7: elbow extension and wrist flexion

• C8: Thumb extension

• T1: finger abduction

LE Myotomes

• L1/2: Hip Flexion

• L3: Knee extension

• L4: Ankle dorsiflexion

• L5: Big toe extension

• S1: Ankle eversion and plantar flexion, hip extension

• S2: Knee flexion

• S3: No specific test action; intrinsic foot m. accept abductor hallucis

Reflexes: main spinal nerve root involved

• Biceps: C5-6

• Brachioradialis: C5-6

• Triceps: C7-8

• Patellar: L2-4

• Achilles tendon: S1-2

• Hamstrings: L5-S2

Hoehn and Yahr scale- PD

• 0: no visible s/s of PD

• 1: s/s on only one side

• 2: s/s on both sides of body and no difficulty walking

• 3: s/s on both sides of body and minimal walking difficulty

  • begin to fall more often

• 4: s/s on both sides of body and moderate difficulty walking

  • Start using assistive devices

• 5: s/s on both sides of body and unable to walk

Glasgow Coma Scale (GCS)

• Best eye response

  • Open spontaneously: 4

  • Open to verbal command: 3

  • Open to pain: 2

  • No eye opening: 1

• Best verbal response

  • Oriented: 5

  • Confused, but able to answer question: 4

  • Inappropriate words: 3

  • Incomprehensible sounds: 2

  • No verbal response: 1

• Best motor response

  • Obeys commands: 6

  • localizes pain: 5

  • Withdrawal from pain: 4

  • Flexion to pain: 3

  • Extension to pain: 2

  • No motor response: 1

• 13 to 15: Mild TBI

• 9 to 12: Moderate TBI.

• 3 to 8: Severe TBI.

APGAR

• Appearance

  • 0: cyanotic/ pale all over

  • 1: peripheral cyanosis only

  • 2: pink

• Pulse (HR)

  • 0: 0

  • 1: <100

  • 2: >100-140

• Grimace (reflex irritability)

  • 0: no response to stimulation

  • 1: Grimace or weak cry when stimulated

  • 2: cry when stimulated

• Active (tone)

  • 0: floppy

  • 1: some flexion

  • 2: well flexed and resisting extension

• Respiration

  • 0: Apnea

  • 1: Slow, irregular breathing

  • 2: strong cry

• Cutoffs

  • 7-10 normal

  • 4-6 moderately abnormal

  • 0-3 immediate resuscitation

FITT

• Frequency

• Intensity

• Time

• Type

Intensity classification VO2 and HR Max

• Light: 30-39% VO2 → 40-49% HR Max

• Moderate: 40-59 VO2 → 50-69% HR Max

• Vigorous: 60% and higher → 70% or higher HR Max

FITT principle and exercise prescription- Weight reduction guidelines for obesity

• Minimum 250-300 min/ week required

• Frequently: > 5 days per week to maximize caloric expenditure

• Intensity: initially moderate 40-60% VO2, progression to > 60%

• Time from 45-60 min/ day

• Type: moderate exercise- Aerobic, resistance and flexibility exercise

FITT Principle and Exercise Prescription- Diabetic/ obesity

• Frequency: 3-7x/ week

• Intensity: Moderate (RPE 11-13)

• Time: 150-300 min/ week

  • 60-90 min session for metabolic syndrome/obesity

• Type: Aerobic, large muscle group activation, resistance training

FITT Principle and Exercise Prescription- Elderly

• Frequency: 5x/ week, 3x/ week

• Intensity: moderate, vigorous

• Time: 30-60 min/ day (150-300 min/week), 20-30 min/ day 75-100 min/week

• Type: aerobic (avoid excessive orthopedic stress), strength training, WBing calisthenics

FITT Principle and Exercise Prescription- Pregnant

• Frequency: 3-4x/ week

• Intensity: Light- moderate

• Time: aprox. 30 min/ day, 120- 150 min/ week

• Type: dynamic, rhythmic activity using large muscle groups

FITT Principle and Exercise Prescription- Cancer

• Frequency: 3-5x/ week

• Intensity: Moderate (RPE 12-13)

• Time: 150 min/ week

• Type: Aerobic, strength, training, flexibility

DVT and pulmonary embolism- Wells criteria

• Previously diagnosed DVT

• Active cancer (w/in 6 months of Dx or receiving palliative care)

• Paralysis, paresis, or recent immobilization of lower extremity

• Bedridden for more than 3 days or major surgery w/in the previous 12 weeks

• Localized tenderness in the center of the posterior calf, popliteal space, or along the femoral vein in the anterior thigh/ groin

• Entire lower extremity swelling

• unilateral calf swelling ( more than 3cm larger than uninvolved side)

• Unilateral pitting edema

• collateral superficial veins (non- varicose)

• Alternative Dx is as likely (or more likely) than DVT → Subtract 2

• Key:

  • > or = to 2 = DVT likely

  • <2 = DVT unlikely

Sensory Organization Test (SOT)

• 6 tests of varying sensory input

  • 1- normal vision, fixed surface

  • 2- E/C, fixed surface (tests somatosensory & vestibular; vision absent)

  • 3-Sway-referenced vision, fixed surface (tests somatosensory & vestibular; vision distorted)

  • 4- normal vision, sway-referenced surface (tests vision & vestibular; somatosensory distorted)

  • 5- E/C, sway-referenced surface (isolates the vestibular system)

  • 6- Sway- referenced vision, sway-referenced surface (isolates vestibular system, vision is inaccurate)

• Dependent on vision- 2,3,5,6

• Dependent on somatosensation- 4,5,6

• Experiencing vestibular weakness or loss- 5,6

Motor learning- all stages

• Cognitive stage

• Associated stage

• Autonomous stage

Motor learning- Cognitive stage

• What to do decision

• Extrinsic feedback more than intrinsic

• Feedback after every trial

• “trial and error” practice initially caused uneven performance w/ frequent errors

• Patient relies more on visual cues

• Use blocked practice to improve performance

• Use distributed practice if task is complex, long, or energy costly or if learner fatigues easily, has short attention, or poor concentration

• Use mental practice to improve performance and leaning, reduce anxiety

• Reduce extraneous environmental stimuli, distractors to ensure attention

Motor learning- Associated stage

• How to do decision

• Intrinsic feedback

• Variable practice

• Feedback- summed, bandwidth, fading

• As performance improves, there is greater consistency and fewer errors and extraneous movements

• Proprioceptive cues becomes increasingly important and dependance on visual cues decrease

• Variable practice order- serial or random (improve retention)

• Avoid extensive augmented feedback

• Progress toward open, changing environment

Motor learning- Autonomous stage

• How to succeed

• Movements are largely error-free with little interference from environmental distractions

• Random practice for retention

• Massed practice is appropriate

• Provide occasional feedback (KP, KR) when errors evident

• Ready learner for home, community, work environments

Types of prevention

• Primary prevention- prevent disease before it occurs in healthy individuals, reduce risk factors, and increase immunity

• Secondary prevention- Early detection and treatment in subclinical stages. This does not prevent the coordination but may decrease duration or severity of disease and thereby improve the outcomes, including improved quality of life

• Tertiary prevention- Reduce disease impact and manage symptoms in diagnosed patients. Rehabilitation and management of existing conditions to prevent complications

GMFCS Scale

• Level 1: patient will walk without restrictions but will have limitations in more advanced gross motor skills

• Level 2: Patient will walk without AD with limitations in walking outdoors and in the community

• Level 3: Patient will walk with AD with limitations in walking outdoors and in the community

  • AD > W/C

• Level 4” patient self mobility will be severely limited; children are transported or use power mobility outdoors and in the community

  • W/C > AD

• Level 5: Patient self mobility will be severely limited, even with the use of assistive technology, and requires caregiver

Pediatric Evaluation of Disability- PEDI

• Children 6 months to 7.5 years

• Three domains: self care, mobility, social function

• Also rates level of caregiver assistance/ equipment needed

• Normal score is 50 ± 10 points, compared to age matched peers

Functional Independence Measure for Children (WeeFIM)

• Children 6 months to 7 years

• Adaptation of FIM scores, rating level of assistance from 1 (total assistance) to 7 complete independence)

• Three domains: Self care, mobility, cognition

• Mean score varies from 18-120 dependent upon age

Mckenzie method

• prone position with pillow under hips

• Prone position (no pillows)

• Prone on elbows

• Prone press up

• Standing

William flexion progression series- TX for spinal stenosis

• PPT

• Single knee to chest

• double knee to chest

• partial sit up

• hamstring stretch (long sit)

• Hip flexor stretch (lunge bow position)

• Squat (in slight lumbar flexion)

Low back manipulation

• If patient socres >/= 4/5

  • Duration of s/s of < 16 days

  • No symptoms distal to the knee

  • lumbar hypomobility

  • at least 1 hip with > 35 degrees of IR

  • Fear avoidance beliefs questionnaire-work subscale (FABQ-W) score of < 19

Functional Independence Measure (FIM)

• 1 → Total assistance (pt. performs less than 25% of the effort)

• 2 → Maximal assistance (pt. performs 25-49 % of the effort)

• 3 → Moderate assistance (pt. performs 50-74% of the effort)

• 4 → minimal assistance (pt. performs >75% effort)

• 5 → supervision (pt. requires verbal cues, set up or stand by)

• 6 → modified independent (pt. requires assistive or adaptive device)

• 7 → independent

PNF- initial mobility ROM

• Contract relax

• Hold relax

• Hold relax active movement

• Joint distraction

• Repeated contraction

PNF- initial mobility trunk

• rhythmic initiation

• rhythmic rotation

• rhythmic stabilization

PNF- stability

• rhythmic stabilization

• alternating isometrics

• Slow reversals

• slow reversal holds

PNF- controlled mobility

• Slow reversal

• Slow reversal hold

• Agonistic reversals

PNF- Skill

• Agonistic reversals

• Normal timing

• Resisted progression

• Slow reversals

• Slow reversal holds

• Timing for emphasis

Berg balance

• Assess risk of falling

• 14 tasks 0-4

• Every day living tasks, static, dynamic balance and transitional mvmts

• Max score 56

• < 45 indicates increased risk for falling

Fugl-Meyer assessment of physical performance (FMA)

• Assess balance specifically for pt. w/ hemiplegia

• 7 items scored from 0-2

• cumm. score 226 with specific subset scores

Functional reach test

• assess standing balance and risk of falling

• Max distance one can reach forward beyond arms length

• Age related standard measurements

  • 20-40→ M: 16.7, W: 14.6

  • 41-69→ M:14.9, W: 13.8

  • 70-87 → M: 13.2, W: 10.5

• Pt. struggles to reach app. distance, increased fall risk

Romberg Test

• Standing, feet together, upper extremities folded, looking at a fixed point straight ahead with eyes open. With eyes open/ eyes closed.

Timed up and Go

• assess mobility and balance

• Pt. sits on supported chair, transfers, walks 10 ft., then turns walks back, return to sitting position

• Healthy adults: < 10 seconds

• Community ambulatory elderly: < 13.5

• Frail elderly: 11-20 seconds

  • Scores > 30 indicative of impaired func mobility

Tinetti Performance Oriented Mobility Assessment

• assess increased fall risk

• STS, STS w/o UE, immediate standing balance with E/O, E/C, standing w/ perturbation, turning 360 degrees

• Full score: 28

• > 24- low fall risk

• 19-24: moderate risk

• <19: high risk

Salter- Harris- Fx Classification

• Type 1- Entire epiphysis

• Type 2- Entire epiphysis and portion of the metaphysis

• Type 3- Portion of the epiphysis

• Type 4- Portion of the epiphysis and portion of the metaphysis

• Type 5- Nothing broken off, compression injury of the epiphyseal plate

Oswestry Disability index

• information on back pain and how it has affected the ability to manage everyday life

• 10 questions rated 0-5

• lower score = lower disability

  • 0-20: minimal disability

  • 21-40: moderate disability

  • 41-60: severe disability

  • 61-80: crippled

  • 80-100: bed bound

Neck disability index (NDI)

• items related to ADL, Pain, and concentration

• 10 items rated 0-5

• lower score = lower disability

  • 0-4: no disability

  • 5-14: mild disability

  • 15-24: moderate disability

  • 25-35: severe disability

  • Over 34: complete disability

Angina scale

• 0: no angina

• 1: Mild, barely noticeable

• 2: moderate, bothersome

• 3: moderately severe, very uncomfortable

• 4: most severe or intense pain ever experienced

Grading scale for pulse strength

• 0: absent, not palpable

• 1+: Pulse diminished, barely palpable

• 2+: Easily palpable, normal

• 3+: Full pulse, increased strength

• 4+: bounding, too strong to obliterate

Edema/ pitting scale

• 1+: indentation is barley detectable

• 2+: Slight indentation visible when skin is depressed, returns to normal in 15 seconds

• 3+: Deeper indentation occurs when pressed and returns to normal w/in 30 seconds

• 4+: Indentation lasts for more than 30 seconds

Intermittent Claudication Scale

• Grade 1: Definite discomfort or pain, but only at initial or modest levels

• Grade 2: Moderate discomfort or pain from which the patient’s attention can be diverted

• Grade 3: Intense pain from which the patient’s attention cannot be diverted

• Grade 4: Excruciating and unbearable pain

Classification of Heart failure- NY heart Association

• Class 1: mild HF → no limitation in physical activity up to 6.5 METs, comfortable at rest, ordinary activity does not cause undue fatigue, palpitations, dyspnea, or anginal pain

• Class 2: slight HF → Slight limitation in physical activity, up to 4.5 METs, comfortable at rest, ordinary physical activity results in fatigue, palpitations, dyspnea, or anginal pain

• Class 3: moderate HF → Marked limitation of physical activity, up to 3 METs, comfortable at rest, less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain

• Class 4: severe HF → Unable to carry out any physical activity, 1.5 METs without discomfort, s/s of ischemia, dyspnea, anginal pain present at rest, increasing with exercises

Classification of Heart Failure- American College of cardiology foundation/ American heart association

• Stage A: At high risk for HF but w/o structural heart disease or s/s of HF

• Stage B: Structural heart disease but w/o s/s of HF

• Stage C: Structural heart disease w/ prior or current s/s of HF

• Stage D: Refractory HF requiring specialized interventions

BMI

• Underweight: <18.5

• Normal: 18.5- 24.9

• Overweight: 25-29.9

• Obese: 30-40

• Extreme Obesity: >40

Wagner Grading system for diabetic ulcers

• Grade 0: No open ulceration, possible existence of bone deformation of hyperkeratosis

• Grade 1: superficial ulcer w/o subcutaneous tissue involvement

• Grade 2: Penetration through the subcutaneous tissue, may expose bone, tendon, ligament, or joint capsule

• Grade 3: Osteitis, abscess, or osteomyelitis

• Grade 4: Gangrene of digit

• Grade 5: Gangrene of foot requiring disarticulation

Bun

• 10-20

Creatine

• 0.5-1.2 mg/ dl

Hemoglobin

• Female: 12-16 g/dl

• Males: 13-18 g/dl

Hematocrit

• Female: 36-46%

• Male: 37-49%

Serum Bilirubin

• Direct (conjugated): .1-.3 mg/ dL

• Indirect (unconjugated): .2-.8 mg/ dL

• Total: .3-1 mg/dL

Urine Bilirubin

• 0

Serum cholesterol

• 150-250 mg/ dL

• Increased in bile duct obstruction, reduced in liver damage

Total protein

• 6-8 g/dL

• Reduced in liver damage

Serum Albumin

• 3.5-4.8 g/dL

• Reduced in liver damage

• decreases with age

Parathrombin time

• Normal: 12-15 seconds

• Prolonged w/ liver damage

• Doubled for people taking anticoagulants

Platelets

• 150,000-400,000/ mm³

• May drop when spleen is enlarged due to portal hypertension

INR

• Normal: .9-1.1

• For individuals on anticoagulants

  • > 2.5 guard against falls

  • > 3 Risk for hemarthrosis

  • > 4 Increase in exercise routine may be contraindicated or modified; discuss w/ physician

  • > 6 Bed rest till corrected

Platelet count

• < 10,000 and/or temperature >100.5 F: no therapeutic exercise/ hold therapy

• 10,000-20,000: therapeutic exercise/ bike w/o resistance

• >20,000: therapeutic exercise/ bike w/ or w/o resistance

Hemoglobin (Hgb)

• < 8 g/dL: essential activities of daily living

• 8-10 g/dL: essential activities of daily living, assistance as needed for safety; light aerobics light weights (1-2 lb)

• > 10 g/dL: ambulation and self-care as tolerated; resistance and aerobic exercises

Hematocrit (Hct)

• <25%: Essential activities of daily living; assistance as needed for safety

• 25-35%: Essential activities of daily living; assistance as needed for safety; light aerobics, light weights (1-2 lb)

• > 35%: ambulation and self-care as tolerated; resistance and aerobic exercises

White blood cell count

• <5000 / mm³ with fever: no exercise permitted

• > 5000/ mm³: light exercises permitted w/ progression to resistive exercise

Recognizing pain patterns

• Vascular: throbbing, pounding, pulsing, beating

• Neurogenic: Sharp, crushing, pinching, burning, hot, searing, itchy, stinging, pulling, jumping, shooting, electrical, gnawing, pricking

• MSK: Aching, sore, heavy, hurting, deep, cramping, dull

• Emotional: tiring, miserable, vicious, agonizing, nauseating, frightful, piercing, dreadful, punishing, exhausting, killing, unbearable, annoying, cruel, sickening, torturing