PTTM Comp

What are the steps in the Patient Management Model?

Examination → Evaluation → Diagnosis → Prognosis → Intervention → Outcomes

What does the ICF model include?

Health condition, body structure/function, activities, participation, personal & environmental factors

What is the purpose of the ICF model?

Provides common language and tracks disease impact on function

What does the Clinical Road Map emphasize?

Examination + pause and reflect after each test/measure

What comes first: Review of Systems or Systems Review?

Review of Systems (subjective)

Purpose of Review of Systems?

Screen major systems and guide test selection

What is Systems Review?

Objective physical screening tests

Why take a patient history?

Build rapport, form hypotheses, identify impairments & limitations

What does SINSS stand for?

Severity, Irritability, Nature, Stage, Stability

Key info gathered in subjective exam?

Chief complaint, PMHx, goals, activity limitations, participation restrictions

Why do we care about tests and measures?

Body Structure Functional Impairments (BSFI)

Differential Diagnosis

Baseline Measurements

Intervention Planning

Tracking Progress

Outcomes

Define critical thinking

The process of actively and skillfully evaluating, analyzing, and applying information to reach an answer or conclusion

Information acquisition → clinical reasoning → clinical decision-making

Define body mechanics

Use of one's body to produce motion that is safe, energy-conserving, and anatomically and physiologically efficient and maintains body balance/control

What are the type of lifts?

Deep Squat lift

Power lift

Straight leg lift

One leg stance lift (golfer's lift)

Half-kneeling lift

Traditional lift

Stoop lift

What are precautions for positioning a patient?

Maintain head/neck in neutral

Extremities supported

Follow diagnosis specific precautions

What do we screen for in integumentary?

Recent rashes, nodules, or other skin changes

Unusual hair loss or breakage

Increased hair growth (hirsutism)

Change in nail beds

Itching (pruritus)

Color

Moisture

Palpation characteristics

Symmetry

Shape

Capillary refill

Volumetric measurement/displacement

What do we screen in cardiovascular?

Vitals

What do we screen in neuromuscular?

Motor function

Fluidity of motion

Balance

Coordination

Reflexes

Cranial nerves (if coordination and reflex show abnormalities)

What do we screen for in musculoskeletal screening?

Gross ROM

Gross strength

Define osteokinematic

Movement of whole bone through space

Define arthrokinematic

Movement of the joint surfaces in relation to one another; articulating bone end roll, glide/slide, or spin on each other

Define reliability

Overall consistency of a measurement, repeatability

What are the types of reliability?

Inter-rater Reliability: between different raters

Intra-rater Reliability: between the same rater

Define validity

Accuracy of a measurement, or measuring what is intended to be measured

T/F: Arthrokinematics are components of the osteokinematic motion

True

What are normal end feels?

Hard: Bony and abrupt resistance felt at the end of PROM, no further motion can occur (ex: elbow extension)

Firm: slight "give" felt at the end of PROM due to joint capsule and surrounding non-contractile tissue limitations at end range (ex: shoulder flexion)

Soft: "mushy" resistance at the end of PROM due to soft tissue compression (ex: elbow or knee flexion)

Define capsular pattern

Joint specific pattern of motion restriction that is due to intra-articular inflammation, capsular fibrosis or anatomical changes involving the entire joint capsule

Define non-capsular pattern

A pattern limited joint ROM that is not the capsular pattern

What are the abnormal end feels?

Tight capsule, capsule adhesion

Empty

Muscle guarding

Effusion

Hard/bony block

Springy (fibrocartilage block)

What are the options for ROM?

AROM: active ROM

AAROM: active assisted ROM

PROM: passive ROM

Gravity Resisted ROM

Gravity Assisted ROM

Gravity Eliminated/Minimized ROM

Define joint play

An accessory motion that does not occur naturally w/ osteokinematic motion

What does distraction load and unload?

Unload cartilage and bone but load capsule

What does compression load and unload?

Unload capsule, load articular cartilage and bone

Define open-packed position

Anatomical position where joint capsule is most slack and bony congruity is minimized, allowing for the greatest joint mobility

Define close packed position

Anatomical position where joint capsule is in the least amount of slack and bony congruity is maximal, allowing for the least joint mobility

What is R1 and R2?

R1: 1st resistance met from the joint capsule

R2: second level of resistance felt as tissue elasticity is taken up; this is where end-feel is assessed

What is the joint mobility grading?

Grade 0: ankylosis or no detectable movement

Grade 1: considerable limitation

Grade 2: Slight limitation

Grade 3: Normal

Grade 4: Slight increase in motion

Grade 5: Considerable increase

Grade 6: Unstable

NOTE: 0-2 = hypomobile, 4-6 = hypermobility

What are the qualities of motion?

Normal: smooth

Crepitus: rough articular cartilage

Grinding: Damaged articular cartilage

Popping, clicking, catching: damaged fibrocartilage

Boggy: effusion

Why do we care about hypo and hypermobility?

Hypomobility: limited associated osteokinematic motion

Hypermobility: altered biomechanics and risk for injury

Why do we perform muscle strength testing?

Detect weakness

May be due to disuse atrophy, stretch weakness, pain, fatigue, disease, or general patient status

Detect muscle imbalances: synergists, antagonists

Determine the ability of the muscles to provide stability, create movement patterns, sustain postures and positions (3Ps)

Define strength

The ability to produce tension and resultant forces based on muscle demands

Define power

Product of force and velocity; number of repetitions of a given intensity in a given amount of time

Define endurance

Ability of muscle groups performing a movement to sustain that movement

Define direct muscle performance deficit

Limited muscle performance directly produces a functional deficit (i.e. inability to lift a child)

Define indirect muscle performance deficit

Limited muscle performance may contribute to poor movement patterns and postures (i.e. excessive tissue loading leading to injury)

Define Break Test

Clinician applies resistance opposite to the line of pull of the muscle being tested in an attempt to "break" the muscle's hole

Define Make Test

Alternative to break test, whereby the therapist applies manual resistance against the line of pull of the muscle or muscle group being tested that matches the patient's resistance but does not overcome it

Define Stabilization

MMT meant to test the prime mover of the joint action and minimize the input of other muscles

Define substitutions

When other muscles/muscle groups contribute to a specific action as a result of weakness in the muscle/muscle group(s) being tested

Define compensation

When other body movements or movement patterns are used to create more force or the appearance of more force output

Define multi-joint active insufficiency

When a two or multi-joint joint muscle is no longer able to generate an effective force due to being placed in a shortened position, which causes the inability to attain maximal cross-bridging at the muscle cell level

Define one-joint muscle active insufficiency

When the muscle is in a fully shortened position, it can't produce optimal force due to inability to attain maximal cross-bridging at the muscle cell level

What is the data gathered from MMT

Strength Quantity- grade

Symptoms- type, location

Quality of contraction- motor patterns

What is the MMT grading?

5: full available ROM, against gravity, strong manual resistance

4+: full available ROM, against gravity, nearly strong manual resistance

4: full available ROM, against gravity, moderate manual resistance

4-: full available ROM, against gravity, nearly moderate manual resistance

3+: full available ROM against gravity, slight manual resistance

3: full available ROM, against gravity, no resistance

3-: At least 50% but not full ROM, against gravity, no resistance

2+: full available ROM, gravity minimized, slight resistance

2: full available ROM, gravity minimized, no resistance

2-: at least 50% but not full ROM, gravity minimized, no resistance

1+: Minimal observable motion (<50% ROM), gravity minimized, no resistance

1: No observable motion (palpable muscle contraction), gravity minimized, no resistance

0: no observable or palpable muscle contraction

What are the MMT patterns for pain and strength?

Strong/painfree: normal

Strong and painful: mild tendon or muscle pathology

Weak and painful: moderate tendon or muscle injury

Weak and painfree: significant/severe tendon or muscle pathology; neural deficit

Define passive insufficiency

Inability of a muscle, when fully lengthened across all joints it crosses, to allow full ROM at each joint

What can limited muscle length cause?

Altered biomechanics

Altered foot mechanics

Length-tension disruption

What can excessive muscle length cause?

Poor control

Joint instability

Ligament stress

Degeneration over time

What factors affect muscle length?

Prolonged immobilization

Muscle injury

Age

Gender

Functional demands

Cultural variations

What are the types of contractures?

Myostatic Contracture: adaptive shortening of a muscle, leading to limited length. No pathology is present

Pseudomyostatic contracture: when a CNS pathology maintains the muscle in a constant state of contraction and in a shortened position

Connective tissue or scar adhesions: when, in response to muscle injury and the normal inflammatory process, the repair process results in poorly organized fibrous tissue instead of healthy tissue. This creates “adhesions” or “scar tissue” within the muscle that can limit extensibility

Irreversible Contracture: when there is a permanent loss of extensibility in the muscle tissue that can not be reversed by external means. This might occur from any of the above

Define coordination

The behavior of 2+ degrees of freedom in relation to each other to produce a skilled activity

What is involved in the central motor system?

Strategy (areas of the neocortex and basal ganglia of the forebrain): The goal of the movement and the movement strategy that best achieves the goal

Tactics (Motor Cortex and Cerebellum): The sequences of the muscle contractions, arranged in space and time, required to smoothly and accurately achieve the strategic goal

Execution (brain stem and spinal cord): activation of motor neuron and interneuron pools that generate the goal-directed movement and make necessary adjustments to posture

What is involved in the peripheral motor system?

Muscles, joints, and their sensory and motor innervation

Define tone

The resistance of muscle to passive elongation or stretch

What are the types of tone?

Spasticity: resistance of movement DEPENDENT upon the velocity of movement

Rigidity: resistance of movement INDEPENDENT of the velocity of movement

Hypotonia: decreased or absent muscle tone

Dystonia: Hyperkinetic movement disorder involving abnormal muscle tone and involuntary movements

What is the modified ashworth grading scale?

0: no increase in tone

1: slight increase, catch and release or min resistance at end of ROM when affected part(s) moved in flexion/extension

1+: slight increase w/ minimal resistance through less than half ROM, manifested by a catch

2: more marked increase in muscle tone through most ROM, but affected part(s) easily moved

3: Considerable increase in tone, passive movement difficult

4: Limb rigid in flexion or extension

What are the descending motor pathways?

Corticospinal tract

Corticobulbar tract

Tectospinal tract

Reticulospinal tract

Vestibulospinal tract

Rubrospinal tract

What are symptoms of ataxia?

Unsteady gait

Dysmetria (overshooting targets)

Intention tremor

Poor balance

What is the main sensory spinal pathway?

Dorsal Column-Medial Lemniscus (DCML) Pathway

Carries important sensory information necessary for coordination

Define reciprocal motion

Ability of opposite limbs to move simultaneously in opposite directions

Define movement composition

Ability of muscle groups to work together synergistically to stabilize joints and produce controlled movement

Define movement accuracy

Ability to judge distance and speed of voluntary movement

Helps determine whether a person can reach a target precisely and efficiently

Define fixation (limb holding)

Ability to maintain a limb position without excessive movement or instability

What is dysdiadochokinesia?

Impaired ability to perform rapid alternating movements (RAM)

Ex: pronation/supination

What is dysmetria?

An inability to accurately judge distance or ROM

Ex: finger to nose

What is intention tremor (terminal dysmetria)?

Tremor that occurs during purposeful movement, especially as limb approaches target

What is resting tremor?

Involuntary rhythmic movement occurring at rest

Often associated w/ Parkinson's disease

What is hypermetria?

Form of dysmetria involving overshooting a target

What is bradykinesia?

Slowness of voluntary movement characterized by reduced movement speed and reduced movement amplitude

Describe the finger-to-nose test

Purpose: assess dysmetria

Procedure: Patient touches their nose, Patient touches examiner's finger/object, Movement repeats back and forth

Normal response: Smooth, accurate movement

Abnormal Findings: Overshooting or undershooting the target, Tremor near the target, Irregular trajectory

Describe finger-to-finger test

Purpose: assess coordination and movement accuracy

Procedure: Patient alternates touching the examiner's finger and their own finger

Abnormal findings may include dysmetria or tremor

Describe finger opposition test

Purpose: evaluate fine motor coordination

Procedure: patient sequentially touches thumb to each fingertip

Normal response: smooth, rapid, accurate movement

Abnormal response: slow or inaccurate finger contact

Describe mass grasp test

Purpose: Assess rapid alternating movements (RAM) and dysdiadochokinesia

Procedure: Patient alternates between Full finger flexion (closing fist) and Full finger extension (opening hand)

Normal response: rapid, rhythmic movement

Abnormal response: slow, irregular, or uncoordinated movement

Describe heel-to-shin test

Purpose: assess dysmetria in LE

Procedure: Patient places heel on opposite knee, Slides heel down the shin toward the ankle, Returns to starting position

Normal Response: Smooth movement along the shin

Abnormal Findings: Heel deviates from shin, Jerky or inaccurate motion, Side-to-side movement

Differences between and R and L side are considered abnormal

Describe foot tapping test

Purpose: Evaluate rapid alternating movements of LE

Procedure: patient rapidly taps their foot

Normal response: fast, rhythmic tapping

Abnormal response: slow, irregular, or asymmetrical movement

What is decorticate posturing?

Flexed UE

Extended LE

Indicates damage above the brainstem

What is decerebrate posturing?

Extension of both UE and LE

Indicates more severe brainstem involvement and loss of inhibitory control

What is a cut off score?

Score that determines positive vs. negative outcome and risk category

Helps classify patients

Describe the function in sitting test (FIST)

Assess sitting balance

Components: sensory, motor, proactive and reactive balance, steady-state control

Best for: inpatient settings, non-ambulatory patients

Scoring: 0-4 per item, total: 56 points

Describe the 5xSTS

Measures: functional LE strength, Transfer ability

Procedure: arms cross, stand/sit 5x quickly

Timing: start on go and end after 5th sit

Failure if uses arms or cannot complete 5 reps

Describe the Functional Reach Test

Measures: ability to move center of gravity outside BOS

Standing version: reach forward without stepping, measure distance of 3rd MCP

Modified Version: done in sitting, multiple trials → average score

Describe the timed up and go

Assesses: mobility, balance, walking ability, fall risk (especially older adults)

Procedure: Sit in chair and stand on go, Walk 3 meter, Turn, return, sit: record total time, cutoffs vary by diagnosis

Describe the Berg Balance Scale

Measures static + functional balance

Tasks include Sit to stand, Transfers, Reaching, Standing on one foot

Scoring: 0-4 per task, total: 56

Key cut off: <45 = increased fall risk

Describe Dynamic Gait Index

Assesses gait with added tasks: Head turns, Speed changes, Obstacles

Scoring: total 24

Interpretation: >22 = safe ambulator, ≤22 = fall risk (especially elderly)

What is the purpose of the Modified Clinical Test of Sensory Interaction in Balance (CTSIB)?

Provides the clinician with a means to quantify postural control under various sensory conditions

What is the purpose of the Romberg?

Test static standing balance

It was developed to screen for myelopathies and neuropathies with associated sensory dysfunction, yet has become part of static balance tests

What is the purpose of the sharpened Romberg?

To assess the static balance of patients with a sensory integration taxing condition

What is the purpose of the Balance Error Screening System Test (BESS Test)?

To assess balance and stability of the ankle joint

What are the types of reflexes?

Deep Tendon Reflexes (DTRs): Muscle stretch response (most commonly tested)

Superficial Reflexes: Cutaneous receptor response, Mediated by UMNs

Primitive (Tonic) Reflexes: Present in infants, disappear with development, Originate in brainstem, Important for survival early in life

Describe the reflex arc of deep tendon reflexes

Tendon tapped → muscle spindle activated

Afferent signals via Type Ia and II sensory fibers

Travel to dorsal horn of spinal cord

2 Pathways: To cortex (awareness) or Direct synapse on alpha motor neuron

Alpha motor neuron → muscle contraction

KEY POINT: monosynaptic reflex, direct synapse causes immediate response