Midterm (REAL !!)

what are the key points of contact to facilitate movement/transfers?

scapula and pelvis!

how to prepare yourself and your client for a safe transfer while using a mobility device?

lock their breaks, increase BOS (stagger!), get down to client level, communicate!, consider precautions, cultural differences, environmental hazards

how do you safely ascend stairs with a client using a cane?

stand behind them! they go cane → strong leg → weak leg

how to safely descend the stairs with a client using a cane?

in front of the client! cane → weak leg → strong leg

what sensory systems are involved in balance/posture?

visual, vestibular, somatosensory

what reflexes support balance?

righting, vestibulo-ocular (VOR), vestibulospinal

righting reflex

automatically maintaining upright position of head when body is displaced

vestibulo-ocular reflex

keeps eyes fixed on an object while the head and body are in motion

vestibulospinal reflex

postural equilibrium during head movement

what postural strategies do we use to maintain balance?

• reactive

  • ankle strategies (during quiet standing)

  • hip strategies

  • stepping/reaching

• anticipatory (pre-positioning)

what are the standing/active balance assessments that we know?

timed up and go (TUG), functional reach, tinetti, berg balance scale

timed up and go

time while a client gets up from a chair, walks a distance, and sits back down (at a comfortable speed), compare to normative values

functional reach test

measure how far a client can reach while standing in one space, can view some of their balance strategies as well. compare to normative data

tinetti

sit → stand, nudged while standing, close their eyes, turn 360, sit back down

berg balance scale

super comprehensive (but also long and harder)

sit → stand → sit, transfer between chairs, stand eyes closed, feet together, reach forward, get something from the ground (while standing), look behind, turn 360, feet on stool, feet in a line, on one foot

what are the sitting balance assessments that we know?

trunk impairment scale, function in sitting test (FIST)

trunk impairment scale

cross leg, touch elbow to mat, lift hip, rotate trunk, lower body (all x2 on both sides)

function in sitting test (FIST)

nudged x3 throughout test. sat! shake head, eyes closed, lift 1 foot, turn to object behind, forward, lateral reach, get object off of ground, scoot (posterior/anterior/lateral)

what must a therapist consider when treating tendinitis/tendinopathy?

when to strengthen - you DONT want to until pain is minimal or zero

order of treatment for tendinitis/opathy

1. re-education, remove/modify aggravating factors

2. rest affected tendon!!

3. pain-free ROM / stretches for tissue extensibility

4. proximal → distal strengthening

what special tests are there for UE peripheral nerve injuries?

• phalen’s (carpal tunnel)

• tinel’s (carpal tunnel, other entrapment)

• finkelstein’s maneuver (dequervains)

• cozen’s (lateral epicondylitis)

• froment’s sign (ulnar nerve injury)

what is finkelstein’s maneuver?

ulnar deviation w/ extended arms and thumb flexed into fist

tests for dequervain’s

what is cozen’s test?

press on the lateral epicondyle (common extensor tendon) while the client extends their wrist against resistance

tests for lateral epicondylitis

modified allen’s test

occulde radial/ulnar arteries, client makes and releases a fist, release arteries, watch for capillary refill/color

assesses radial and ulnar blood flow to hand

froment’s sign

hold object between thumb/index finger, practitioner tries to pull it out

assesses adductor pollicis strength → impacted if ulnar injury

what kind of common peripheral nerve injuries are there?

• ulnar nerve:

  • claw hand (extension of pinky/index)

  • fromet’s sign (adductor pollicis)

  • wartenburg’s sign (palmar interossei) - index/pinky don’t adduct at rest

• median nerve

  • ape hand (opponens pollicis)

• radial nerve

  • wrist drop (extensors)

what kind of nerve entrapements are there?

• ulnar

  • carpal tunnel, guyon’s tunnel, cubital tunnel (proximal/medial forearm pain)

• median

  • carpal tunnel

• radial

  • PIN / radial tunnel syndrome → radial tunnel palsy, supinator syndrome

    • pain is in muscle belly rather than @ lateral epicondylitis

generally complaints of hand falling asleep, burning/tingling / numbness, clumsiness

how to calculate total active motion (TAM) in digits?

subtract digit’s flexion from extension, add up all of that between the fingers. can compare to total passive motion (TPM) to see how much ROM they have!

ex. MCP: 20-40, PIP: 40-90, DIP: 0-10 TAM = 80

if limited motion of a digit, how do you test to see if it’s intrinsic or extrinsic tightness?

extrinsic: FLEX MP joint, there will be less PIP/DIP passive flexion (extrinisic extensors are tight)

intrinsic: EXTEND MP joint, there will be less passive PIP/DIP flexion

if tight forearm/wrist, how to assess if it’s extrinsic flexors or extensors? treatment?

extensors: less passive digit flexion when wrist is in FLEXION

flexors: less passive digit extension when wrist is EXTENDED

prolonged stretches, place-and-hold, static orthoses at end range (@ night), dynamic/static orthoses during day

digital lag vs digital contracture

lag = limited AROM, PROM is fine

contracture = limited AROM and PROM d/t soft tissue shortening

orthoses for post-surgical FLEXOR tendon healing

dorsal block orthosis

(blocking it from stretching and damaging the newly healing tendon)

orthoses for post-surgical EXTENSOR tendon healing

palmar block orthosis, typically on affected digit

(blocking it from stretching and damaging the newly healing tendon)

hip precautions (posterior approach)

no adduction (crossing legs), no IR, no hip flexion > 90 degrees

hip precautions (anterior approach)

no hip extension, ER past neutral, no excessive hip abduction. no bridging

what are the stages of pressure sores?

1. non-blanchable redness, intact skin

2. partial thickness lost, exposed dermis

3. full-thickness skin loss

4. full-thickness skin and tissue loss

what kinds of wounds are there?

trauma, mechanical pressure, vascular insufficiency.

acute + chronic (last more than 30 days)

precautions w/ different stages of fracture healing

• weeks 1-2: gentle PROM, one-handed ADLs, AROM of uninvolved joints

  • hematoma, fibrocartilage callus, bony callus starts to form

• week 4: gentle sub-max isometrics

• week 6: AROM gravity-reduced, wean off sling

• week 8-12: no sling, isotonic strengthening

• week 12+: return to normal activities

(bone remodeling is days 18+ lmao)

essentially don’t want any learned non-use or secondary complications!

what are the kinds of strokes?

ischemic & hemorrhagic

what are ischemic strokes? kinds?

blood flow to brain is occluded (~87% of strokes)

• thrombotic: clot in artery

• embolic: clot from elsewhere travels to brain and lodges there

• lacunar: deep structures of the brain are occluded, less common and can go unnoticed

what are hemorrhagic strokes?

blood vessel breaks, there is bleeding in brain (~13%, mostly intracerebral)

non-modifiable stroke risk factors

age, race, gender (more in women, think more likely to live longer), genetics/family history

modifiable stroke risk factors

• metabolic: hypertension, diabetes, heart rhythm disorders

• behavioral: smoking, excessive drinking, inactivity, poor nutrition, bad sleep habits

• psychosocial: depression, social isolation, loneliness

stroke symptoms

BEFAST

B: balance (loss of balance, dizziness)

E: eyes (blurred vision)

F: face (one side drooping)

A: arms (arm/leg weakness)

S: speech (difficulty speaking)

T: time to call 911 (lol)

what tonal changes can occur during a stroke?

spasticity (hypertonicity) & flaccidity (hypotonicity)

spasticity (generally)

increased response to stretch (overactive velocity-dependent stretch reflex). increased resistance to movement, stereotypic posturing, excessive co-contraction, stereotypical movement strategies

what is stereotypic UE posturing after a stroke?

shoulder IR, elbow/wrist flexion. (loss of ER)

hypotonicity

low muscle tone, flaccidity

when does hypertonicity occur?

• intermittent (dependent on activity, posture, balance demands)

• during voluntary movement (stereotypic patterning)

• positional (changes the muscle length-tension relationship)

after stroke, scapula resting position

downwardly rotated, depressed, retracted

(d/t trunk control problems, imbalance in musculature)

how can a stroke impact scapulohumeral rhythm?

delayed onset of lower traps (for upward rotation),

• no shoulder pain

  • early/longer activation of infraspinatus (reduced impingement)

• shoulder pain

  • delayed/early inactivity of serratus anterior

UE flexor synergy

shoulder abduction, ER. elbow flexion, supination, wrist/finger flexion

UE extensor synergy

shoulder IR, elbow extension, pronation, finger extension (usually across body)

what kind of pain can occur after a stroke? (NOT in acute phase)

• joint pain (nociceptive)

  • during biomechanical joint motion, passive/active (this is impingement)

• muscle pain (nociceptive)

  • tight/hypertonic/spastic tissue is moved too quickly, with too much force, with poor alignment

• central post-stroke pain (neuropathic)

  • sense perception is altered (hyperalgesia, allodynia)

• complex regional pain syndrome

  • increased sensitivity to tactile stimulation, edema, limited ROM, osteopenia

what is hyperalgesia

abnormal increased sensitivity to pain

what is allodynia

pain in response to non-painful stimuli

mental health after stroke

1/3 depression, 1/4 anxiety (these increase chances of another stroke. most don’t receive mental health services after stroke)

also impulsivity, apathy, pseudobulbar affect (lability), delirium, decreased self-esteem

subluxation

17-64% of stroke survivors - separation of humeral head and glenoid fossa (commonly anterior/inferior)

not always a problem!! just that soft tissues are stretched/lax. not painful on its own, but can increase likelihood for impingement during movement

reasons: flaccidity of integral muscles, postural malalignment, mishandling, gravity

what is FUEL (functional upper extremity levels)?

way to categorize/sequence movement w/ one affected UE!

1. nonfunctional

2. dependent stabilizer

3. independent stabilizer

4. gross assist

5. semi-functional assist

6. functional assist

7. fully functional

when do you use the modify approach to intervention after a stroke? why might you not want to?

promotes early engagement in ADLs while protecting affected extremity

BUT over-reliance can promote and reinforce learned non-use, which is BAD (immobility, weakness, pain) !!

what is PNF? (proprioceptive neuromuscular facilitation)

• uses awareness of body position and movement through specific commands/cues to achieve new movement patterns

• triplane movements emphasized - prescribed movements

• multisensory (visual, auditory, tactile)

• resistance, stretch, traction, approximation all important

what is NDT? (neurodevelopmental treatment)

problem-solving approach to treatment, does not have prescribed movements

• client centered, organized around activity, hands-on

• large emphasis on therapeutic handling, facilitating “as normal movement as possible”

• “movement learning happens in the context of doing”

(jan does this)

what is the task-oriented approach?

“normal” movement emerges from dynamic interaction of body systems and task objectives, environmental constraints

• can target any factors, be remedial, adaptive, or both!

• addresses movement in context !!

• emphasis on analyzing own movement, solving problems

slings, pros/cons!

pros:

• can protect affected UE from injury during transfers

• enables therapists to control other areas of the body during function training

• may prevent prolonged dangling, relieves brachial plexus pressure

cons:

• can contribute to learned non-use, soft tissue tightness

• can create dependence on them

• blocks sensory input

overall ?? use sparingly and w good reason, AVOID slinging across chest

lap trays pros/cons!

pros:

• shoulder can be positioned in neutral position

• arm is free to move, can be functional

• useful for wheelchair users

cons:

• can be limiting in terms of transfers - is considered a restraint if they can’t manage it independently!

arm rest pros/cons!

pros:

• shoulder in neutral position

• supports weight of UE while seated

• can move in/out of wheelchair easier than a lap tray*****

cons:

• may cause shifts in shoulder alignment during weight changes

• ****if they remember! if cognition is a concern, they may try to transfer w/o unstrapping which is dangerous and hurts

how to prepare shoulder for movement?

assess posture, AROM, PROM (and why it may not be same as AROM)

assess scapular mobility - glide in all directions, shoulder ER

assisting w/ passive overhead movements

• avoid elevating humerus >90 degrees W/O scapular upward rotation, glenohumeral external rotation

  • like get in there and do that

• avoid use of overhead pulleys

• range to point of light resistance

mirror box therapy

reflection of moving non-affected limb gives illusion of movement in affected limb

can be used at any stage of recovery regardless of affected limb function. uses those mirror neurons!

mental practice/motor imagery

visualizing/rehearsing movement

• external/visual (imagine themselves moving)

• internal/kinesthetic (imagine sensation of movement)

constraint-induced movement therapy (CIMT)

• constraining non-affected UE during 90% of waking hours

• intense graded practice w affected UE, task-specific (training is up to 6 hours/day for 2 weeks)

possible causes of hemiplegic shoulder pain

NOT subluxation

consequence of spasticity and sustained hemiplegic posture, impingement

what to start with when moving hemiparetic shoulder?

scapular elevation → shoulder flexion (no more than 90 degrees) → protraction → upward rotation of scapula (ER of shoulder too)

what to look at when first assessing a hemiparetic limb?

assess their active patterns first, then parts. Ex ask them to raise their hand, then assess shoulder elevation, etc