NPTE FF Nmeumonics and Study Strategies

Stages of Lymphedema (numbers) vs Grading of Edema (numbers)

• Lymphedema 0-3 (lymph03dema)

• Grading is from 1-4

Lymphedema vs Lipedema

Lymph: Unilateral or asymmetrical, cellulitis, not painful, distal edema, + Stemmer

Lip: Bilateral and symmetrical, cellulitis RARE, painful and bruise easily, absent stemmer

Anthopometric Measurements (Girth, Volumetric, Bioimpedance, Lymphoscintigraphy)

Girth→ Proximal areas

Volumetric→ Distal Areas

Bioimpedance→ Pre/post surgery

Lymphoscintigraphy→ Lymphatic Insufficiency

What is abnormal palpation of lymph nodes

• tender, hard, and immobile

• Indicative of malignancy!! → REFER TO PHYSICIAN

Lymphangitis vs Lymphadenitis vs Lymphadenopathy

• Angitis → Vessels inflamed due to infection, present with red streaks, pain, fever

• Adenitis→ Nodes inflamed, enlarged, painful due to infection

• Adenopathy→ Enlargement of nodes, non tender and fixed = malignancy whereas tender = infection

What is the most efficient lymphedema PT management?

Exercise combined with external forces of compression

Complete Decongestive Therapy 2 Stages

Phase 1 → Intensive

Phase 2→ Maintenance

What all is involved in phase 1 of complete decongestive therapy?

• MLD (Proximal to distal AREAS, distal to proximal STROKES)

• Multiple layer compression bandaging

• Skin and nail care

• Exercise

What all is involved in phase 2 of complete decongestive therapy?

• Self MLD

• Compression therapy

• Skin and nail care

• Exercise

Contraindications to Manual Lymphatic Drainage (7)

1. Acute infection → don’t wanna spread it

2. Cardiac Failure → can create system overload

3. Renal Failure → can create system overload

4. Active Malignancy → May spread it

5. Uncontrolled Hypertension → System overload

6. Acute DVT → May spread it

7. Severe asthma → fluid could trigger bronchospasm

What bandage do we use for lymphedema and why?

Short stretch because it has low resting pressure and high working pressure → we WANT patient being active

• more resistance = more muscle pumps fluid = more fluid return

Wrap distal to proximal with most pressure being distally

How should exercise choice be ordered lymphedema?

Proximal to distal to CLEAR THE TRAFFIC JAM

Imaging for UMN vs LMN

UMN → MRI and CT

LMN → EMG and nerve conduction velocity

Cardinal Signs for PD (TRAP)

PD →

Tremors (Intention)

Rigidity

Akinesia

Postural Instability (due to thoracic kyphosis)

Cogwheel vs Lead Pipe Rigidity

Cogwheel → Smooth and consistent

Lead Pipe → Ratchet like and jerky (rigid tremor)

Signs/Symptoms PD

Anosmia (Smell→ one of first symptoms)

Freezing gait

Dec arm swing

Inc steps per turn

Micrographia

Constipation (decreased movement of muscles)

Hypophonia

OH, Fatigue, Weakness

Flat Affect

Restrictive Lung Disease (due to dec ROM w dec movement and also due to posture)

Hoehn and Yahr PD Scale

1→ Unilateral

2→ Bilateral

3→ Balance impaired BUT INDEPENDENT

4→ standing and walking with AD, all symptoms present (walker has 4 legs)

5→ Confined to bed or WC

What will be seen during on/off phases of levidopa/carbidopa treatment?

On → dyskinesia (snake like, repetitive, large mm groups, involuntary)

Off → dystonia (prolonged contraction/spasms, a specific group)

schedule PT during ON PHASE

High protein diet can block effectiveness of medication

Signs/Symptoms of MS

UMN

Optic neuritis

Trigeminal Neuralgia

Cerebellar symptoms

Pseudobulbar affect

Unique Signs and Symptoms of MS (Ms Lucc Sin is 85)

Multiple Sclerosis

Lhermitte’s

Uthoff’s

Cranial Nerve 2 → Optic Neuritis → Marcus Gunn

Charcot’s Triad

Scanning speech

Intention Tremor

Nystagmus

85 degrees for water

Will also have trigeminal neuralgia

Types of MS

1. Relapse Remitting → Short attacks w full or partial recovery, may or may not leave deficits

2. Primary Progressive → Steady inc in disability without attacks

3. Secondary Progressive → Starts off as RR then turns into primary progressive

4. Progressive Relapsing (WORST) steady increased disability with attacks

ALS affects…

ALS leaves sensation intact

• Attacks motor neurons

• Is an upper and lower motor neuron condition

Signs/Symptoms of ALS..

UMN/LMN

Pseudobulbar affect (SAME AS MS)

Muscles → extensor weakness causes neck flexion

Respiratory mm weakness will lead to death

Signs and Symptoms of GBS

• Distal to proximal LMN damage

• Rapid and progressive

• Glove and stocking pattern

Bilateral, symmetrical

CN 7, 9, 10, 11, 12 effected

Functions of Frontal Lobe

A CEO

Aphasia (Brocas)

Controls plans, programming, movement

Emotional, behavior, personality → executive function

Olfaction (Smell)

Functions of Temporal Lobe

• Hearing and language comprehension

• Wernicke’s Aphasia when affected

BEN has Broca

Broken speech

Expressive Aphasia
Non Fluent Aphasia

FRONTAL LOBE, ask yes/no questions

Wernicke’s Aphasia

Word Salad, Receptive Aphasia, Fluent Aphasia

TEMPORAL LOBE, gestures/demonstrations

Deficits seen L Parietal Lobe vs R Parietal Lobe

Left = Language

Right = Perceptual

Nmeumonic to remember cranial nerves and if they’re sensory/motor

• Some- Oh - Olfactory (ONE nose)

• Say- Oh- Optic (TWO eyes)

• Marry- Oh- Oculomotor

• Money- To- Trochlear (Cute shoes)

• But- Touch- Trigeminal

• My- And- Abducens (Lateral)

• Brother- Feel- Facial

• Says- Very- Vestibulocochlear

• Big- Good- Glossopharyngeal

• Brains- Velvet- Vagus

• Matter- Ah- Accessory Spinal

• More- Heaven- Hypoglossal

How to remember location of cranial nerves?

CE → 1,2

MI → 3,4

PONS → 5,6,7,8
MEDU → 9,10,11,12

Describe Pupillary Light Reflex, What CN involved?

When you shine a light into someones eyes, CN2 receives the info, integrates it and sends info to BILATERAL CN3 to constrict pupils (protect the eye)

BOTH should constrict if normally working

What will be seen if cranial nerve 3 is affected?

• Strabismus (lateral deviation- CN3 can’t adduct so CN6 will laterally pull eye)

• Ptosis

• Pupillary Dilation

CN 5 and CN 7 functions, what reflex are they involved in

CN 5- SENSATION to face (5 feels) and anterior 2/3 of tongue, Jaw Jerk Reflex

CN 7- MOVEMENT of face and TASTE of anterior 2/3 of tongue, lacrimation and salivation

Both dampen sound

CN5 is afferent and CN7 is efferent to corneal reflex

Tests for Hearing loss

RINNE tells you type (sensorineural vs conductive)

WEBER tells you side

What is normal for Rinne test, what indicates sensorineural vs conduction

Normal AC > BC

Sensorineural AC > BC

Conduction BC > AC

How to determine which ear experiencing loss with Weber

CANS

Conductive → affected ear is heard louder

Sensorineural → Normal ear heard louder

What reflex are CN 9 and 10 involved in?

Gag

9 → afferent (posterior tongue sensation and taste)

10 → efferent (deviation of uvula)

CN 12 lesions seen as?

LICK YOUR LESION

Tongue deviates toward affected side

Muscles innervated by CN 11

SCM and traps

Characteristics of UMN

• Spasticity, inc tone, inc reflexes, pathological reflexes, dec sensation, spasms, synergies

Characteristics of LMN

• hypotonia, hyporeflexia or areflexia, dec sensation, fasiculations, weak or absent voluntary movement

Characteristics of Basal Ganglia involvement

• Rigidity, resting tremors, brady or akinesia

• Dec or normal tone, normal sensation

Characteristics of cerebellar involvement

• hypotonia, dec or normal reflexes, normal sensation, ataxia, nystagmus, dec coordination, intention tremor

ACA CVA deficits

ABCD = Kid/Baby → “child-like” symptoms

Urinary incontinence, problems with imitation, problems with bimanual tasks, apraxia, slow/delayed motor, contralateral grasp reflex, sucking reflex

Affects contralateral LE

MCA CVA Deficits

MPH

Mouth

Perceptual Disorders

Homonymous Hemianopsia

Will affect contralateral UE/face

Unilateral Neglect…

More commonly as L sided (R Lesion)

• Encourage awareness of and use of hemiparetic side

• Active visual scanning

Homonymous Hemianopsia…

• Will affect contralateral side

  • EX R lesion will affect L sides of visual field

  • R lesion will affect L temporal and R nasal

PCA CVA Deficits (Peripheral vs Central)

• Peripheral → CL homonymous hemianopsia, visual agnosia, dyslexia WITHOUT agraphia, memory deficits, topographical disorientation

• Central→ THALAMIC PAIN SYNDROME

Differences between R and L sided strokes

R→ Child Like

• Perceptual issues, Impulsive, Quick, Safety Risk, Rigid thinking, very positive

L→ Elderly Like

• Language deficits, slow and cautious, distractible, depressed

UE Spasticity Pattern

CHICKEN DANCE

• Shoulder Retraction and downward rotation

• Humeral adduction, IR, depression

• Elbow and wrist flexion/adduction

• Forearm Pronation

• Hand/finger flexion, clenched/adducted thumb in palm

LE Spasticity Pattern

BALLERINA

• Pelvic retraction

• Hip adduction, IR, Extension

• Knee extension

• Plantarflexion, Inversion, Equinovarus, Toes Claw→ TMT ext, MTP flex

• Toes Curl TMT and MTP flexion

UE Flexion Synergy

• Johnny Bravo

• Shoulder retraction/elevation

• Shoulder abduction and ER

• Elbow flexion

• Wrist and finger flexion

LE Flexion Synergy

Sitting with leg crossed over the other

• Hip flexion, abduction, ER

• Knee flexion

• Ankle DF and inversion, toe DF

UE Extension Synergy

• Scap protraction

• Shoulder adduction/IR

• Elbow extension

• Forearm pronation, wrist and finger flexion

LE Extension Synergy

BALLERINA

• Hip extension, adduction, IR

• Knee extension

• Ankle PF and inversion

• Toe PF

Brunnstrom Stages of Stroke Recovery

Stage 1: Flacid

Stage 2: Beginning of minimal voluntary mvmt, synergy and tone

Stage 3: PEAK Spasticity and Synergies

Stage 4: Movement outside of synergy, tone starting to decrease

Stage 5: Inc complex movements

Stage 6: Individual Joint movement, coordinated movement

Stage 7: Normal movement

Stages 1-3 RLA

1→ COMA, NO response

2→ Generalized response, non purposeful whole body movement, inconsistent

3→ Local Response, purposeful and local, specific, inconsistent (FOLLOW SIMPLE COMMANDS, CLOSE EYES)

Stages 4-6 RLA

4→ Confused Agitated (DOES NOT COOPERATE) no selective attention, no memory

5→ Confused Inappropriate (will begin to be able to socialize S=5) consistently respond to simple commands

6→ Confused Appropriate (Goal oriented behavior develops G=6) more carryover of skills

Stages 7-8 RLA

7→ Automatic Appropriate

8→ Purposeful Appropriate (judgement is impaired in emergency or stressful situations)

7,8 ready to graduate! → Work on home, school, community reintegration

How do vitals change with incremental exercise?

• Heart rate and cardiac output increase linearly

• BP

  • MAP increases linearly

  • SBP increases

  • DBP SHOULD REMAIN FAIRLY CONSTANT

What are the BP guidelines?

Normal→ less than 120/80

Elevated→ 120-129 AND less than 80

Stage 1→ 130-139 or diastolic 80-89

Stage 2→ 140 or 90

HYPERTENSIVE CRISIS→ 180 and/or over 120

PPP Pronation of PRUJ

Pronation

PRUJ

Posterior Glide

Opposite for supination, Supination = Anterior Glide

Changes that INITIALLY occur with altitude changes

HR inc

BP inc

CO inc

SV no change

Changes that occur with altitude acclimation

HR inc (ex you still get excited to see your significant other even after years)

BP and CO normalize

SV decreases

Buoyancy affect on WB at C7, Xiphoid, and ASIS

C7= 10%

Xiphoid= 33%

ASIS= 50%

Decreased swelling and improved circulation due to hydrostatic pressure exerted by water

Aquatic therapy effect on vitals

@ beach, heart is happy

HR, BP, and VO2 decrease

CO and SV have to increase to makeup for HR dec

Trick to remember RPE levels

RPE= 6=20

SHVEM (13 somewhat hard, 15 hard, 17 very hard, 19 extremely hard, 20 max exercion)

and reverse for light

Auscultation Sounds Heart

• R 2 ICS→ Aortic

• L 2 ICS → Pulmonic

• L 3 ICS → Erb

• L 4 ICS → Tricuspid (sternal border)

• L 5 ICS → Mitral (midclavicular line)

Lub = What closing

“Primary” valves closing→ mitral and tricuspid

Dub = What closing

“Secondary” valves closing → pulmonary and aortic

S3 and S4 associated with…

S3→ Ventricular gallop, heart failure

S4→ Atrial gallop, atrial contraction

Tight and weak muscles→ UPPER CROSSED SYNDROME

• Tight muscles PUTS on stress

  • Pecs

  • Upper traps

  • Top corner of scap- Levator Scap

  • SCM

• Weak Drink Mango Lassi

  • DNF

  • Mid Trap

  • Low Trap

  • Serratus

TOLL for Screw Home Mechanism

Tibia Open Chain- Lateral for locking (extension)

(closed chain→ femur has to move has → will do the opposite (ex: extension femur will medially move)

Shoulder UR and DR

UR→ serratus, upper and lower traps

DR→ levator, rhomboids, pecs

Thumb flexion/extension R/G

Same R/G

• Flexion→ radial Adduction → ulnar glide

• Extension → radial Abduction → radial glide

Thumb abd/add R/G

• Opposite R+G

• Abduction → volar roll, dorsal glide

• Adduction → dorsal roll, volar glide

SC joint roll and glides

• Elevation/Depression→ opposite R + G

• Protraction/Retraction → same R+G

TMJ Arthrokinematics

• Elevation= Closing = rolls anterior and slides posterior

• Depression= Opening = rolls posterior and slides anterior (EARLY PHASE)

  • Condyle and disc slide together in forward and inferior direction

• Protrusion = Mandibular condyle and disc translate anteriorly

• Retrusion = Mandibular condyle and disc translate posteriorly

• Lateral Excursion = Ipsilateral pivot point and contralateral rotates anteriorly and medially

Anatomical Directions for OKC and CKC Pronation and Supination

OKC

• Pronation EDAB

• Supination IPAD

CKC

• Pronation EPAD

• Supination IDAB

Supine ALPS test for SIJ

When in supine

Anterior Longer Posterior Shorter

• If the leg is long it is anteriorly rotated, if the leg is short it is posteriorly rotated

Difference in lung volume changes restrictive vs obstructive

Everything decreases except OLD FART

o- obstructive

F- FRC (RESIDUAL- CANNOT GET AIR OUT)

a

R- RV (RESIDUAL- CANNOT GET AIR OUT)

T- TLC (air not getting out, total capacity increases)

T- TV

Ways to remember Gold’s Classification for COPD Diagnosis

FEV1/FVC fraction will always be less than 70% with any level of COPD

• Mild - 80%

• Moderate- 50-80%

• Severe- 30-50%

• Very Severe- <30%

Huffing is used mainly for what condition?

COPD- allows glottis to remain open to allow for secretions to expel

How to remember pitch and intensity of each lung sound

Closer to neck → higher pitch and intensity

Further down in lungs → softer and lower pitch

• Tracheal: High pitch and intensity

• Bronchial: Loud intensity and high pitch

• Bronchovesicular: Intermediate pitch and intensity

• Vesicular: Soft intensity and low pitch

Duration of lung sounds (exp vs insp)

Bronchovesicular and tracheal→ same duration

Vesicular→ Longer inspiratory (takes LONGER for air to get to bottom of lung)

Bronchial→ Longer expiratory (closer to mouth, expiratory sounds “take over”)

Descriptions of ABnormal lung sounds

• Rhonchi→ snoring (low pitch, continuous)

  • COPD, pneumonia, cystic fibrosis, bronchiectasis, chronic bronchitis

• Wheeze→ whistle (high pitch)

  • Asthma, COPD

• Crackles (Rales)→ high pitched, not continuous POPPING

• Pleural Rub→ Rubbing 2 papers together, heard in lateral lower chest

Which abnormal lung sound is indicative of cardiac condition? What heart sound is heard with CHF

• Crackles (C= Cardiac = Crackles)

• S3 Heart sound indicative of CHF (CHF= 3 Letters = S3 sound)

What are voice sounds with lung auscultation?

ABNORMAL, indicative of secretions which create consolidation in lungs

• Bronchophony (99)

• Egophony (E sounds like A)

• Whispered Pectoriloquy (increased loudness of whispering)

Erb vs Klumpke’s Palsy

• ERB (5r6) → C5-6 affected

  • head stretches downward

  • loss of abduction and ER (waiter tip deformity)

• Klumpke (81umpke) → C8-T1

  • stretching of arm OH

  • paralysis of hand intrinsics

  • claw hand

Scheuermann Disease

SH SH SH

• Schmorl nodes, scheuermann, schroth (treatment)

An extension bias condition, will have inc thoracic kyphosis and lumbar lordosis

Pain w extension and rotation

Need to stretch pecs, strengthen thoracic extensors and scapular stabilizers

Key Points about Pediatric Outcome Measures

• PEDI → will mention caregiver assistance and social function

• WeeFIM → adaptation of FIM, includes cognition

Both span 6 months to 7 years

GMFCS

1- Walk without restrictions, limitation in advance gross motor

2- Walk without AD, with limitations walking within community

3- AD> WC limitations walking outdoors and in community

4- WC > AD self mobility severely limited, transported outdoors or use power WC

5- Patient self mobility severely limited, even with AD requires caregiver

Plagiocephaly and Torticollis

• Occur on opposite sides

  • L torticollis will be R plagiocephaly

  • Torticollis is named after SCM affected

  • Plagiocephaly named after flat side (occipital bossing will be contralateral side)

Reflex Integration

1-2 Mon: Flex, extend, flexor withdrawal, crossed extension

3: Rooting reflex (^3^) → lips look like a 3, rooting integrates at 3 months

2-5: traction (cervical traction max is 25lbs)

6: PAMS TP

• Plantar grasp

• ATNR

• Moro

• Sucking

• TLR

• Positive Support

9: Plantar (need WB to integrate)

12: Babinski and STNR

When do grasps develop?

Pincer → 3 Jaw Chuck → Fine Pincer/Precision

10-15 months

Developmental Milestones Poem

3 I lift my head (POE, Cervical Extension)

4 Lay on my side (Supine → SL)

5 Prone to supine (babies hate tummy time, will try to get out of it, sup → prone develops right after at 6-7)

6 I sit upright (ring sit, supported, UE)

7 quadruped

At 8 i cant wait to cruise (9)

Creep, cruise, and stand alone at 9

Then walk (12) and stack 2 cubes (10-15, need control of release)

APGAR stands for, how is it graded, what are norms

Appearance (blue, blue extremities, pink)

Pulse (absent, <100, 100-140)

Grimace (no response, grimace, flexor withdrawl or cry)

Activity (flaccid, some flexion, active movement of extremities)

Respiration (absent, weak cry, strong cry)

Normal is 8-10

Check at 1 min, 5 min, 10 min only if needed

Compensation in gait for LLD with stance phase

• Long limb will DF in late stance to try to even out

• Short limb will PF in stance to try to reach ground

Mechanical Traction Contraindications

H-P-H

• Uncontrolled hypertension

• Immobilization

• Peripheralization of symptoms

• Acute Injury or Inflammation

• Joint hypermobility or instability