PT 515: Physical Therapy Examination

Midterm 1 Content (Lecture & Lab)

APTA’s vision

transform society by optimizing movement to improve human experiences

APTA’s mission

build a community that advances the profession to improve society’s health

BU’s DPT mission

produce clinical leaders that provide high standards of empathetic care to improve patient outcomes through critical thinking and evidence based practice. graduates can apply clinical reasoning to patient centered care and engaged with research

Empathetic patient centered care

understanding and respecting experiences of others, meeting patients where they are at without bias, collaboration between patient & PT, shared decision and goal making, compassion & active listening

critical thinking/clinical reasoning

do you know and understand (knowledge), using what you know, behaving and engaging in a world with the patient, being curious

evidenced informed practitioners

integrating best current evidence, clinical expertise, and patient values —> appraising literature, applying in practice and assessing its application

human movement system

comprises anatomic structures and physiological functions that interact to move the body or its component parts

• integumentary, muscular, skeletal, nervous, cardiovascular, pulmonary, endocrine

where does movement emerge from

the integration of environment (conditions of the task), the task itself (stand up), and organism (human condition)

systematic approach to movement assessment

what is the task performed and under what conditions?

is the movement strategy used typical?

is the movement strategy optimal or suboptimal?

what will you test based on your observations?

is the movement strategy adaptive or maladaptive?

what are the consequences of the movement strategy?

what is the ICF

international classification of functioning, disability and health

what are the bidirectional components to the ICF model

health condition: physical condition like CP or ASD

body structure and function: anatomical and physiological components of the body and any impairments there may be

activity: execution of a task or action by the individual

participation: the patients involvement in life (work, mom, etc.)

environmental factors: physical, social, and attitudinal environment that people live in

personal factors: patient’s unique background and lifestyle

patient interviews are step 1 to a PT exam

gather information about current condition

identify patients beliefs and expectations about current health condition

identify patients goals for PT

establish a therapeutic relationship with patient

basic structure/components for interview

demographics (age, gender, language, etc.)

current condition/history of present illness (when, how, improvement, seen providers, treatments, has this happened before, expectations)

past medical history (current medications and past conditions)

living environment (housing/setting, other people/pets, support system)

social/health habits (drugs, alcohol, smoking, sleep, health education)

prior level of function (mobility prior to and after condition, assistive devices, etc.)

activities and participation (activities currently do/enjoy and role in society)

apnea

no respiratory rate

bradycardia

under 60 bpm

diastole

pressure in arteries when heart relaxes after contraction

dyspnea

shortness of breath

hypertension

high blood pressure

hypotension

low blood pressure

pulse

heart beats per minute

tachycardia

over 100 bpm

systole

pressure of blood in arteries when heart contracts

rate of perceived exertion

on scale of 6-20 or 1-10 and describes about of work patient feels they are doing

oxygen saturation

measures the % saturation of oxygen in arterial blood

usually 98% for young healthy individuals

blood pressure

measured on left arm which is supported listening for 1st and 4th karotkoff sounds

usual is <120/80

unusual is >120/80 or less than 90/60

tachypnea

fast respiratory rate

respiratory rate

breaths per minute

usual is 12-16

oxygen travel into lungs

nose, pharynx, trachea, left/right bronchi, bronchioles, alveoli

blood flow through heart

right atria, right ventricle, pulmonary artery, lungs, pulmonary veins, left atria, left ventricle, aorta, body

sagittal plane motions & axis

flexion & extension about a horizontal (x-axis)

coronal plane motions & axis

ABduction & ADDuction about A-P axis (anterior-posterior)

transverse plane motions & axis

internal/medial & external/lateral rotation about vertical axis (y-axis)

Humeroulnar (Elbow) Joint

hinge joint with 1 degree of freedom —> does flexion & extension

Metacarpophalangeal (MCP) joint

condyloid joint with 2 degrees of freedom —> flexion, extension, abduction, adduction

Acetabulofemoral (Hip) Joint

ball and socket joint with 3 degrees of freedom —> flexion, extension, abduction, adduction, internal rotation, external rotation

Convex on concave rule of arthrokinematics

a convex bone moving about a concave bone will opposite directions for the roll and glide

Concave on convex rule of arthrokinematics

A concave bone moving about a convex bone will have the same direction for the roll and glide

what is a treatment plane

parallel to the deepest point of the concavity of the concave bone

loose-pack position

relaxed ligaments, least bony congruency, most mobility —> position where you can produce traction, compression, and anterior/posterior glides in a joint

closed-pack position

most bony congruency and stability at a joint

elbow loose-pack position

70 degrees flexion and 10 degrees supination

elbow closed pack position

full extension and full supination

MCP loose-pack position

slight flexion

MCP closed-pack position

full flexion

Hip loose-pack position

laying supine with slight flexion (about 30 degrees), slight abduction (about 30 degrees), and external rotation

hip closed-pack position

slight abduction, internal rotation, and extension

producing traction

pulling perpendicular to treatment plane

producing compression

pushing perpendicular to treatment plane

producing glide

pushing anterior/posterior parallel to treatment plane

Are there accessory joint structures at elbow?

none

are there accessory joint structures at MCP

volar plates

are there accessory joint structures at hip?

labrum and ligamentum teres

active insufficiency

when a biarticulate muscle can’t produce enough force because it can’t shorten any more

passive insufficiency

a biarticulate muscle is at its maximum length across both joints and can’t lengthen any more

sitting up tall in a chair with anterior pelvic tilt and performing full knee extension differs from doing full knee extension when sitting relaxed. Why?

if someone can budge the leg by moving it with hands, then it is active insufficiency of the rectus femoris muscle not being able to generate enough force (length of hamstring is good)

if someone can’t budge the leg by moving it with hands, then it is passive insufficiency of the hamstring because it can’t lengthen enough for the quad to shorten

in a standing position flex the knee to see if you can touch your bottom with your foot. Reasons for why you can’t?

if someone can budge the leg by moving it with hands, then it is active insufficiency of the hamstring muscle not being able to generate enough force (length of quad is good)

if someone can’t budge the leg by moving it with hands, then it is passive insufficiency of the rectus femoris because it can’t lengthen enough for the hamstrings to shorten

in a long seated position holding one leg close to chest and other fully extending. Then try lifting up the straight leg. Reason for why its hard?

if someone can budge the leg by moving it with hands, then it is active insufficiency of the rectus femoris muscle not being able to generate enough force (length of hamstring is good)

if someone can’t budge the leg by moving it with hands, then it is passive insufficiency of the hamstrings because it can’t lengthen enough for the rectus femoris to shorten

passive range of motion

measures the total amount of available motion at the joint

the patient does nothing

standard measurement for ROM

active range of motion

measures how willing the individual is to move, some degree of strength

patient is doing this themself with muscle and neurological activation

when to exam joint ROM

when joint mobility may be contributing to an individual’s activity or participation limitations

to determine the health and wellbeing of a joint

before measuring the strength of a muscle

when not to/be careful about measuring ROM

if a passive movement of joint with cause injury

there is a limitation imposed by a health condition (surgery or fracture)

tools to measure ROM

standard goniometer, half circle protractor, finger goniometer, inclinometer, digital apps

there is inter and intra rater reliability between all these devices

± 5 degrees for a standard error of measurement

standard practice for measuring ROM

always move the limb in the cardinal plane

stabilize at the proximal segment

using proper size and type of goniometer

boney landmarks

recording results with a start-end (quantitive) and a end-feel (qualitative)

normal/typical end-feels

hard, soft, firm

abnormal/atypical end-feels

empty (couldn’t get to an end)

boggy/squishy (inflamed feels like water is inside)

crepitant (crunchy/creeky)

springy (bounce back from a structure in the way)

what does hard end feel include

bone stopping the movement

what does firm end-feel include

some give but stops —> joint capsule, ligaments, muscle length stopping it

what does soft end-feel include

soft tissue stopping it (room to give) —> muscles squishing together

standard procedure for ROM

1. explain the test & ask for consent

2. position patient in starting position

3. stabilize the proximal joint segment

4. passively move the joint through the ROM and determine end-feel

5. eyeball the degrees of motion (vocalize estimate)

6. return the limb to starting position

7. palpate the bony landmarks, align the goniometer, and record starting position

8. move the limb passively through ROM

9. re-palpate and align the goniometer

10. read the value on the limb and record the reading

Example of proper ROM documentation

Hip abduction 0-40 degrees with firm end feel

indications to assess for joint play

make inference about joint function

determine the type of resistance between joint surfaces

determine any tissue injury or inflammatory process

determine level of patients pain/tolerance to movement

red flags for joint play

fear on part of patient or therapist

signs of neoplasm, fracture or systemic disturbance

rheumatoid collagen

what does joint play assess

the available mobility of the capsule and supporting ligaments

pain provocation

pain alleviation

steps to perform joint play

1. explain test to patient & ask for consent

2. position patient comfortably to minimize muscle tension

3. stabilize the proximal joint segment with stabilizing hand

4. grip the moving segment as close to the joint line as possible

5. position the patient in the loose-pack/resting position for the joint

6. perform the joint play assessment by moving the moving segment either parallel or perpendicular to the treatment plane and determine end-feel

7. compare to the opposite side and determine if mobility is normal, hypo, or hyper

normal joint play

motion feels same as the other side

hypomobile joint play

motion is limited or stops faster compared to the other side

hypermobile joint play

motion is excessive or goes on longer despite applying same force when compared to the other side

normal end-feel for joint play

firm

abnormal end-feel for joint play

soft, hard, empty, crepitant, springy, boggy

even if end-feel is firm having any pain is still abnormal

ROM assesses

osteokinematic motion —> done when we don’t see sufficient movement in function and suspect limited mobility

Joint play assess

arthrokinematic motion —> done when we find abnormal ROM (too little or too much)

knee flexion normal ROM

0-135 degrees with soft/firm end feel

knee extension normal ROM

0-10 degrees with firm end feel

knee flexion/extension axis

lateral epicondyle of femur

knee flexion/extension moving arm

toward lateral malleolus parallel to longitudinal axis

knee flexion/extension stationary arm

toward greater trochanter parallel to longitudinal axis

hip flexion normal ROM

0-120 degrees with soft/firm end feel

hip abduction normal ROM

0-45 degrees with firm end feel

hip flexion axis

greater trochanter

hip flexion stationary arm

parallel/towards the trunk

hip flexion moving arm

towards lateral epicondyle of femur parallel to longitudinal axis

what is in a neurological exam

sensation, reflexes, and force production

what is sensation

ability to perceive stimuli from the body and environment

what does doe we examine with sensation

touch, danger, temperature, proprioception, special senses

indications for sensory exam

patient has numbness/loss of sensation, tripping, delayed responses, lack of control, asymmetry across body

dorsal column

back of the spinal cord

deals with vibration, proprioception , and discriminatory touch

anterolateral system

front of spinal cord

deals with crude touch, pain/nociception, and temperature

central nervous system includes..

brain

spinal cord

peripheral nervous system includes…

all nerves outside brain and spinal cord, including the cranial nerves

how to test crude touch

perceiving touch through a cotton ball —> information sent to brain through anterolateral system