observation and strength

observation

• begins in the waiting room

• overt pain behaviours such as guarding, bracing, rubbing, grimacing and sighing

  • is it constant, periodic or occasional

    • how is the pain “irritated”

• compare both sides

  • are there structural deformities

  • Any differences in bony and soft tissue contours

• static observations

  • eg. LL alignment, swelling, muscle bulk

  • colour/texture differences of the skin

    • any indications of recent injury or surgery

  • any heat, swelling or redness in the associated area

• dynamic observations

  • eg. WB during gait

  • crepitus or abnormal sounds in the joints when moved

• attitude, facial expression and willingness to move

posture - stance observation

• alignment of body segments

• interrelated to movment

  • movement begins from a posture to a posture in the same/different location

• commonly assesed' using a “plumb line”

• upright posture - supported by “antigravity” muscles

  • primarily neck and back extensors

  • hip and knee extensors

• have to consider chronic posture in 21st century adults

  • have to consider if pathological

    • cause pain or limits function

  • although my not be pathologic still needs to be considered when programming exercises

  • normal stance affected by age, size, sex and body type

• postural adjustments are rapid and automatic in normal function

• requires proprioceptive, visual and vestibular systems

postural observation

• plumb line/grid board

• suitable state of undress

  • no shoes

• palpate bony landmarks

• record results

• reassess over course of treatment

• it is difficult to maintain posture as we often want to move

what does the postural assessment tell us

• clients willingness to move joint, coordination, level of consciousness, attention span, joint ROM and moments that cause or increase pain

• there may be issues to act on but the issue may not be the posture

  • may be how weaknesses present

  • changes may affect posture but not the end all be all

  • weakness and tightness are more so problematic then overall posture

• many factors are a “given” considering how we live

• the prolongation of a certain postion for too long is the issue

  • not the specific posture that is problematic

• observations can be both tactile and observational at same time

  • stand as usual and move through joints assessing for an abnormalities or differences between two dies

    • takes 30s to go through

    • take notes on what is found

      • do they mean anything or not?

assessment of AROM

• willingness to move joint

• coordination

• level of consciousness

• attention span

• joint ROM

• moments that cause or increase pain

• muscle strength

• ability to follow instructions

• abiltiy to perform functional activities

• normative values dont mean much but instead “is it equal between both sides”

  • rotation of spine is always seated and with legs all the way back

    • dont allow cheating w/ hips

decreased AROM

• restricted joint mobility

• muscle weakness

• pain

• inability to follow instructions

• unwillingness to move

assessment of PROM

• determines mvmnt at the joint

  • as the therapist moves through movment

• often greater than AROM due to elastic stretch of muscle tissue and decreased bulk

• focus on limitations observed with AROM

observation during ROM testing

• onset of pain

  • when and where during movment does pain begin

  • does the movment increase its intensity

• patient reaction

  • non-verbal cues, guarding or facial expressions that indicate discomfort or difficulty

    • patients may adapt leading to compensations

• observable restriction

  • is movement visibly limited

  • what is the nature of this restriction

• pattern of movements

  • how does patient compensate

  • is the movement smooth and coordinated or erratic

• rhythm and quality

  • speed, control and smoothness of the motion

• associated joints

  • how adjacent joints move in relation to

• willingness to move

  • hesitation or apprehensiveness performing the movement

• end feel

  • quality of resistance at the end of the range

    • explored further in PROM

contraindications of PROM

• when muscle contraction or motion of that part of body could disrupt the healing process or result in injury or deterioration of the condition

  • suspected or confirmed

    • joint sublux/dislocation

    • unhealed or unstable fracture

    • rupture of a tendon/ligament

    • infectious or actor inflammatory process

    • myositis ossificans or ectopic ossification

  • post-surgery

    • tissue healing process can be disrupted

  • osteoporosis or bone fragility

    • forced measurements may cause iatrogenic injury

  • precautions

    • presence of pain

    • infection or inflammation around a joint

    • hypermobiltiy

    • instability

    • haemophilia

    • bony ankylosis

    • after prolonged immobilization

perform PROM

• establish joints ROM

• determine quality of movement throughout ROM and end-feel

• determine whether capsular or noncapsualr pattern is present

• determine presence of pain

muscle weaknessss

• inability to generate the necessary force for effective motor performance

causes of muscle weakness

• muscle atrophy

  • disuse

  • neurogenic

• strain

  • contractile tissue - mm tissue damage

  • non-contractile tissue - tendon damage

  • both - msk tendinous junction

grade 1 strain

• mild strain affecting limited number of fibres in the muscle

• no decrease in strength

• full AROm and PROm

• pain and tenderness are often delayed to the next day

  • DOMS falls not this category

grade 2 strain

• mmoderate

• nearly half of muscle fibres torn

• acute nad significant pain accompanied by swelling

• minor decrease in muscle strength

grade 3 strain

• severe

• complete rupture of the muscle

• either tendon separated from muscle belly or muscle belly is actually torn in 2 parts

• severe swelling and pain

• complete loss of function

assessing level of strain

• history of MOI

  • circumstances

  • symptoms

  • previous problems

• clinical examination

  • palpation

    • detect larger tears

    • perimuscular oedema

    • increased muscle tone

  • comparison to other side

  • MMT

• early ultrasound and MRI recommended

implications of muscle weakness

• tendinopathy

• central or peripheral sensitization

• ligament sprain

• neurologic conditions

tendionpathy

• tendon degeneration impairing muscle-to-bone force transmission

central or peripheral sensitisation

• affecting central drive to the muscle

ligament sprain

• instability causing improper joint loading and force

  • boen ot bone connection

central fatigue and pain

• fatigue muscles

  • fatiguing knee extensor muscle → fatigued knee extensor

  • fatiguing knee flexor → unfatigued knee extensor

  • contralateral knee extensor muscle → unfatigued knee extensor muscles

    • when hamstring have been working and testing quads

      • although the quads haven’t been working there is decreased drive of the antagonists d/t pain in the area

      • implication of the fatigued muscle on the other side

        • requires some recovery

          • no cross over effect limb to limb

• w/o nociceptive input there is plenty of force

  • the addition of the painful nocipetive input limits drive you have to contract

strength testing

• strength can be tested ismetcially, isotonically or isokinetically

  • MMT

  • dynamometry

• functional

  • 4x STS

  • STS in 30s

  • STS in 60s

  • bicep curl test

  • 10RM

isometric strength measurement

• muscle actively generate tension but do not change length

• more control and less able to subsitide

• may bot accurately reflect functional ability

• only assesses one part of joint range/muscle length combinations

dynamic strength measurements

• muscles change length while actively generating tension

• great if using biodex

  • difficult without

• poor access generally

MMT

• good reliability and validity

• good external and internal validity

• quick and easy

• useful for very weak muscles

• difficult ot maintain standard resistance through full ROM

• general assessment rater than measurement

• not a quantitative rating

  • ordinal scale only

dynamometer

• hand hel

  • isometric

• dynamic

  • contrcnet - isokinetic

force velocity relationships

• concentric

  • force a muscle can generate is inversely related to velocity of movement

  • as movment velocity increases the muscles ability to generate force decreases

• eccentric

  • force a muscle can generate is directly related to the velocity of ovment

  • faster eccentric contractions can lead to greater force production

power output

• product of force and velocity

  • maximized when force nad velocity are at optimal levels

• ability to generate torque at different movment velocities is crucial for activities that require combination of strength and speed

  • eg. sprinting, jumping and certain sport movements

MU recruitment

• MU recruited at varing movment velocities

• slower moment recruit more MU

  • greater force product

• fast movements rely on recruitment of fewer but faster contracting mU

optimal muscle length

• generate max force

  • resting or physiological length of muscle

• optimal overlap between actin and myosin filaments in sarcomeres

  • allow for most effective cross-bridge formation and force production

too short muscle length

• actin and myosin filaments have limited overlap

  • force generating capacity is reduced

• active insufficiency of the muscle

too long muscle length

• actin and myosin filaments also have limited overlap

  • reducing force-generating capticy

• passive insufficiency

other functional strength tests

• TUG

  • broad concept of mobility

• 5x STS

• 30s STS

• 6 MWT (+ others)

• timed star climb

• upper limb

  • not a lot of options currently