Foundations II Exam #1

What are the 6 parts of the Patient/Client Management Model (P/CMM)?

• examination

• evaluation

• diagnosis

• prognosis

• intervention

• outcomes

What are the important parts of the examination section of the P/CMM?

• history

• systems review

• tests & measures

What are some of examples of the specific information recorded in the examination section of the P/CMM?

• HPI (hx of present illness) / CC (chief complaint)

• pain assessment (if relevant)

• medical/surgical hx

• social hx (family/roommates, home setup)

• current functional status (home, work, recreation)

• pt goals

What information would you want to know when doing a pain assessment?

• onset (length of sxs, precipitating factors)

• location (initially vs. now, does it travel?)

• aggs & eases (positions, activities, etc.)

• intensity (pain scales… VAS, NPRS)

• descriptors (sharp, burning, aching, etc.)

• associated sxs (neurological signs)

What are some examples of things that could be recorded during your tests & measures?

What are the different parts of a physical therapy diagnosis?

• participation restriction (work, social event, athletics, role)

• activity limitation (actual activities… running, jumping, walking)

• impairment (msk related… bones, lig., sensations)

What is an example framework for a physical therapy diagnosis?

Patient presents with [relevant impairments] that limit/restrict the patient’s ability to [functional limitations/activities] and participate in [participation restrictions]. {Signs and symptoms consistent with [suspected pathology/medical diagnosis].}

What is a prognosis?

• predicts the potential for, & optimal level of, improvement & the timeframe needed to get there

  • categories: excellent, good, fair, poor

What is the difference between anticipated goals and expected outcomes?

• anticipated goals: short-term goals, stepping stones to reach expected outcomes, can involve impairments but should be linked to function

• expected outcomes: long-term goals, what the pt will do by the end of POC, must be functional, should include pt’s own goals

What is the purpose of setting goals?

• provides a target for the pt

• help measure progress & plan interventions

• establishes timeframe & communication w/ others

• justify the need for “skilled” care

What are SMART goals?

• specific - what function you what to see

• measurable - a way to quantify results

• achievable - is the goal even possible

• realistic - will pt factors allow result to occur

• timely - a time frame to see results

What is the purpose of a screening?

• recognize the need for a medical referral/consultation to another healthcare professional

• determine if sxs are mechanical in nature → if hx, MOI and/or findings c/w msk or neuromuscular dysfunction

What’s the difference between a PT diagnosis and a medical diagnosis?

• medical: identification of disease, pathology, or injury

• PT: identification of movement impairments or limitations of function/QoL

What are the different categories of a PT diagnosis?

• musculoskeletal

• neuromuscular

• cardiopulmonary

• integumentary

What are the different levels of arousal?

• alert - awake, eyes open, attentive

• lethargic - sleepy, slow response, inc. arousal from stimuli

• obtunded - difficult to awaken, max. stimuli to inc. arousal

• stupor - strong (noxious) stimuli to maintain consciousness

• coma - unable to arouse/actively participate

What questions would you ask to examine a patient’s orientation?

• person - what’s your name

• place - where are you

• time - what’s today date

• event - why are you here

What sensation are superficial exteroceptors responsible for?

• superficial sensation from cutaneous/subcutaneous tissue

  • pain, light touch, temperature, pressure

What receptor is responsible for light touch, temperature, and pressure?

• superficial exteroceptors

What sensation are deep interoceptors responsible for?

• deep sensation from viscera & blood vessels

What sensation are proprioceptors responsible for?

• external stimuli from muscles, tendons, ligaments, joints, fascia

  • position sense, awareness of joints at rest, kinesthesia (proprioception)

What receptor is responsible for proprioception and positional awareness?

• proprioceptors

What are some examples of combined cortical sensations?

• stereognosis

• two-point discrimination

• tactile localization

What are some examples of proprioceptors?

• free nerve endings

• ruffini endings

• pacinian corpuscles

• golgi tendon organs

What sensation are free nerve endings responsible for?

• mechanical changes in joints (movement, compression)

What sensation are free Ruffini endings responsible for?

• encapsulated nerve endings → respond to joint position & slow, sustained stretching

What sensation are Pacinian corpuscles responsible for?

• rapidly adapting → detect high-frequency vibrations & joint pressure changes

What sensation are Golgi tendon organs responsible for?

• alterations in joint tension & force

What is stereognosis?

• the ability to recognize the 3D shape of an object by touch alone

What is two point discrimination?

• the ability to distinguish between two separate points of stimulation on the skin

What is tactile localization?

• the ability to identify the precise location on the body where a touch, pressure, or pain stimulus is applied (superficial exteroceptors)

What is a reflex arc?

• neural pathway that controls a reflex, bypassing the brain for faster processing

What are the different levels of reflexes?

• 0 absent

• 1+ diminished response

• 2+ normal

• 3+ brisk/more reflexive than normal

• 4+ very brisk/hyperreflexive

What is Babinski’s sign?

• a plantar reflex elicited by a light stroke applied to the plantar side of the foot

  • normal → great toe flex.

  • abnormal → great toe ext./fanning of toes

What are the components of a UQS/LQS?

• postural assessment

• AROM

• dermatomes

• myotomes

• reflexes

What are movements are tested for AROM in an UQS?

• cervical flex./ext.

• cervical side bending

• cervical rotation

What are movements are tested for AROM in an LQS?

• lumbar flex./ext.

• lumbar side bending

• lumbar rotation

What dermatomes are tested for an UQS?

• C4 - T2

What is the dermatome for C4?

• over trapezius - ridge of the shoulder

What is the dermatome for C5?

• lat. brachium to elbow

What is the dermatome for C6?

• lat. forearm/elbow to lat. ½ of hand (1st & 2nd digits)

What is the dermatome for C7?

• lat. arm - 3rd digit

What is the dermatome for C8?

• med. ½ of hand (4th & 5th digits) to med. elbow

What is the dermatome for T1?

• med. elbow to brachium

What is the dermatome for T2?

• med. side of upper arm to axilla region

What dermatomes are tested for a LQS?

• L2 - S1

What is the dermatome for L2?

• ant. mid thigh

What is the dermatome for L3?

• ant. med. distal thigh

What is the dermatome for L4?

• med. 1st digit, anteromed. calf

What is the dermatome for L5?

• lat. calf (big toe web-space)

What is the dermatome for S1?

• lat. foot

What is the myotome for C1/2?

• cervical flex. & ext.

What is the myotome for C3?

• cervical lat. flex.

What is the myotome for C4?

• shoulder elevation

What is the myotome for C5?

• shoulder abd.

What is the myotome for C6?

• elbow flex. & wrist ext.

What is the myotome for C7?

• elbow ext. & wrist flex.

What is the myotome for C8?

• digit flexion & thumb ext.

What is the myotome for T1?

• finger abd.

What is the myotome for L2?

• hip flex.

What is the myotome for L3?

• knee ext.

What is the myotome for L4?

• dorsiflex.

What is the myotome for L5?

• great toe ext.

What is the myotome for S1?

• plantflex. & ankle eversion

What is the myotome for S2?

• knee flex.

What tendons are tested for reflexes during an UQS?

• biceps (C5 - C6) → elbow flex.

• brachioradialis (C6) → elbow flex.

• triceps (C7) → elbow ext.

What tendons are tested for reflexes during a LQS?

• patellar (L3 - L4) → knee ext.

• achilles (S1 - S2) → plantarflex.

What are some coordination assessments?

• point-to-point: alternate nose → examiner’s finger

• rapid alternating movements: rapidly alternate pronation & supination on thighs as fast as possible (heel-to-shin for LE)

What are different levels of abnormal tone?

• flaccidity: dec. resistance, limp

• spasticity: velocity-dependent inc. resistance, non-newtonian

• dystonia: erratic volitional movements, spasms

• rigidity: resistance throughout ROM, stiff

What are the three components of pain?

• discriminative: ability to detect & define pain

• affective: emotions associative w/ pain

• cognitive: how the brain processes pain

What are the different neurophysiological pain mechanisms?

• nociceptive

• peripheral neuropathic

• nociplastic

What is the pain pattern of nociceptive pain?

• localized to area of injury/dysfunction

• mechanical/anatomic in nature

• pain w/ movement, dull/throbbing at rest

What treatments does nociceptive pain respond well to?

• posture education

• muscle stretching & joint mobilization

• muscle strengthening & motor control exercises

What is the pain pattern of peripheral neuropathic pain?

• dermatomal/cutaneous distribution

• associated w/ hx of n. injury or pathology

• pins & needles, burning/freezing, tingling, shock

What is nociplastic pain?

• hypersensitive NS response → overactive pain pathways, can’t regulate pain signals

• chronic pain cycle → inc. activity in pain centers leads to worsening sxs over time

How do nociceptors transmit pain signals?

• via A𝛿 or C fibers

What’s the main difference between A𝛿 and C fibers?

• A𝛿 : myelinated, localized → rapid, sharp response

• C : unmyelinated (slow), poor localization → slow, dull response

What are the timeframes that differentiate acute and chronic pain?

• acute → <2 weeks

• chronic → >3 months

What is fear-avoidance?

• exaggerated fear of reinjury/inc. pain from movement → can be more disabling than initial pain/injury

What is pain persistence?

• denial/ignoring of pain → don’t want to accept functional limitations

What is the SINSS construct in pain assessment?

• severity - intensity, impact

• irritability - aggravation vs. ease

• nature - type/quality

• stage - acute/subacute/chronic

• stability - progression of sxs over time

What are the different levels of irritability (SINSS) during a pain assessment?

• minimal: 2:1 aggravating to easing/rest

• moderate: 1:1 aggravating to easing/rest, moderate activity levels, can return to sleep in <30 min of changing positions

• maximal: 1:2 aggravating to easing/rest, very little activity, frequently interrupted sleep needing >30 min to return to sleep

What are the different natures (SINSS) of pain?

• mechanical/inflammatory nociceptive (aching)

• neurogenic (burning)

• central (nociplastic)

• viscerogenic (organ or referred)

• autonomic (ANS dysfunction)

• affect (pt characteristics & pain management)

What determines a measurement’s reliability?

• when it is consistent time after time w/ as little variation as possible

What is test-retest reliability?

• consistency of repeated measurements separated in time w/ no changes in measured values

What is inter/intra-rater reliability?

• inter-rater: degree measurements by multiple therapists will be consistent

• intra-rater: degree measurements by the same therapist will be consistent

What determines a measurement’s validity?

• degree to which a meaningful interpretation can be inferred from a measurement

  • ex. NPRS → good for pt pain, bad for function levels

What is a floor effect?

• limitation of a measure b/c the instrument can’t detect a further dec. in score

  • ex. giving 5th graders a calculus exam, everyone will fail

What is a ceiling effect?

• limitation of a measure b/c the instrument can’t detect a further inc. in score

  • ex. giving math majors an algebra exam, everyone will get 100%

What is a minimal detectable change (MDC)?

• the smallest amount of change that can be detected by a measure that corresponds to a change in ability

What is a minimal clinically important difference (MCID)?

• the smallest amount of change that is considered important by the pt or clinician

What is clinical utility?

• the extent to which the test or measure is useful in yielding data needed for the situation (how relevant the data is for what you’re trying to determine)

What is a base of support (BOS)?

• boundary created by body part(s) in contact w/ supporting surface

What is center of mass (COM)?

• mean location of total mass in the body (standing → 2/3 of body height above BOS)

What is center of gravity (COG)?

• mean location of moments & forces acting on the body

What is a line of gravity (LOG)?

• a vertical line passing from the center of gravity down to the ground

What is a center of pressure (COP)?

• a point representing the average location of force being applied to the ground by the individual

What is a patient’s limits of stability?

• furthest distance in any direction a person can lean without loss of balance or altering the original BOS (normative: 12 degree ant.-post., 16 degrees med.-lat w/ stance width of 4in)

What are different dynamic strategies for balance control?

• ankle strategy

• hip strategy

• stepping strategy

When viewing posture from a lateral view, what are the significant landmark positions?

• ears: positioned over shoulders

• shoulders: level w/ chest open, not rounded forward

• spine: normal curves

• pelvis: neutral, no excessive tilt

• knees: should be extended

• feet: neutral

What is the normal position for pelvic alignment?

• 9 - 12 degrees of ant. pelvic tilt