Basic Exam-Exam 2 Lecture

What part of the body does an Upper Motor Neuron lesion effect?

-Brain or Brainstem

-Problem of the axon of UMN located in brain or brainstem

What part of the body does a Lower Motor Neuron lesion effect?

-Problem of LMN is located in spinal cord or brainstem

-Problem of the motor nerves arising from lower motor neurons

What does neurologic testing help us differentiate?

If a patient has an upper motor neuron lesion, lower motor neuron lesion, if there's a problem with the muscle itself, problem with the sensory receptors or sensory nerves

What are Dermatome?

-A region of skin supplied by AFFERENT(sensory) fibers of a given spinal nerve

-Dermatomes overlap and variation from the diagrams

-Because of overlap b/w adjacent dermatomes, damage to one nerve root may result in no sensory loss or loss to a small area

What are Myotomes?

Skeletal muscles or groups of muscles innervated by EFFERENT fibers of one or more nerve roots

What are Deep Tendon Reflexes(DTR)?

-Assesses the integrity of the DTR efferent(motor) and afferent (sensory) components circuit

What does it mean when there's a Upper Motor Neuron Syndrome(lesion)?

-Problem of upper motor neurons are located in the brain or brainstem; or problem of the axon of upper motor neurons

What is the effect of a UMN Lesion?

-Paralysis or paresis (weakness) present in group of muscles

-Often stereotypic postures and movement patterns in the UE and LE

-Classic description: Spastic Paralysis

-Spasticity/Increased DTRs/Abnormal Cutaneous (sensory) reflexes

-Abnormal timing of muscle activation so can't isolate movements

-May see slight disuse muscle atrophy

How is spasticity characterized by?

-Increased resistance to passive stretch that's velocity dependent

-Meaning the faster the limb is passively moved, more resistance is applied to the passive movement

-Example: Jill is a patient with spasticity. If I try to open her hand I will get there eventually, but the faster I try to move her hand the more the muscle will pull back tighter triggering the reflex.

*** Performing passive range of motion on these patients is critical and teaching themselves to perform PROM because if a joint hasn't been going through its full ROM all of the structures will adapt and that becomes problematic.

What are the effects of LMN syndrome(lesion)?

-Paralysis present segmentally-along myotomes

Classic Description: Flaccid Paralysis

-Loss of motor activity is due to disruption of the efferent pathway

-Decreased or absent DTR

-Muscle Atrophy

-Example: A person who has no ability and no tone to their arm at all it's just hanging. This is typically a LMN lesion.

Example: What happens when spasticity UMN lesion patient tries to eat?

-The patient isn't able to isolate the movements. They can't just bend their elbow and eat. You would see everything flex when they're trying to flex or they have no control. The flexors are dominant in the UE and the extensors tend to be dominant in the LE.

Peripheral Nervous System Lesion begin at?

-The Nerve Roots

**the lesion location dictates the name

Nerve Root

-Lesion of a nerve root; trauma or pressure on a nerve root

What is Radiculopathy?

-Any disease of a nerve root

What's an example of Radiculopathy?

-Compression from degenerative joint disease and herniated disks

What is Peripheral Neuropathy?

-Lesion in the peripheral nerve

What is Mononeuropathy?

Trauma or pressure on a single peripheral nerve

What is an example of Mononeuropathy?

Carpal Tunnel Syndrome-compression of median nerve

What is Polyneuropathy?

Trauma or pressure on many peripheral nerves

What's an example of Polyneuropathy?

Diabetes/Autoimmune Disorders/Vitamin Deficiencies

If the pressure or compression is at the Posterior (dorsal) aspect of the nerve root what occurs?

-SENSORY CHANGES

-Radiating pain in the nerve root distribution (dermatome)

-May or may not be accompanied by pain in the spine and restriction of spinal movement

If the pressure or compression is at the Anterior (ventral) aspect of the nerve root what occurs?

-MOTOR IMPAIRMENTS:DEPENDS ON NERVE ROOT INVOLVED

-Decreased Deep Tendon Reflex

-Strength Loss(myotome) may see atrophy

-AROM may be limited

What happens if the pressure is on both the dorsal and the ventral root before they split?

Both could be affected

If a brain bleed or damage to the hypothalamus and the motor cortex occurs what happens?

-The reflex pathway just keeps on continuing, which is what creates spasticity because that motor response is not being inhibited

-If I try to flex, all of my flexors flex because I lost some of that control which is a designated UMN lesion

What are Neuropathies?

-Disorder of cranial or spinal nerves

What causes Neuropathies?

-Combination of motor, sensory, and autonomic dysfunction

What are the sensory changes that occur due to Neuropathies?

-Parathesia: Decrease in the sensory feeling
-Dysthesia: abnormal sensation
-Proprioception can be affected

What are the Motor changes that occur due to Neuropathies?

-Atrophy with distal weakness

-Decreased or absent DTR

-Ataxia: Abnormal Gait Pattern

How can systemic diseases lead to peripheral neuropathy?

-This is anytime where the nerves are impacted because of the levels within our blood

-Example: Diabetes

How can Trauma lead to peripheral neuropathy?

-We can accidentally slice a peripheral nerve and therefore lead to issues

-We can have trauma that compresses and injures a peripheral nerve

What is Plexopathy?

-Lesions of the brachial plexus (motor changes)

What occurs from a lesion of the brachial plexus?

-Simultaneous weakness of muscles from 2 or more adjacent nerve roots and from 2 or more peripheral nerves

Example: What's the effect from a lesion that occurs at the C5 root of the brachial plexus?

-We know that the Biceps are innervated by the Musculocutaneous Nerve at C5&C6 nerve root level.

-If C5 is blocked off you would see potential weakness but not necessarily complete weakness due to still having innervation from C6.

Causes of Mononeuropathy?

-Entrapment
-Trauma

Causes of Polyneuropathy?

-Diabetes Neuropathy
-Hereditary
-Multiple Entrapments

Cause of Radiculopathy?

-Herniated Disc
-Spondylosis
-Herpes Zoster

Cause of Plexopathy (Brachial and Lumbosacral)?

-Trauma
-Idiopathic
-Neoplasm
-Radiation

What is Manual Muscle Testing?

-Part of a comprehensive exam

-Technique used to determine the "strength" of a skeletal muscle or muscle group

-MMT is a test of HYPERTROPHY strength

What are the 2 classic techniques of MMT?

1. Daniels + Worthingham
-Primarily group testing (example: Hip Abductors)

-"Make" test that involves movement

-This is more functional

2. Kendall MMT(this is what we use)
-Primarily isolated muscle testing; some group testing which helps us more for clarifying diagnostic reasoning and clinical reasoning

-Gives more information about specific muscles related as well to nerve root and peripheral innervations

-"break test" that puts subject into shortened position and ask them to hold

Why perform MMT?

-Determines current status

-Assists in current "PT Diagnosis" and even more important for PROGNOSIS

-Aids in establishing initial and revised treatment goals and treatment plan

-Provides "objective" indication of change (progress, lack of progress, deterioration)

-Provides helpful documentation for subject motivation

-Aids in predicting functional outcomes and possible limitations

-Aids in determining need for adaptive orthotic equipment

-Aids in researching the effectiveness of specific interventions

What are the concerns when performing Kendall MMT?

-Test Position

-Fixation/Stabilization

-"Test" Itself is the action of the muscle

-Pressure/Resistance

-Substitution

-MMT Grading achieved

Basics of MMT

Patient placed/assumes the test position
-Specific to the muscle
-Into muscle function
-Assists with stabilization/fixation
-Places part against gravity's resistance

-Patient asked to hold the test position

-Resistance is placed in the direction opposite of function

Positioning Choice of MMT

1. Place patient in a static position that subject is asked to "hold"
-Saves time
-Testing muscle in action in shortened position (middle to end of ROM)
-Can see substitutions easily (**if substituted on first hold or the first "can you hold this against gravity" you're going to REINSTRUCT and try again because it may be due to miscommunication or even additionally cue them to "hold here")

2. Test can refer to a dynamic movement of a muscle/group of muscles into its/their action
-More Functional
-Can see/feel discrepancies in range

Kendall Positioning

-When performing Kendall MMT ALWAYS place the patient in the position and ask them to hold

What do you do if the patient can't assume the position during Kendall MMT?

-Document that I couldn't take that MMT

What if the patient can get in the MMT test position but they can't hold the test position and a substitution occurs. What do you do?

-Place the patient in an anti-gravity position and must be documented

Scenario One-Patient holds test position

-Pressure/Resistance(force applied):

1. Force exerted by examiner in direction opposite action of muscle/group tested. Example: function of quadriceps is extension

2. Pressure applied gradually allowing muscles to "SET"; release gradually

3. Pressure applied to distal end of bone on which muscle inserts (ex: quads at ankle)
**Exception: Pain/Injury @ Intervening joint

Scenario Two-Patient cannot hold test position

-An alternate position is found that eliminates gravity

-Then patient is asked to move into the test position

-Grade is then determined by the amount of movement

What does Grading depend on?

-Amount of resistance applied in a specific test position versus resistance through range
"break test" versus "make test"

-The ability of the muscle/group to move through all or part of the range in gravity resisted or gravity eliminated position

-Presence of muscle contraction detected by palpation/sight

What is the grading scale requirements for a 5/5 on MMT?

-Normal
-Patient is able to hold the test position against resistance

What is the grading scale requirements for a 4/5 on MMT?

-Good
-Patient able to hold test position against moderate resistance

What is the grading scale requirement for a 3+/5 on MMT?

-Fair+
-Patient able to hold test position against minimal resistance

What is the grading requirement for a 3/5 on MMT?

-Fair
-Patient is able to hold test position against gravity without substitution

What are the requirements for a 2+/5 on MMT test?

-Poor+
-Moves through full arc to test position with gravity eliminated and holds against slight pressure

What is the grading requirement for a 2/5 on MMT?

-Poor
-Patient moves through full arc to achieve the test position with gravity eliminated

What is the grading requirement for a 2-/5 on MMT?

-Poor-
-Patient moves through partial ROM with gravity eliminated

What is the grading requirement for a 1/5 on MMT

-Trace
-Tendon becomes prominent or feeble contraction felt in the muscle, but no visible movement of the part

What is the grading requirement for a 0/5 on MMT?

-Zero Absent
-No contraction is palpated in the muscle

Critical Concept(MUST KNOW)

Amount of pressure applied & position determines grade assigned
-Must know the test positions
-Must apply the pressure gradually so that you can tell what amount of resistance the patient can resist prior to "breaking" or substituting
-If the substitution occurs the level below at which it occurs becomes the grade

When a substitution occurs during MMT we should first think..?

-Does the subject understand exactly what they are supposed to do; could be poor instruction or

-Motor planning problems(this is how they have always done that motion)

-Other muscle groups attempt to compensate for absent or decreased function of a weak or paralyzed muscle being tested or

-Combination of all these

What is the definition of Validity?

-How truthful is MMT as a measure of strength? "strength" meaning hypertrophy strength

-"Relatively" valid test in regards to hypertrophy

-Must have careful observation, palpation, stabilization, and correct test position otherwise it decreases the reliability and validity of the measure

What is Intra-Rater Reliability?

-Relatively good with same, consistent technique

-Need to practice to improve reliability

What is Inter-Rater Reliability?

Relatively good with same, consistent technique

-**THIS HAS MORE VARIATION THAN INTRA-RATER

-Need to practice to improve reliability

What are some concepts associated with MMT?

Attempt to test all muscles/groups appropriate to a particular position before changing test positions

-plan ahead
-Keep track of responses during the testing

What are limitations of MMT?

-Small changes in strength not easily assessed b/c it's only relatively reliable and valid; pressure grading based PT's perception

-Semi-subjective/subjective data vs objective data

-Some feel "break" or "make" tests are not as good as testing the strength throughout the range

-Indicated only for those patients that can perform isolated joint movements versus some patients with Upper Motor Neuron Lesion move in "stereotypical patterns or synergies"

-Ceiling Effects

How do Children impact MMT Grading?

Typical: Most grades are based on young to middle adult strength, yet applied to all ages

Children:
-Grades

How do Older Adults impact MMT grading?

-Should be graded no differently

-Utilize same parameters

-Controversy: "Normal" or "good" for "age" is NOT appropriate

-Anticipate Decline

**Keep in mind as individuals age, their joint ROM decreases &/or they may not be able to get into the standard test position

How do age changes impact MMT?

-Ability to generate tension decreases with age

Age 60 a typical decline 18-40% due to:
1) Decreased size of muscle fibers
2) Decreased number of motor units
3) Decreased delivery of energy sources

-Acquired weakness over time as a result of:
1) Faulty Posture
2) Handedness Patterns
3) Occupational stresses/strains

Critical Principles of Kendall (MUST KNOW)

-Majority of time place muscle(s) "In position of function"

-Exception: When position of body in relation to gravity requires the test position to be altered

Example: Anterior or Posterior Deltoid MMT When Sitting

-WE WANT THE FIBERS PERPENDICULAR TO GRAVITY MAKING IT AGAINST GRAVITY THAT"S WHEN THE MUSCLE WORKS THE HARDEST

Critical Principles of Kendall (MUST KNOW)

-Tendency to "isolate" specific muscles versus "group" testing

-Rarely resists rotation component, unless this is the major action of the muscle(s) being tested. It is very rare for us to resist rotation. We often place a patient into a rotated position, but we don't try to rotate.

Example: Upper Trap MMT Test. We placed the shoulder into function and the head into function. As we are pushing, we're looking at the side bending and elevation not trying to rotate but placing them into rotation for the test position. Most pushing is in a straight plane not the transverse plane.

Critical Principles: Amount of Resistance (MUST KNOW)

-Increase/Decrease resistance gradually

-Apply resistance proportionally to: PCSA (Physiological Cross Sectional Area).
Example: My wrist extensor PCSA is smaller than my quadricep PCSA. So when I resist the wrist I'm going to resist with less force compared to the quadriceps where I'll be pushing more due to bigger PCSA.

Critical Principle: Leverage

-Leverage: Kendall uses in most instances a LONG LEVER ARM(Unless Contraindicated) (this is also why petite physical therapists can create the same kind of pressure as a jacked physical therapist)

-Most Often: Pressure is applied against DISTAL part on which muscle inserts

-Sometimes: Pressure applied against a PART MORE DISTAL than the bone of insertion & an "INTERVENING" MUSCLE OR GROUP of muscles MUST HOLD in order to use long lever arm

Critical Principle: "Ceiling" Effects (MUST KNOW)

-The level above which variance in an independent variable is no longer measurable

-Even though you have given the patient a "4/5" or "5/5" grade, this may not translate into the patient being able to functionally perform a certain activity

-Once reach 5/5 can't assess further difference

Critical Principle: Leverage (MUST KNOW)

-Will the "Intervening Muscle" hold so that you can use the longer lever arm?

-Ex: If I'm testing the middle trapezius my posterior and middle delt have to work to maintain the glenohumeral position for me to transfer the pressure of the long lever arm to the scapula

-Most of the time we will be using long lever arms BUT there are some exceptions such as MMT of HIP ADDUCTORS

What's a static muscle contraction?

Isometric=force developed without motion around a joint axis; technically no work is performed (W=F x D)

What's a Dynamic Muscle Contraction?

-Eccentric Contraction (shortening)
-Concentric Contraction (Lengthening)

What are examples of static devices?

-These test the Isometric hold
1) Cable Tensiometer
2) Hand Held Dynamometer
3) Hand Grip Dynamometer
4) Pinch Dynamometer
5) Isokinetic Device set at "0" Velocity or speed

What are examples of Dynamic Devices?

-These use Isokinetic motion= concentric or eccentric contraction in which a constant velocity is maintained throughout the muscle action

1)Biodex
2) Cybex
3) Kincom

How does the Hand Held Dynamometer work? What type of test is it static or dynamic?

-Static
-Utilizes internal load cell to determine maximum force generated at a specific point in the ROM
-See these most utilized in research

What are the Objective/Subjective Components of a Measure?

1. Objective Components
-Enhances Reproducibility
-Minimize Biases

2. Subjective Component
-Minimizes reproducibility
-Allows for Variability

GOAL: MINIMIZE THE SUBJECTIVE COMPONENTS, ENHANCE THE OBJECTIVE COMPONENT

How do Cable Tensiometer devices work? Are they a Dynamic or Static test?

-Static
-Measuring a linear force generated along a long axis
-hard to do in clinic
-used 1st by researchers

How do Hand Grip Dynamometer work? Is this a static or dynamic test?

-Static
-Device held in patients hand; patient grips as forcefully as he/she can against an immoveable bar
-Have to be Calibrated

How does the different settings on the hand grip dynamometer effect the demonstration of effort applied by the patient?

-Can change the distance on the handle to determine if maximum effort is occurring

-Position 1: closest to the handle tests the muscle in the short position they should be able to generate a low amount of force

-Moving it to position 2, 3, and 4 it will be testing the muscles in the mid range and be able to produce the greatest amount of force

-Moving the position to 4&5 it will test the muscle at the lengthened position with force production decreased

-Once all positions have been tested it should produce a muscle length tension curve cause of changing the position of the muscle

How does the Pinch Dynamometer work? Is this a static or dynamic test?

-Static
-Device held between thumb and one of other digits; subject pinches as forcefully as he/she can against an immovable bar
-Use a key pinch grip
-Need a minimum of 3 trials and average them

What's the significance of using Isokinetic Units?

-Specialized equipment measuring peak torque generated at a pre-set angular velocity

-Provide maximum resistance through entire ROM

-Newer units accommodate to patient's changing ability through the range

Features of Dynamic Devices for Dynamic Tests?

-Test Procedures

Stabilization: Large piece of equipment; subject is in specified position; straps aid in fixation

-Fixed axis at pre-set constant velocity

-Open versus closed kinetic chain

- Single Plane of movement being tested(the error in this is it's not very functional. Even though it is still testing strength we don't move in a single plane most of the time)

-Speed chosen ranges from "0" speed (isometric) to high speed (concentric or eccentric)

**You CAN create an isometric test(static test) even though it's an ISOKINETIC test(dynamic test) by setting the speed they move at 0 degrees per second meaning no movement is occurring(isometric contraction)

Disadvantages of Dynamic Testing?

-Measure isometric or dynamic movement
-Equipment expensive to purchase/maintain
-Trained personnel for testing, training, & data interpretation
-Calibration
-Alternative for training strong subjects(used as a Strengthening tool or "Biofeedback took")
-Feasibility

-Biofeedback tool: If I push this hard and the dial goes up. I can be watching that and generate a force to try to reach a goal and get feedback for my efforts.

-Reliability and Validity is stronger because we've got a weighted resistance, but since it became that it didn't impact their function the negatives have outweighed the positives so you're not seeing it in clinics as much.

MMT versus Instrumental Testing

-Both require specific protocols to ensure reliability of results

-Both measure single plane movements versus functional performance

-Both emphasize open kinetic chain activities

-MMT seems to be more reliable and valid at LOWER strength levels; Instrumental testing seems to be more reliable and valid at HIGHER strength levels (*Controversial)

-Both have good intra rater reliability and less inter rater reliability

-Some feel that stabilization may be an issue with Instrumental Testing because the compression on a muscle makes it not work as hard as if it's not restrained

-Some feel that Instrumental Testing is difficult because instruments do not conform well to the body part versus the "hand" with MMT

-Instrumental testing strength results cannot be compared unless you are using the same Instrumental Testing unit

-Both agree that the experience of the tester will affect reliability

-Instrumental units vary in level of expense with regards to purchase as well as maintenance; your hands are "free"

-Instrumental Testing "norms" or "normative values" are established for specific populations

Instrumental Muscle Testing Studies

-They're going to have the weight (resistance) of the patient divided by the length of the bone so that it becomes more normalized data so it can assist someone really large to be able to push higher weights versus someone who's very petitie and not being able to generate the same force.

What is the definition of reliability?

-The extent to which repeated measures are consistent

-All measures have error. Error can be systematic or random and comes from many sources

Why does context matter for reliability?

-Reliability is not all or none. consider if the reported reliability is sufficient for the given situation

-Reliability established for one group of raters doesn't equate another group of raters

-Reliability established for one group of people with a particular disorder doesn't equate to another group of people with a different disorder

What is Rater Reliability?

Are people conducting the measurements achieving consistent measures?

What are the 2 types of rater reliability?

-Intra rater Reliability (within self)
-Inter rater Reliability (Between Raters)

Example: Clinician A achieves consistent (similar) leg length measures when measuring 10 patients on 2 different occasions. What type of rater reliability is this?

Intra Rater Reliability

Example: Clinician A and Clinician B achieve consistent (similar) leg length measures when each clinician measures the same 10 people. What type of rater reliability is this?

Inter Rater Reliability

Example: Reliability was computed for each neurologic and provocative clinical examination measure using dichotomized findings from the involved limb obtained by 1 RATER PAIR that examined 50 patients. What type of rater reliability is this?

-Inter rater reliability because it consists of 2 different people taking a measurement

What is Test-Retest Reliability?

Given no real change, are the measures stable over time?

Example: People answering a survey of patient satisfaction respond similarly when given the same survey 2 weeks apart. What type of test is this?

Test-Retest Reliability

What type of test is a patient reported outcome measure(patients fill out a questionnaire on how they're doing)?

Test-Retest Reliability

What is Equivalence Reliability?

-Do different measurement techniques of the same phenomenon provide equivalent results?