5/18/2020
PRINCIPLES
OF PT
EVALUATION
A compilation and summarized
lecture notes (STUDOCU.COM)
From OUR LADY OF FATIMA UNIVERSITY FILES
TEP 2 LECTURE REVIEWER
EXAMINATION OF SENSORY FUNCTION
Sensory Integration
- It is the ability of the brain to organize, interpret and use sensory information.
- Neurological process that organizes the sensation from one’s own body and from
the environment and make it possible to use the body effectively within the
environment
Purpose of Sensory Integration
✓ Explaining behaviors of individuals with impaired sensory integration functions.
✓ Establishing a Plan of Care to address specific impairments
✓ Predicting expected outcomes of the selected interventions
Sensation & Movement
1. Feedback Control
- Uses sensory information received during the movement to monitor and adjust output
2. Feedforward Control
- It is a proactive strategy that uses sensory information obtained from experience
Primary Roles of Sensation Movements
✓ Guide selection of motor responses for effective interaction with the environment
✓ Adapt movements and shape motor programs through feedback for corrective
action.
✓ It Also protects the organism from injury
Sensory Integrity
- Intactness of cortical sensory processing, including proprioception, pallesthesia,
stereognosis and topognosis
Somatosensory
- AKA: Somatosensation
- Sensation received from the skin and musculoskeletal system
Clinical Indications
✓ History
✓ Systems of Review
Pattern of Sensory Impairment
- Pattern identification is accomplished using knowledge of skin segment (Dermatome)
innervation by the dorsal roots and peripheral nerves.
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Dermatomes
- AKA: Skin-segment
- Refers to the skin area supplied by one dorsal root.
C1= No dermatome (Pure Motor)
C2=Occiput
C3= Supraclavicular fossa
C4= Superior Acromioclavicular Joint
C5= Lateral side of the forearm (Deltoid Area)
C6= Thumb
C7= Middle Finger
C8= Little Finger
T1= Medial side of the forearm
T2= Apex of Axilla
T3= 3rd ICS
T4= At nipple line
T5= 5th ICS
T6= Xiphoid Process
T7= 7th ICS
T8= 8th ICS
T9= 9th ICS
T10= Umbilicus
T11= 11th ICS
T12= Inguinal Ligament
L1= Between T12 and L2
L2= Mid-anterior Thigh
L3= Medial Femoral Condyle
L4= Medial Malleolus
L5= Dorsum of the Foot
S1= Lateral Heel
S2= Popliteal Fossa
S3= Ischial Tuberosity
S4-S5= Peri-anal Area
Spinal Cord Tract
- Provides data that reflect integrity of the spinal cord tracts that carry somatosensory
information.
Age-Related Sensory Changes
- Alterations in sensory function occur with normal aging.
Arousal
- It is the physiological readiness of human system for an activity.
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ATTENTION
- Selective awareness of the environment or responsiveness to a stimulus or task
without being distracted by other stimuli
Level of Consciousness
1. ALERT
- Patient is awake and attentive to normal interactions.
- Interaction with therapist are normal and appropriate.
2. LETHARGIC
- Patient appears drowsy and may fall asleep
- Interactions with therapist may be diverted
- Patient may have difficulty in focusing or maintaining attention on a question or task.
3. OBTUNDED
- Patient is difficult to arouse from a somnolent state and is frequently confused when
awake.
- Repeated stimulation is required to maintain consciousness
- Interaction with therapist may be largely unproductive.
4. STUPOR
- AKA: Semi-coma
- Patient responds only to strong, generally noxious stimuli and returns to the
unconscious state when stimulation is stopped.
- When aroused, patient is unable to interact with the therapist.
5. COMA
- AKA: Deep coma
- Patient cannot be aroused by any type of stimulation
- Reflex motor responses may or not may be seen.
Orientation
- Refers to the patient awareness of time, person, place and event
- To document: If the patient is fully oriented in this domain, you can write Oriented x4
- If the patient is not fully oriented to one or more domains, (e.g. Oriented x2 (time,
place)
COGNITION
- Defined as the process of knowing and includes both awareness and judgement.
3 AREAS FOR TESTING COGNITION-DEPENDENT
FUNCTION TESTING
1. Fund of Knowledge
- Defined as the sums total of an individual’s learning and experience in life
2. Calculation Ability
- Examines foundational mathematical abilities.
- Dyscalculia (Difficulty in accomplishing calculation
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- Acalculia (inability to calculate)
3. Proverb Interpretation
- Examines the patient’s ability to interpret use of words outside of their usual context
or meaning.
Types of Memory
1. Long-Term Memory
- AKA: Remote Memory
- Can be examined by requesting information on date and place of birth, number of
siblings, date of marriage, schools attended and historical facts.
2. Short-Term Memory
- Can be addressed by verbally providing the patient with a series of words ornumbers.
Hearing
- Note should be made of how alterations in voice volume and tone influence patient
response.
Visual Acuity
- A gross visual examination can be made by use of a standard Snellen chart mounted
on the wall or visual acuity cards for use at bedside
Classification of Sensory System
Sensory Receptors
- AKA: Sensory Nerve Endings
- Located at the distal end of an afferent fiber.
- Highly sensitive to the type of stimulus
Labeled Line Principle
- Specificity of nerve fiber sensitivity to a single modality of sensation
- Individual tactile sensations are perceived when specific types of receptors are
stimulated.
3 DIVISION OF SENSORY RECEPTORS
1. Superficial Sensation
a. Exteroreceptors
- Responsible for superficial sensation
- They receive stimuli from the external environment via the skin and subcutaneous
tissue.
- Responsible for the perception of pain, temperature, light touch, and pressure
2. Deep Sensation
a. Proprioceptors
- Responsible for deep sensation
- Receive stimuli from muscles, tendons, ligaments, joints, and fascia,
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- Responsible for position sense and awareness of joints at rest, movement awareness
(kinesthesia), and vibration
3. Combined and Cortical Sensation
- These sensations require information from both exteroceptive and proprioceptive
receptors, as well as intact function of cortical sensory association areas.
- The cortical combined sensations include stereognosis, two-point discrimination,
barognosis, graphesthesia, tactile localization, recognition of texture, and double
simultaneous stimulation.
Spinal Pathways
- Sensations are mediated by either the ANTEROLATERAL SPINOTHALAMIC SYSTEM or
the DORSAL COLUMN-MEDIAL LEMNISCAL SYSTEM
1. Anterolateral Spinothalamic System
- Initiates self-protective reactions and responds to stimuli that are potentially harmful
in nature.
- (+) Slow-conducting fibers of small diameter (unmyelinated)
- Function: Concerned with transmission of thermal and nociceptive information, and
mediates pain, temperature, crudely localized touch, tickle, itch, and sexual sensations
2. Dorsal Column-Medial Lemniscal System
- Involved with responses to more discriminative sensations.
- Contains fast-conducting fibers of large diameter with greater myelination
- Function: Mediates the sensations of discriminative touch and pressure sensations,
vibration, movement, position sense, and awareness of joints at rest.
Types of Sensory Receptor
I. Mechanoreceptors
- Respond to mechanical deformation of the receptor or surrounding area
A. CUTANEOUS RECEPTORS
- Located at the terminal portion of the afferent fiber.
1. FREE NERVE ENDINGS
- Found throughout the body
- Stimulation of free nerve endings results in perception of pain, temperature, touch,
pressure, tickle and itch sensation.
2. HAIR FOLLICLE ENDINGS
- AKA: Hair-End Organs
- At the base of each hair follicle a free nerve ending is entwined.
- The combination of the hair follicle and its nerve provides a sensitive receptor.
- These receptors are sensitive to mechanical movement and touch.
3. MERKEL’S DISCS
- AKA: Tactile Discs
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- Located below the epidermis in hairless smooth (glabrous) skin with a high density in
the fingertips.
- They are sensitive to low-intensity touch, as well as to the velocity of touch, and
respond to constant indentation of the skin (pressure)
- They provide for the ability to perceive continuous contact of objects against the skin
and are believed to play an important role in both two-point discrimination and
localization of touch.
4. RUFFINI ENDINGS
- Located in the deeper layers of the dermis
- Encapsulated endings are involved with the perception of touch and pressure
- They are slowly adapting and particularly important in signaling continuous skin
deformation such as tension or stretch
- They are also found in joint capsules and assist with joint position sense
5. Krause-End Bulb
- AKA: Bulboid Corpuscle
- Located in the dermis and conjunctiva of the eye
- They are believed to be low-threshold mechanical receptors that may play a
contributing role in the perception of touch and pressure.
6. Meissner Corpuscle
- AKA: Corpuscle of Touch
- Located in the dermis, these encapsulated nerve endings contain many branching
nerve filaments within the capsule
- They are low-threshold, rapidly adapting and in high concentration in the fingertips,
lips, and toes, areas that require high levels of discrimination.
- Plays an important role in discriminative touch (e.g., recognition of texture) and
movement of objects over skin
7. Pacinian Corpuscles
- AKA: Lamellated Corpuscle
- subcutaneous tissue layer of the skin and in deep tissues of the body (including
tendons and soft tissues around joints)
- stimulated by rapid movement of tissue and are quickly adapting
- They play a significant role in the perception of deep touch and vibration.
II. Deep Sensory Receptors
- Located in muscles, tendons, and joints
- Concerned primarily with posture, position sense, proprioception, muscle tone, and
speed and direction of movement
A. MUSCLE RECEPTORS
1. MUSCLE SPINDLE
- The muscle spindle fibers (intrafusal fibers) lie in a parallel arrangement to the
muscle fibers (extrafusal fibers).
- They monitor changes in muscle length (Ia and II spindle afferent endings) as well as
velocity (Ia ending) of these changes.
- Plays a vital role in position and movement sense and in motor learning.
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2. GOLGI TENDON ORGANS (GTO)
- Located in series at both the proximal and distal tendinous insertions of the muscle
- Monitor tension within the muscle.
- Provide a protective mechanism by preventing structural damage to the muscle
in situations of extreme tension
- This is accomplished by inhibition of the contracting muscle and facilitation of the
antagonist
3. FREE NERVE ENDINGS
- These receptors are within the fascia of the muscle.
- They are believed to respond to pain and pressure.
- PACINIAN CORPUSCLES
- AKA: Lamellated Corpuscles
- Located within the fascia of the muscle, these receptors respond to vibratory stimuli
and deep pressure.
B. JOINT RECEPTORS
1. GOLGI TYPE ENDINGS
- These receptors are located in the ligaments, and function to detect the rate of joint
movement.
2. FREE NERVE ENDINGS
- Found in the joint capsule and ligaments,
these receptors are believed to respond to
pain and crude awareness of joint motion
3. RUFFINI ENDING
- Located in the joint capsule and ligaments
- Ruffini endings are responsible for the direction and velocity of joint movement.
- ALSO KNOWN FOR RUFFINIT (HOT)
4. PACINIFORM ENDINGS
- These receptors are found in the joint capsule and primarily monitor rapid joint
movements.
III. THERMORECEPTORS
- Respond in temperature
IV. NOCICEPTORS
- Respond to noxious stimuli and result in the perception of pain
V. CHEMORECEPTORS
- Respond to chemical substances and are responsible for taste, smell, oxygen levels in
arterial blood, CO2 concentration and osmolality (concentration gradient) of the body.
VI. Photic
- AKA: Electromagnetic Receptors
- Respond to light with in the visible spectrum
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Spinal Cord Pathway
VEM
Corticospinal: Rapid skilled voluntary; decussation of the pyramids (medulla inf. Border)
Rubrospinal: Facilitates flexor muscles & inhibit extensor/anti-gravity muscles
Tectospinal: Reflex postural movement in response to visual stimuli
Vestibulospinal: Facilitate extensor muscles & inhibit flexor muscles
Olivospinal: Influence activity of motor neurons
Reticulospinal: Inhibit/facilitate movement
DAS
Spinothalamic Tract
a. Anterior Spinothalamic
- Light Touch & Pressure
b. Lateral Spinothalamic
- Pain & Temperature
Spinocerebellar
- Unconscious jt/mm sense
Dorsal Column
- Conscious
- Proprioception
- Kinesthesia
- Vibration
EQUIPMENT
1. PAIN
- Large safety pain / Large paper clip (one segment open
2. TEMPERATURE
- Two standard laboratory test tubes with stoppers
3. LIGHT TOUCH
- COTTON / TISSUE / CAMEL BRUSH
4. VIBRATION
- Tuning Fork / Earphones
5. STEREOGNOSIS (OBJECT RECOGNITION)
- Comb, fork, paper/ etc.
6. 2 POINT DISCRIMINATION
- Aesthesiometer
- ECG CALIPER
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7. RECOGNITION OF TEXTURE
- Cotton, wool, burlap, silk
TERMINOLOGY DESCRIBING COMMON SENSORY IMPAIRMENT
Abarognosis- Inability to recognize weight
Allesthesia- Sensation experienced at a site remote from a point of stimulation
Allodynia- Pain produced from non-noxious stimuli
Analgesia -Complete loss of pain sensitivity
Astereognosis/Tactile Agnosia- Inability to recognize the form and shapes of objects by
touch
Atopognosia- Inability to localize a sensation
Causalgia- Painful, burning sensations, usually along the distribution of a nerve
Dysesthesia- Touch sensation experienced as pain
Hypalgesia- Decrease sensitivity to pain
Hyperalgesia- Increase sensitivity to pain
Hypesthesia- Decrease sensitivity to sensory stimuli
Pallanesthesia- Loss or absence of sensibility to vibration
Paresthesia- Abnormal sensation such as numbness, prickling, or tingling, without
apparent cause
Thalamic Syndrome- Vascular lesion of the thalamus resulting in sensory disturbances
and partial or complete paralysis of one side of the body, associated with severe,
boring-type pain; sensory stimuli may produce an exaggerated, prolonged, or painful
response
Thermanalgesia- Inability to perceive heat
Thermanesthesia- Inability to perceive sensations of heat and cold
Thermhypesthesia- Decreased temperature sensibility
Thermhyperesthesia-Increased temperature sensibility
Thigmanesthesia- Loss of light touch sensibility
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EXAMINATION OF MOTOR FUNCTION
MOTOR CONTROL
- Complex set of neural, physical and behavioral process that govern posture and
movement.
REFLEX PATTERNS
- Automatic (Walking and Breathing)
- Motor Skills (Writing and Reading)
HOW IS IT DEVELOPED?
Motor Program
- Abstract representation that, when initiated, results in production of a coordinated
sequence.
- Brain and Spinal Cord
Motor Plan
- A set of Motor Program
Motor Memory
- Recall of the motor program
- INITIAL MOVEMENT CONDITION
- HOW THE MOVEMENT FELT, LOOKED AND SOUNDED (SENSORY CONSEQUENCES)
- SPECIFIC MOVEMENT PARAMETERS (KNOWLEDGE OF PERFORMANCE)
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- OUTCOME OF THE MOVEMENT (KNOWLEDGE OF RESULTS)
Neuroplasticity
- Capacity of the brain to adapt to injury through mechanism of repair and change.
Motor Learning
- Set of internal processes associated with practice or experience leading to relatively
permanent changes.
FEEDBACK
- Response-produced information receives during or after the movement
- Use to monitor output for corrective actions.
FEEDFORWARD
- Sending signals in advance of movement to ready the sensorimotor systems
- Allows for anticipatory adjustments in postural activity.
MOTOR CONTROL THEORIES
1. Dynamic Control Systems Theory
- Units of the CNS are organized around a specific task demands
- SMALL TASK: small part of the brain will activate it
- COMPLEX TASK: All parts of the brain will activate it
2. Hierarchical Control Theory
Represented by the association areas of the neocortex and basal ganglia of the
forebrain
Concerned with strategy: the goal of the movement and the movement strategy that
best achieves the goal
Represented by the motor cortex and cerebellum,
Concerned with tactics: the sequences of muscle contractions, arranged in
space and time, required to smoothly and accurately achieve the strategic goal.
Represented by the brain stem and spinal cord
Concerned with execution: activation of the motor neuron and interneuron pools that
generate the goal-directed movement and make any necessary adjustments of posture
EXAMINATION OF MOTOR FUNCTION
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I. PATIENT HISTORY
A. GENERAL INFORMATION
a. Name
b. Age
c. Occupation
d. Handedness
e. Status
f. Religion
g. Referring Unit
h. Referring Doctor
i. Date of Referral
j. Physiatrist in Charge
k. Date of Consultation
l. Diagnosis
m. Chief of Complaint
n. Informant/Reliability
B. BRIEF HISTORY
a. History Illness
b. Functional Limitation
C. LABORATORY/ANCILLARY PROCEDURES
D. MEDICATIONS
E. PAST MEDICAL HISTORY
F. FAMILY MEDICAL HISTORY
G. PERSONAL/SOCIAL/ENVIRONMENTAL
HISTORY
II. SYSTEMS OF REVIEW
- Screening examinations for identification of potential problems that may require
extensive testing.
III. SPECIFIC TEST AND MEASURES
1. VALIDITY
- Accurately measures the parameter of performance being examined.
2. RELIABILITY
- Reflected in the consistency of results obtained by a single examiner over repeat
trials (INTRARATER RELIABILITY) or among multiple examiners (INTERRATER
RELIABILITY)
3. SENSITIVITY
- Refers to the proportion of times that a method of analysis correctly identifies an
abnormality as being present (True Positive)
4. SPECIFICITY
- Refers to the proportion of times that a method analysis correctly identifies an
abnormality as being absent (True Negative)
5. QUALITATIVE
- Utilizes observations of complex aspects of performance.
6. QUANTITATIVE
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- Use objective measurement as a way of examining performance
FACTORS THAT MAY CONSTRAIN THE MOTOR
FUNCTION EXAMINATION
1. Mental Status
a. Consciousness
- Refers to a state of arousal accompanied by awareness of one’s environment.
Minimally Conscious State
- AKA: Vegetative State
- Characterize by return of sleep-wake cycle and normalization of the vegetative
function such as respiration, digestion and blood pressure control
Persistent Vegetative State
- Individuals who remain in a vegetative state 1 year or longer after TBI and 3 months
or more for anoxic brain injury.
- Caused by severe brain injury
Glasgow Coma Scale
- Gold standard instrument used to document level of consciousness in acute brain
injury.
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Interpretation
- Mild TBI: 13-15
- Moderate TBI: 9-12
- Severe TBI: 3-8
Pupillary Size & Reaction
1. BILATERALLY SMALL
- Sympathetic pathways in hypothalamus
- Metabolic Encephalopathy
2. PIN-POINTED
- Hemorrhagic Pontine Lesion
- Narcotic Overdose
3. FIXED IN MID POSITION AND SLIGHTLY DILATED
- Midbrain Damage
4. BILATERALLY LARGE, FIXED, DILATED
- Anoxia or Drug Toxicity
5. UNILATERAL FIXED AND DILATED
- Temporal lobe herniation Inverted U-Principle
- AKA: Yerkes Dodson Principle
- An appropriate level of arousal allows for optimal motor performance; very low or
high levels of arousal can cause deterioration in motor response.
b. Orientation
- Refers to the patient’s awareness of time, place, person and circumstances.
c. Attention
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- Selective awareness of the environment or responsiveness to a stimulus or task
without being distracted by other stimuli
- Types of Attention
1. Selective Attention
- Can be examined by asking the patient to attend to a particular task.
- e.g. Digit Span Test
2. Sustained Attention
- It is examined by determining how long the patient is able to maintain attention on a
particular task
- Attention span
3. Alternating Attention
- AKA: Attention Flexibility
- Examined by requesting the patient to alternate back and forth between two different
tasks.
4. Divided Attention
- Requesting patient to perform two tasks simultaneously
- e.g. Walkie Talkie Test
d. Memory
- It is the process of registration, retention and recall of past-experience, knowledge
and ideas.
TYPE OF MEMORY ACCORDING TO INFO
1. Declarative Memory
- AKA: Explicit Memory
- Involves the conscious recollection of facts, past events, experiences and places.
2. Motor Memory
- AKA: Procedural Memory
- Involves recall of movement or motor information and storage of motor programs,
sub-routines, schema as well as perceptual and cognitive skills.
TYPE OF MEMORY ACCORDING TO LENGTH OF TIME
1. Short Term Memory
- AKA: Recent Memory
- Refers to the capability to remember current, day to day events.
- Learn new materials and retrieve material after an interval of minutes, hours or days.
2. Long Term Memory
- AKA: Remote Memory
- Refers to the recall of facts or events that occurred years before.
3. Immediate Memory
- AKA: Immediate Recall
- Refers to an immediate registration and recall of information after an interval of a
few seconds.
4. Working Memory
- Keep track of many bits of information simultaneously and to cause recall of this
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✓ Constructional Ability
✓ Communication
Elements of Motor Function
1. Tone
- Resistance of a muscle to passive elongation or stretch.
Postural Tone
- Pattern of muscular tension that exists throughout the body and affects group of
muscle.
Tonal Abnormalities
1. HYPERTONIA
- Increase Muscle Tone
- Antagonist
2. HYPOTONIA
- Decrease Muscle Tone
- Antagonist and Agonist
3. DYSTONIA
- Impaired or disordered tonicity
HYPERTONIA
Spasticity
- Motor disorder characterized by a velocity-dependent increase in muscle tone with
increase resistance to stretch.
- Upper Motor Neuron Lesion
- Increase Speed = Increase Tone
Clasp-Knife Response
- Sudden inhibition or letting go of the limb (relaxation) in response to a stretch
stimulus.
Clonus
- Characterized by cylical, spasmodic alternation of muscular contraction and
relaxation in respone to sustained stretch of a spastic muscle
RIGIDITY
- Hypertonic state characterized by constant resistance throughout ROM that is nonvelocity dependent.
- Associated with lesion of basal ganglia system
a. Lead-Pipe Rigidity
- Constant resistance
b. Cogwheel Rigidity
- Hypertonic State with superimposed ratchet-like jerkiness and commonly seen in UE.
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OPHIOSTHOTONUS
- Characterized by strong and sustained contraction of the extensor muscle of neck
and trunk.
DECORTICATE RIGIDITY
- Sustained contraction and posturing of
a. UE: FLEXION
b. LE: EXTENSION
DECEREBRATE/Abnormal Extensor Response
- Sustained contraction and posturing of trunk and limbs in a position of full extension
HYPOTONIA/FLACCIDITY
- Decrease or (-) Tone
- Decrease or (-) Reflex
- Paresis
- Muscle Fasiculation and Fibrilation
- Neurogenic Atrophy
- Lower Motor Neuron Lesion
DYSTONIA
- Prolonged involuntary movement disorder characterized by twisting or writhing
repetitive movements and increased muscular tone.
DYSTONIC POSTURING
- Refers to sustained abnormal postures caused by contraction of muscles that may
last for several minutes, for hours or permanently
- LESION: BASAL GANGLIA (NUCLEI)
FOCAL DYSTONIA
- Affect only one part of the body.
- Seen in spasmodic torticollis, wry neck or writer’s cramp
SEGMENTAL DYSTONIA
- Affects 2 or more adjacent areas
EXAMINATION OF TONE
1. Initial Observation of Resting Posture and Palpation
2. Passive Motion Testing
3. Active Motion Testing
4. Special Tests: Pendulum Test
EXAMINATION OF TONE
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Typical Patterns of Spasticity
Modified Ashworth Scale
Deep Tendon Reflexes
1. Jaw Reflex (CN V)
- Stimulus: Patient is sitting, with jaw relaxed and slightly open. Place finger on top of
chin; tap downward on top of finger in a direction that causes the jaw to open
- Response: Jaw rebounds and closes
2. Biceps (C5, C6)
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- Stimulus: Patient is sitting with arm flexed and supported. Place thumb over the
biceps tendon in the cubital fossa, stretching it slightly. Tap thumb or directly on
tendon.
- Response: Slight contraction of elbow flexors
3. Brachioradialis (C5, C6)
- Stimulus: Patient is sitting with arm flexed onto the abdomen. Place finger on the
radial tuberosity and tap finger with hammer
- Response: Slight contraction of elbow flexors
4. Pronator Teres (C6, C7)
- Stimulus: With the elbow in semiflexion and the forearm semi-pronated, tapping over
either the volar surface of the distal radius or the dorsal aspect of the styloid process of
ulna
- Response: Slight contraction of elbow flexion and forearm pronation
5. Finger Flexors (C6-T1)
- Stimulus: Hold hand in neutral position. Place finger across palmar surface of distal
phalanges of four fingers and tap
6. Hamstrings
a. Medial Hamstrings (L5, S1)
- Stimulus: Semimembranosus Tendon
- Response: Knee flexion
b. Lateral Hamstrings (S1, S2)
- Stimulus: Biceps femoris tendon
- Response: Knee flexion
7. Patellar/Knee Jerk (L2, L3, L4)
- Stimulus: Patient is sitting with knee flexed, foot unsupported. Tap tendon of
quadriceps muscle between the patella and tibial tuberosity.
- Response: Slight contraction of knee extensors
8. Achilles/Ankle Jerk (S1, S2)
- Stimulus: Patient is prone with foot over the end of the plinth or sitting with knee
flexed and foot held in slight dorsiflexion. Tap tendon just above its insertion on the
calcaneus. Maintaining slight tension on the gastrocnemius-soleus group improves the
response.
- Response: Slight contraction of plantar flexors
Deep Tendon Reflex Grading
Superficial Reflexes
Plantar (S1, S2)
- Stimulus: With blunt object (key or wooden end of applicator stick), stroke the lateral
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aspect of the sole, moving from the heel to the ball of the foot, curving medially across
the ball of the foot.
Abdominal
a. Upper Abdominal/Above (T8-T10)
- Stimulus: Position patient in supine, relaxed. Make brisk, light stroke over each
quadrant of the abdominals from the periphery to the umbilicus
- Response: Umbilicus moves up and toward area being stroked
b. Lower Abdominal/Below (T10-T12)
- Stimulus: Position patient in supine, relaxed. Make brisk, light stroke over each
quadrant of the abdominals from the periphery to the umbilicus
- Response: Umbilicus moves down and toward area being stroked
Gluteal Reflex (L4-L5, S1-S3)
- Stimulus: Tapping the lower portion of the sacrum or the posterior aspect of the ilium
near the origin of the gluteus maximus muscle
- Response: Skin tenses in gluteal area
Cremasteric Reflex (T12, L1-L2)
- Stimulus: Stroking or lightly scratching or pinching the skin on the upper, inner
aspect of the thigh
- Response: Scrotum elevates
Pathological Reflexes
1. Gordon’s
- Stimulus: Squeezing of calf muscles firmly
- Response: Extension of big toe and fanning of four small toes
2. Schaeffer
- Stimulus: Pinching of Achilles tendon in middle third
- Response: Flexion of foot & toes
3. Chaddock’s
- Stimulus: Stroking of the lateral side of the foot beneath lateral malleolus
- Response: Extension of big toe and fanning of four small toes
4. Oppenheim’s
- Stimulus: Stroking of anteromedial tibial surface
- Response: Extension of big toe and fanning of four small toes
5. Hoffman’s
- Stimulus: Flicking” of terminal phalanx of index, middle, or ring finger
- Response: Reflex flexion of distal phalanx of thumb and of distal phalanx of index or
middle finger (whichever one was not “flicked”)
6. Souques Phenomenon
- Stimulus: Passive elevation of the Upper limb to 90 degrees of shoulder flexion
- Response: Contraction of finger extension
7. Raimiste’s Phenomenon
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- Stimulus: Resist of abduction on one side
- Response: Abduction of contralateral extremity
8. Marie-Foix Reflex
- Stimulus: Sudden passive flexion of toes
- Response: Flexion of LE (hip and knee flexion, ankle dorsiflexion and toe flexion)
9. Bechterev-Mendel Reflex
- Stimulus: Percussion of the middle sole or heel
- Response: Flexion of toes
10. Rossolimo’s Sign
- Stimulus: Tapping of the plantar surface of toes
- Response: Flexion of toes
11. Piotrowski
- Stimulus: Percussion of tibialis anterior
- Response: Dorsiflexion and supination of foot
12. Stransky
- Stimulus: Small toe forcibly abducted then released
- Response: Dorsiflexion of the great toe
13. Bing’s Sign
- Stimulus: Pricking of dorsum of the foot with a pin
- Response: Great toe extension
CRANIAL NERVE TESTING
TRIGEMINAL NERVE
a. MAXILLARY DIVISION
- Pure Sensory
b. MANDIBULAR DIVISION
- Mixed
c. OPTHALMIC DIVISION
- Pure Sensory
EXIT
1. ANTERIOR CRANIAL FOSSA
- CN 1: Perforation in Cribriform Plate Ethmoid Bone
2. MIDDLE CRANIAL FOSSA
- CN 2: Optic Canal
- CN 3,4,5,6: Superior Orbital Fissure
- CN 5 (MAXILLARY): Foramen Rotundum
- CN 5 (MANDIBULAR): Foramen Ovale
3. POSTERIOR CRANIAL FOSSA
- CN 7,8: Internal Acoustic Meatus
a. COCHLEAR: Anterior
b. VESTIBULAR: Posterior
- CN 9,10, 11: Jugular Foramen
- CN 11: Foramen Magnum
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- CN 12: Hypoglossal Canal
ORIGIN
- CN 1: Telencephalon
- CN 2: Diencephalon
- CN 3-4: Midbrain
- CN 5-8: Pons
- CN 9-12: Medulla Oblongata
NUCLEUS AMBIGUUS
- Connects CN 9 and CN 10
OLFACTORY NERVE
- Transmit olfactory impulses to the olfactory epithelium of the nose to the brain
- Most Common Contused Nerve
- Not a real nerve (outgrowth of the telencephalon)
- Function: For smelling
- Test: Non-noxious odors
- Clinical Implications:
1. Rhinorrhea
- Excretion of white fluid due to head trauma
- Paano malalaman kung sipon or CSF ang lumabas?
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a. *CSF: sweet due to glucose
b. Sipon: Salty and and Wet
2. ANOSMIA
- Inability to smell
- Bilateral (Both Nostrils)
a. Increase Mucous in nasal septum
b. Coryza: Sipon
c. Pertussis: Whooping Cough (if child 100 days of coughing)
- Unilateral
OPTIC NERVE
- Optic Pathway transmits visual impulse of retina to the brain
- Not a real nerve (Outgrowth of the Diencephalon)
a. Macula: Highest Resolution
b. Retina: Rods (Non-color) and Cones (Color)
- Function: Vision
- Test:
a. VISUAL ACUITY: Snellen Chart
b. CONFRONTATION TEST: Patient will cover his eyes then PT put object towards the
midline and then patient will identify object.
CLINICAL IMPLICATIONS
1. MONOCULAR BLINDNESS
- Ipsilateral Optic Nerve
- Left Monocular Blindness
- Right Monocular Blindness
2. BITEMPORAL HEMIANOPSIA
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- Optic Chiasma
a. Bitemporal
b. Binasa
3. HOMONYMOUS HEMIANOPSIA
- AKA: Contralatera Homo Hemi
- Optic Tract
- Optic Radiation
- Bicipital Lobe
- Naming: Right Homonymous Hemianosia
4. QUADRANT ANOPSIA
- Calcarine Sulcus
a. Superior/Coneal/Parietal Fibers of Optic Radiation
b. Inferior/Lingual/Temporal Fibers of Optic Radiation
- Naming: Contralateral
- Damaged:
a. Superior: Inferior Quadrant Anopsia
Inferior: Superior Quadrant Anopsia
EXAMPLE
- Right Cuneal is damaged: Left Inferior Quadrant Anopsia
- Left Temporal Fibers is damaged: Right Superior Quadrant Anopsia.
5. ANISOCORIA
- Unequal size of pupils
6. DYSCORIA
- Different shape of pupils
7. CORRECTOPIA
- Different position of Pupils
8. HETEROCHROMIA
- Iridum or Iridis
- Different color of Iris
a. Complete: Full (2 iris)
b. Sectoral: Part of Iris (1 iris)
c. Central: Spikes radiating from pupils (1 iris)
VESTIBULOCOCHLEAR NERVE
- AKA: Statoacoustic Nerve
- Function:
a. Hearing (Cochlea)
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b. Balance (Vestibule)
- VESTIBULAR ASPECT
I. UTRICLE AND SACCULE
- Detects linear head movement
- MNEMONIC: “HUVS”
- HU= Horizontal Utricle
- VS= Vertical Saccule
II. SEMICIRCULAR CANAL
- Detects rotatory head movement
- 3 pairs = 6
a. SUPERIOR/ANTERIOR: HEAD FLEXION
b. INFERIOR/POSTERIOR: HEAD EXTENSION
c. HORIZONTAL/LATERAL: HEAD ROTATION
TEST:
1. DIX-HALLPIKE TEST
- Benign Paroxysmal Positional Vertigo
- The test is performed by having the patient long-sit on a plinth with the head rotated
approximately 30° to 45°. The examiner stands behind the patient with one hand
supporting the head/ neck and the other hand supporting the trunk. The patient is
then assisted into a supine position with the patient’s head slightly below the horizontal
plane, and the position is maintained for 30 to 60 seconds
- (+) Dizziness and Nystagmus
2. TEMPERATURE (CALORIC) TEST
- For Inner Ear Problem
- The examiner alternately applies hot and cold test tubes several times just behind the
patient’s ears on the side of the head; each side is done in turn
- (+) Inducement of Vertigo
- MNEMONIC: “COWS”
a. COLD = Left Nystagmus
b. HOT = Right Nystagmus
- AUDITORY ASPECT
a. OUTER EAR
- External Surroundings → Collect Sound Waves → External Auditory Meatus →
Eardrum
b. MIDDLE EAR
- Ossicles
- Malleus, Incus, Stapes
- Vibrate to Inner Ear
c. INNER EAR
- Interpret Soundwaves to Electrical Impulse.
- Soundwaves travel in 2 ways
1. Air Conduction
- Outer and Middle Ear
2. Bone Conduction
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- Inner Ear (By passes outer & Middle Ear)
CLINICAL IMPLICATION
1. HEARING LOSS
a. CONDUCTIVE
- Reduction of all sounds
b. SENSORINEURAL
- Inner Ear
- Different Interpreting of Sounds.
c. CORTICAL
- Brain
2. MÉNIÈRE’S DISEASE
- Inner Ear
- Fullness of Ear & Tinnitus (Vibrate pero si
patient lang nakakarinig ng sounds)
3. PRESBYACUSIS
- Deafness due to old age.
TEST
1. RINNE’S TEST
- The Rinne test is performed by placing the base of the vibrating tuning fork against
the patient’s mastoid bone.
- The examiner counts or times the interval with a watch.
- The patient tells the examiner when he or she no longer hears the sound, and the
examiner notes the number of seconds.
- The examiner then quickly positions a still-vibrating tine 1 to 2 cm (0.5 to 0.8 inch)
from the auditory canal and asks patient to indicate when he or she no longer hears the
sound.
- The examiner then compares the number of seconds the sound was heard by bone
conduction and by air conduction. The counting or timing of the interval between
the two sounds determines the length of time that sound is heard by air conduction
- Air-conducted sound should be heard twice as long as bone-conducted sound. For
example, if bone conduction is heard for 15 seconds, the air conduction should be
heard for 30 seconds
2. SCHWABACH TEST
- This test compares the patient’s and examiner’s hearing by bone conduction
- The examiner alternately places the vibrating tuning fork against the patient’s
mastoid process and against the examiner’s mastoid bone until one of them no longer
hears a sound.
- The examiner and patient should hear the sound for equal amounts of time.
3. WEBER TEST
- The examiner places the base of a vibrating tuning fork on the midline vertex of the
patient’s head.
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- The patient should hear the sound equally well in both ears If the patient hears
better in one ear (i.e., the sound is lateralized), the patient is asked to identify which
ear hears the sound better.
- To test the reliability of the patient’s response, the examiner repeats the procedure
while occluding one ear with a finger and asks the patient which ear hears the sound
better.
- It should be heard better in the occluded ear
4. BING TEST
- Vibrating tuning fork is applied to the mastoid bone and then the external auditory
canal is occluded by pressing on the tragus.
- If hearing is Louder, test is (+) seen in normal person ore one with SNHL
- If hearing remains same or less, test is (-) indicating CHL
- This test is useful in mixed hearing loss where conducting impairment is minimal and
tympanic membrane is intact as in osteosclerosis.
5. TICKLING WATCH TEST
- The ticking watch test uses a nonelectric ticking watch to test high-frequency
hearing.
- The examiner positions the watch approximately 15 cm (6 inches) from the ear
to be tested, slowly moving it toward the ear.
- The patient then indicates when he or she hears the ticking sound. The distance can
be measured and will give some idea of the patient’s ability to hear high-frequency
sound.
6. WHISPHERED VOICE TEST
- The patient’s response to the examiner’s whispered voice can be used to determine
hearing ability
- The examiner masks the hearing in one of the patient’s ears by placing a finger
gently in the patient’s ear canal.
- Standing approximately 30 to 60 cm (12 to 24 inches) away from the patient, the
examiner whispers one- or two-syllable words and asks the patient to repeat them.
- If the patient has difficulty, the examiner gradually increases his or her volume until
the patient responds appropriately.
- The procedure is repeated in the other ear.
- The patient should be able to hear whispered words in each ear at a distance of 30 to
60 cm (12 to 24 inches) and respond correctly at least 50% of the time
PURE MOTOR CRANIAL NERVE
OCULOMOTOR NERVE
- Tested together with CN 4 and 6
a. SUPERIOR DIVISION: Lateral Palpebrae Superioris & Superior Rectus
b. INFERIOR DIVISION: Medial Rectus, Inferior Rectus and Inferior Oblique.
TROCHLEAR NERVE
- Smallest Cranial Nerve in the body
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- Longest and Most Slender intracranial nerve.
- SO4 LR6
- Function: Movement of the eyeball
ABDUCENS NERVE
- Lateral Rectus
- Function: Movement of the eyeball
Clinical Indication
A. CN 3 Incomplete Lesion
1. INTERNAL OPTHALMOPLEGIA
- (-) Pupil Constriction
- (+) Extraocular Muscle
2. EXTERNAL OPTHALMOPLEGIA
- (-) Extraocular Muscle (weak)
- (+) Pupil Constriction
B. CN 3 COMPLETE LESION
- Extraocular Muscle Weakness
- External Strabismus
- (-) Pupil Constriction
- (+) Ptosis (80% only)
- *FULL OPENING OF THE EYE
80% = Parasymphathetic (CN 3)
20%= Symphatetic (Muelier mm = LPS)
C. WEAK SUPERIOR OBLIQUE MUSCLE
- Eyes are downward and Inward
D. DIPLOPIA
1. Vertical = Cranial Nerve 4
2. Horizontal = Cranial Nerve 6
E. STRABISMUS
- Banlag
1. ESOTROPIA
- CN 6
- Internal Strabismus
2. EXOTROPIA
- CN 3
- External Strabismus
F. WEAK LATERAL RECTUS
- Eyes on the middle
ACCESSORY NERVE
- 2 Parts
- Cranial & Spinal Nerve Roots (CN 2,3,4)
- SCM & Upper Trapezius
- Function: Shoulder Elevation
- Test: Resist the action of the muscle.
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HYPOGLOSSAL NERVE
- Tongue muscle and movement
- 4 Muscles
a. Genioglossus: Forward
b. Hyoglossus: Downward
c. Styloglossus: Curves
d. Palatoglossus: Upward
CLINICAL INDICATION
- Ipsilateral
1. LOWER MOTOR NEURON LESION DAMAGE (L) CN 12
- Tongue will deviate toward left side
- Uvula: Contralateral Cranial Nerve 9
2. UPPER MOTOR NEURON LESION ® CVA
- Contralateral
Cranial Nerve Testing (Lab)
1. CN 1 – OLFACTORY
➢ SENSORY
✓ Testing Procedure: Non-noxious stimuli on a cotton ball
✓ Condition: Anosmia
2.
➢
✓
a.
b.
✓
CN 2 – OPTIC
SENSORY
Testing Procedure:
Visual Aquity: Snellen Chart (20ft distance)
Peripheral Vision: Confrontation Test
Condition: Blindness, Myopia (impaired far vision), Presbyopia (impaired near vision)
3. CN 3/4/6 –
OCULOMOTOR/TROCHLEAR/ADDUCENS
➢ MOTOR
→ ANATOMICAL
→ TESTING
> III: Eye can’t look upward, downward and inward
> IV: Eye can’t look down when eye is adducted
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> VI: Eye can’t look out
✓ Condition: Internal Stabismus/External Strabismus
4. CN 5 – TRIGEMINAL
* MIXED
➢ SENSORY
✓ Testing Procedure: Light touch cotton on forehead, maxilla and mandible
➢ MOTOR
✓ Testing Procedure: Clench teeth and hold against resistance
5. CN 7 – FACIAL
* MIXED
➢ SENSORY
✓ Testing Procedure: Saline or Sugar on cotton swab
➢ MOTOR
✓ Testing Procedure: Facial Expression
6. CN 8 – VESTIBULOCOCHLEAR
➢ SENSORY
✓ Testing Procedure:
a. Vestibular Aspect
1) Dix Hallpike Test
- Long sitting, head rotation of 30 – 45 deg. on unaffected side, supine, head slightly
below horizontal plane maintaining rotation. (30 – 60 secs)
- (+) Nystagmus, Vertigo
2) Caloric Test
- Water irrigation on External Auditory Canal
- Warm water: Same side Nystagmus
- Cold water: Opposite side Nystagmus
- “COWS”
> Abnormal Response: Unequal duration of Nystagmus
b. Cochlear Aspect
1) Weber Test
- Tuning fork on vertex
- (N) Same intensity on each side
- If one side heard it better, occlude the ear: should be heard well on occluded ear.
CHL: sound is hear on poor ear
SNHL: sound is heard on good ear
2) Rinne Test
- Tuning fork at mastoid process until vibration is not heard » position in EAM
- (N) air > bone = 2:1
CHL: bone ≥ air
SNHL: air >bone but > 2:1 ratio
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7. CN 9 – GLOSSOPHARYNGEAL
* MIXED
➢ SENSORY
✓ Testing Procedure: Salty or Sour on cotton swab
➢ MOTOR
✓ Testing Procedure: Say “AH” check for deviation in uvula
8. CN 10 – VAGUS
* MIXED
➢ SENSORY
✓ Testing Procedure: Swallowing/Phonation
➢ MOTOR
✓ Testing Procedure: Gag Reflex
9. CN 11 – SPINAL ACCESSORY
➢ MOTOR
✓ Testing Procedure
SCM: I\L lateral flexion, C/L rotation
Upper Trapezius: Shoulder shrug
10. CN 12 – HYPOGLOSSAL
➢ MOTOR
✓ Testing Procedure: Tongue movements
SUPERFICIAL CUTANEOUS REFLEX
Major Visceral Reflex
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CONSENSUAL REFLEX
NEUROGENIC DISORDERS OF SPEECH & LANGUAGE
Normal Process
1. Cerebration
- Thought communication
2. Respiration
- Mechanical & Chemical
3. Phonation
- Vocal cords, subglottic pressure (rel. intensity), length and tension of vocal cords
(rel. pitch)
4. Resonation
- Modified & amplified by cavities (pharyngeal, oral & nasal)
5. Articulation
- Production of phonemes
- Manner of Articulation
a. Plosive: (stop sounds: pbtkg)
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b. Fricative: (turbulent, closed nasal cavity – fvthsvshzhh)
c. Nasal: (open nasal cavity, closed oral: mnng)
d. Liquid: (soft palate raised: r,l)
e. Semi-vowel: (w,y)
f. Unvoiced (p,s)
g. Voiced: (all vowels & some consonants)
h. Substantive: (nouns & verbs)
i. Less substantive: (Prepositions, conjunctions, pronouns)
- Place of articulation
a. Labial: (pbwm)
b. Labiodental: (fv)
c. Dental: (th)
d. Alveolar: (tdszylrn)
e. Palatal: (shzh)
f. Velar: (kgng)
g. Glottal: (h)
6. Intelligibility
- How a person “sounds” when speaking
CLASSIFICATION AND NOMENCLATURE
1. FLUENT APHASIA
- Characterized by impaired auditory comprehension and fluent speech that is of
normal rate and melody.
- Usually associated with a lesion in the vicinity of the posterior portion of the first
temporal gyrus of the left hemisphere.
- When condition is severe, word and sound substitutions may be of such magnitude
and frequency that speech may be rendered meaningless
- Greatest difficulty in retrieving those words that are substantive (nouns and verbs)
- Tend to have some degree of impaired awareness and are rarely physically disabled.
- Most Common Type of Fluent Aphasia is Wernicke’s Aphasia / Sensory Aphasia /
Receptive Aphasia.
a. WERNICKE’S APHASIA
- Usually the result of a lesion in the posterior portion of the first temporal gyrus of the
left hemisphere.
- Characterized by impaired auditory comprehension and fluently articulated speech
marked by word substitutions
- Impaired reading and writing
- May produce what seem like complete utterances and use complex verb tenses, they
often add a word or phrase and “augment” speech production.
- Speech is often produced at a rate greater than normal.
- (+) reverse phonemes and/or syllables (hopspipal/trevilision) and may produce
neologisms (nonsense words).
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ANOMIC APHASIA
- Characterized by a significant word-finding difficulty in the context of fluent,
grammatically well-formed speech
- (-) Auditory Comprehension
- May be proficient in producing circumlocutions to skirt the lack of specificity of
language use.
2. NON-FLUENT APHASIA
- Characterized by limited vocabulary, slow, hesitant speech, some awkward
articulation, and restricted use of grammar in the presence of relatively preserved
auditory comprehension
- Associated with anterior lesions usually involving the third frontal convolution of the
left hemisphere
- Patient tend to express themselves in vocabulary that is substantive (nouns, verbs)
and lack the ability to retrieve less substantive parts of speech (prepositions,
conjunctions, pronouns).
- They tend to have good awareness of their deficit and usually have impaired motor
function on the right side (right hemiplegia–paresis)
a. BROCA’S APHASIA/MOTOR APHASIA/ EXPRESSIVE APHASIA / VERBAL APHASIA
- It is the result of a lesion involving the third frontal convolution of the left
hemisphere, the subcortical white matter, and extending posteriorly to the inferior
portion of the motor strip (precentral gyrus)
- Characterized by awkward articulation, restricted vocabulary, and restriction to simple
grammatical forms in the presence of a relative preservation of auditory
comprehension.
- Writing skills generally mirror the pattern of speech and reading may be less impaired
than speech and writing
- may be limited to one- and two-word productions for
- Expression and find it impossible to combine words into sentences.
- Articulation may be awkward and effortful
3. GLOBAL APHASIA
- A severe aphasia with marked dysfunction across all language modalities and with
severely limited residual use of all communication modes for oral–aural interactions
- Not a type of aphasia but rather a designation of severity.
- Generally has extensive damage, which may be anywhere in the left hemisphere, and
is sometimes bilateral.
4. ACQUIRED APHASIA
- Result of cerebral damage caused by head injury, tumor, or stroke results in the
same syndromes manifest in adults with aphasia.
5. PRIMARY PROGRESSIVE APHASIA
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- Slowly progressive isolated aphasia not due to stroke, trauma, tumor, or infection,
which does not fit neatly into existing aphasia classification schemes
- It can exist in the absence or relative absence of generalized intellectual and
behavioral disturbances or cognitive impairment generally associated with dementia.
DYSARTHRIA / MOTOR SPEECH DISORDER
- Refers to an impairment of speech production resulting from damage to the central or
peripheral nervous system, which causes weakness, paralysis, or incoordination of the
motor–speech system.
- Any one or all of the components of the motor–speech system (respiration,
phonation, articulation, resonance, and prosody) may be compromised by neural
damage.
- Generally reflected in deficits occurring in multiple motor–speech systems, but may
sometimes
ANARTHRIA
- When patients are totally unintelligible as the result of severe motor–speech system
impairment
5 PRIMARY TYPES OF DYSARTHRIA
1. SPASTIC DYSARTHRIA
- Characterized by imprecise articulation, slow labored articulation, hyper nasality,
harsh to strained phonation, and monotonous pitch.
- Result of bilateral pyramidal system damage involving the corticobulbar tracts (upper
motor neurons)
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- May cause weakness and paresis of the face and tongue musculature on the side
opposite to the lesion.
2. FLACCID DYSARTHRIA
- Characterized by slow/labored articulation, hypernasality, and hoarse, breathy
phonation.
- Phrases may be short, inhalation is shallow, and the control of exhalation may be
reduced
- A reduction in the variation of pitch and loudness with audible inspirations
- Most of these deviant speech characteristics are related to muscular weakness and
reduced muscle tone, which affects speech accuracy.
3. ATAXIC DYSARTHRIA
- Characterized by disturbances of timing, movement, range, control, and coordination
of the muscles of speech and respiration.
- Speech is imprecise, slow, and irregular
- There may be intermittent periods of explosive inflection, syllable stress, and
loudness patterns.
- Phonemes may be prolonged; pitch and loudness are monotonous
- Lesions producing ataxic dysarthria are bilateral, generalized lesions involving the
deep midline nuclei and pathways of the cerebellum
4. HYPOKINETIC DYSARTHRIA
- Characterized by variable articulatory precision, slow rate of speech, harsh, hoarse
voice quality, excessive and overly long pauses, prolonged syllables, and reduced
phonation
- Caused by lesions of the substantia nigra.
5. HYPERKINETIC DYSARTHRIA
- Characterized by variable articulatory precision, vocal harshness, prolonged sounds
and intervals between words, monotonous pitch, and loudness
- Caused by lesions of the basal ganglia and/or their extrapyramidal projections.
APRAXIA OF SPEECH / DYSPRAXIA / VERBAL APRAXIA / CORTICAL DYSARTHRIA /
PHONETIC DISENTEGRATION
- Difficulty initiating speech, articulatory struggling, periods of error-free speech
production, and a greater number of sound production errors as utterance length
increases.
- Individuals with AOS do not generally have deficits in performing non-speech
movements of the oral musculature.
DYSPHAGIA
- Defined as a condition in which an individual has had an interruption in either eating
function or the maintenance of nutrition and hydration
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Cardiovascular Rehabilitation
General Information
a. Age
b. Race
- African-American
c. Gender
- Male
d. Body Mass
- Obese
3 Major Risk Factors according to Cunningham Study
- Smoking
- Hyperlipidemia
- Hypertension
1. Past Medical History
- Pulmonary Disorder
- Neuromuscular Disorder
- Past oncologic disorder treated with radiation therapy
- Obesity
- Pre-mature birth
- Auto-immune Dysfunction
- Vascular Dysfunction
- Endocrine or Metabolic Disorder
2. Family History
- DM
- Hypertension
3. Personal, Social Environmental History
a. Smoking
b. Occupational exposure to irritants or allergens (e.g. carbon monoxide, chemicals)
c. Residing in locations with higher levels of air pollution
d. Sedentary Lifestyle
e. Personality Type
- Type A: Time urgency with stress
- Type D: Suppression of emotions
f. Diet
- Low mineral intake
- Low anti-oxidant intake
- Low essentially fatty acid intake
Blood Test (Cardiac Enzymes)
37
Laboratory Test
1. Blood Test (Cardiac Enzymes)
2. Electrolytes
3. CBC
4. Liver & Kidney Tests
5. Lipid and Like Values
- LDL (Low-density lipoprotein)
- HDL (High-density lipoprotein)
- ICL
- Triglycerides
Patient Complaint
- Most common Signs & symptoms
a. Angina
- Often described as heart pain
- “If an elephant is sitting upon my chest”
- “If someone is squeezing my chest
- Substernal burning/pain
- Chest pressure
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- Chest tightness
- Classical representation for substernal pain is accompanied by Levine Sign
- Due to: Myocardial Ischemia
39
Pulse
- Normal Values: 60-100 bpm
- Preferred Site: Radial Pulse
40
- Most accurate site: Apical pulse
- Rate: Bradycardia/Tachycardia
- Quality
a. Paradoxical Pulse
- AKA: Pulsus Paradoxus
- Decrease amplitude of the pressure wave detected during quiet inspiration with a
return to full amplitude on expiration
- Commonly seen in patient with COPD
b. Pulsus Alterans
- Marked by a fluctuation in amplitude between beats (a weak and a strong), with
minimal change in overall rhythm
Grading Pulse Quality
Vital Signs: Respiratory Rate
- Normal: 12-20 cpm
- Appearance: Skin color and body traits
- Sign of Poor Cardiovascular Function
a. Pale and Cyanotic Skin
b. (+) Diagonal Ear Lobe Crease
c. Cyanosis: When O2 saturation is <85%
d. Diaporesis: Excessive sweating
e. Presence of Edema in the extremity
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- Body Habitus or Somatotype: Can also provide information about cardiovascular risk
- Pear-shaped Body: 3 times more likely to develop cardiovascular disease
Anthropometric Measurement
1. Body Weight
Ideal Body weight should be made in reference to body type
- Small Body Frame: Calculated Ideal Body
Wt. x 0.9
- Large Body Frame: Calculated Ideal Body
Wt. x 1.10
2. Finger Pressure
2. Girth Measurement
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- Appropriate Site: Mid-calf/Middle Forearm
4. Skin Fold Calipers
5. BMI
Grading of BMI
- Underweight: Below 18.5
- Normal: 18.5-24.9
- Overweight: 25.0-29.0
- Obese: >30
6. Jugular Vein Distention
- Simply the filling of the jugular vein(s) with excessive fluid such that they become
visibly distended
- Due to: ® sided heart failure
- Procedure:
✓ Patient placed semi-supine at 45°
✓ Rotate the head slightly to the opposite side
✓ Pressed the external jugular vein above and parallel to the clavicle approximately 1020 seconds
✓ Measure the highest visible pulsation
✓ (N) Level: Less than 3-5cm
Using Stethoscope
1. Diaphragm
- For high-frequency sounds and should be used with firm pressure
2. Bell
- Foe low-frequency sounds and should be used
- If firm: Change to diaphragm
- Alternating light and firm can differentiate normal from abnormal heart
Exercise Tolerance Test (ETT)
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- Purpose: To examine the ability of the cardiovascular system to accommodate to
increasing metabolic demand
2 Major Goals
- Detect presence of ischemia
- Determine functional aerobic capacity
▪ The patient exercises through stages of increasing workloads, expressed in units of
oxygen
▪ MET’s at rest= 3.5 mL/kg/min.
Aerobic Capacity & Endurance
- 6MWT
- <300 m: Poor Long Term Endurance
AB
Formula:
ABI = Highest Ankle SBP/ Highest Arm SBP
BP= COxTPR
PP= SBP-DBP
CO=SVxHR
MAP= SBP+2DBP/3
RPP = HRxSBP
EXAMINATION OF BALANCE AND COORDINATION
COORDINATION
- Ability to receive smooth, accurate and coordinated movement
- Joint and muscle involvement: Multiple joint & Muscles
- Dependent on
a. Somatosensory
b. Visual
c. Vestibular
d. Intact Neuromuscular Function (brain to SC)
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- Coordination impairments: Awkward, extraneous. Uneven and inaccurate
2 TERMS ASSOCIATED IN COORDINATION AND BALANCE
a. Dexterity
- Refers to skillful use of the fingers during fine motor task
b. Agility
- Refers to the ability to rapidly and smoothly initiate, stop or modify movements while
maintaining posture.
TYPES OF COORDINATION
1. INTRALIMB
- Refers to the movement occurring within a single limb
2. INTERLIMB
- Refers to the integrated performance of two or more limbs working together.
3. VISUAL MOTOR
- Ability to integrate both visual and motor abilities within the ENVIRONMENTAL
context to accomplish a goal.
- Example: Eye-hand or Eye-hand-head (to fixate the eyes)
MOTOR SYSTEM
1. Motor Cortex
2. Descending Efferent Pathway
3. Cerebellum – Ipsilateral; balance
4. Basal Ganglia
5. Dorsal-Column Medial Lemniscal Pathway
ASTHENIA
- Generalized muscle weakness associated with cerebellar lesions.
- Example: Myasthenia Gravis
- Mm grade: 1 (hypotonia)
DYSARTHRIA
- One word at a time patients (scanning speech)
DYSDIADOCHOKINESIA
- Impaired ability to perform rapid alternating movements
- (-) Rapid movement of forearm supination and pronation.
DYSMETRIA
- Inability to judge the distance or range of a movement
a. Hypometria
- Underestimation of the required range needed to reach an object or goal
b. Hypermetria
- Overestimation of the required range needed to reach an object or goal
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DYSSYNERGIA
- AKA: Movement Decomposition
- Sequential Movement pattern rather than a smooth activity
ASYNERGIA
- Loss of the ability to associate muscles together for complex movements.
GAIT ATAXIA
- AKA: Cerebellar Gait
- Involve ambulatory patterns that typically demonstrate a broad BOS due to no
sensation of the floor
HYPOTONIA
- Decreased muscle tone
- DTR is also decreased
NYSTAGMUS
- Rhythmic, oscillatory, back and forth movements of the eyes
- Side to side or up and down
- Terminate SPT for head/neck
REBOUD PHENOMENON
- Loss of check reflex or check factor, which functions to halt forceful active movement
when resistance is removed
- Isometric movement
TREMOR
- Involuntary oscillatory movement resulting alternate contractions of opposing muscle
groups
a. Static Tremor / Postural Tremor
- At rest; during movement no tremor
b. Kinetic Tremor/Intention Tremor
- Occurs during movement; at rest no tremor
HEAD TITUBATION
- Head oscillation (side to side or up or down)
BASAL GANGLIA PATHOLOGY
AKINESIA
- Inability to initiate a movement
ATHETHOSIS
- Slow, writhing, twisting and worm-like movements
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- Commonly seen in Pediatric Rehabilitation
BRADYKINESIA
- Decrease amplitude and velocity of voluntary movements.
CHOREA
- Characterized by involuntary, rapid, irregular and jerky movements involving multiple
joints
CHOREOATHETHOSIS
- Characteristics of both chorea and athethosis
DYSTONIA
- Sustained involuntary contractions of agonist and antagonist muscles
- Hard to manipulate
HEMIBALLISMUS
- Large amplitude, sudden, violent, flailing motions of the arms and legs of one side of
the body.
HYPERKINESIS
- Increase muscle activity or movement
HYPOKINESIS
- Decrease muscle activity or movement
RIGIDITY
- Increase muscle tone causing greater resistance to passive movements
a. Lead-Pipe Rigidity
- Uniform, constant resistance as limb is moved.
b. Cog-wheel Rigidity
- Series of brief relaxations or catches as limb is possibly moved.
- Ratchet-like
RESTING TREMOR
- Involuntary, rhythmic, oscillatory movement observed at rest
DC-ML PATHOLOGY
- Lack of position sense
- Lack of awareness of movement
- Impaired localized touch sensation
- Wide BOS
- Dysmetria
SCREENING
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- ROM-BASELINE; Decrease then Increase
ROM of patient
- MMT
- Sensation
COORDINATION TEST
2 CATEGORY TESTS
- Gross Motor Tests
- Fine Motor Test
2 SUBDIVISION
- 4 movement capabilities
- Alternate or reciprocal motion
- Movement composition
- Movement accuracy
- Fixation or limb holding
Progression of Coordinated Test
- Unilateral Task
- Bilateral Symmetrical Tasks
- Bilateral Asymmetrical Tasks
- Multi-time tasks
EXAMINATION OF POSTURAL CONTROL AND
BALANCE
POSTURAL CONTROL
POSTURAL ORIENTATION
- Control the body’s relative position
- Gravity
a. Reactive Postural Control
- External pertuberance
b. Proactive Postural Control
- Internal stability
c. Adaptive Postural Control
- Allows to modify sensory and motor systems.
BALANCE
1. Sensory & Perception
- Detect body position
2. Motor System
- Organization and execution of muscle
contraction + increase synergistic action
3. Higher CNS
- Integration and processing
POSTURAL ALIGNMENT AND WEIGHT DISTRIBUTION
- Grinds/Grines
- COM: 2 inches anterior to S2
LATERAL
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✓ Lateral to External Auditory Meatus
✓ Slightly Anterior to Shoulder Joint
✓ Midline Trunk
✓ Posterior to hip joint
✓ Anterior to knee joint
✓ Anterior to ankle joint
QUIET STANCE
- Tibialis Anterior, Gastroc-Soleus Complex:
Ankle and Hip
- Iliopsoas, Tensor Fasciae Latae, Gluteus
Medius: Level Pelvis
- Abs and Errector Spinae: Trunk
Knee is still extended because of Ligaments
MOTION ANALYSIS SYSTEM
- Muscle Contraction
- Enclosed plate, deviations, weight bearing
LIMITS OF STABILITY
- Maximum distance an individual is able to or willing to lean in any direction without
loss of balance or changing BOS.
- Influenced by:
a. Anterior and Posterior
- Patient’s Height and Foot Length (should be longer)
b. Medial and Lateral
- Patient’s height, foot width distance (should be wide apart)
c. Velocity
- Velocity and displacement
EXAMINATION & DOCUMENTATION
a. Visual Inspection
- Plumb Lines/ Grid Lines
b. Posturography
- Force plate (Ground reaction force, center of pressure, center of force)
Checked the following
a. Initial stance position and posture
b. Mean sway path
c. Zone of Stability
- E.g. lean (L) side move then mas stable di raw nagsway masyado then that’s the
zone of stability.
d. Postural Sway
- (N) minimal sway
e. Sway Envelope
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- Direction of sway
SENSORIMOTOR INTEGRATION IN POSTURAL COTROL
1. VISUAL PROPRIOCEPTION
- Important source of information for the ability to perceive movements and detect
the relative orientation of body segments and orientation of the body in space.
POSTURAL CONTROL
- Visual
- Vestibular
- Sensorimotor
Focal Vision (Cognitive/Explicit Vision)
- Localizing features of environment
Ambient Vision (Sensorimotor/Implicit Vision)
- Unconscious control of the environment
Optic Ataxia
- Problem with the ambient vision
- Can’t control/see how far or near the object is but can see, you just can’t grab it.
Visual Agnosia
- Problem with the focal vision
- Can’t recognize the object
Somatosensory inputs
- Where we rely mostly; biggest role
- If it is damaged; visual system will take place
- Include
a. Cutaneous & Pressure Sensation from body segments in contact with support
surface
b. Muscle and Joint Proprioception throughout the body
c. Light touch contact from the hands on a stable surface.
Vestibular System
- Important source of information for postural control and balance.
a. Semi-circular Canal
- Angular; fast head movements
b. Otoliths
- Linear, slow head movements
c. VOR (VESTBULO-OCULAR REFLEX)
- Gaze stabilization during head movements
d. VOS (VESTIBULO-SPINAL REFLEX)
- Postural Tone, Muscle Activation in relation to head position
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TESTS
1. Romberg Test
- Stand with feet together, eyes open unaided for 20-30 seconds
- Stop if there is sway but continue if it does not occur.
- Eyes Closed
- If Eyes open may sway: Lesion in CNS
- (+) Sway; unable to maintain posture and balance
- (-) Sway: Able to maintain posture and balance.
- Indications: Lesion on posterior column /
Dorsal Column Peripheral Neuropathy
2. Sharpened Romberg Test
- Tandem position
- Heel of one foot anterior to toes of other foot
- Same instruction
SENSORY ORGANIZATION TEST
- Moving platform, AP-ML
- Moving visual surround -> Visual Conflict
- 30 seconds each condition
6 CONDITIONS
1-3 STABLE SURFACE
1. Eyes open; baseline
2. Eyes closed
3. Visual Conflict
4-6 MOVING SURFACE
4. Eyes open
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5. Eyes closed
6. Visual Conflict
CONDITION 5 & 6 – VESTIBULAR
- (-) Somatosensory input
- If patient is stable; intact (+) Vestibular System
- If patient demonstrate sway: problem in Vestibular System
VISUALLY RELIANT
- Problem during condition 2,3,5,6
- We can check if patient is visually reliant by checking if there is an increase in sway
SURFACE DEPENDENT
- Dependent on somatosensory input
- 4,5 and 6 (Increase sway here)
VESTIBULAR: 5,6
VISUALLY: 2,3,5,6
SURFACE: 4,5,6
SENSORY SELECTION PROBLEM: 3,4,5,6
- Increase sway and instability
SCORING: CHECK THE SWAY OF PATIENT
1- Minimal Sway
2- Moderate Sway
3- Severe Sway
4- Loss of Balance
CTSIB (CLINICAL TEST FOR SENSORY INTERACTION IN
BALANCE)
- Medium Density foam – surface
- Mediated Visual Dome (Japanese Lantern)
– Visual
- 30 seconds each condition, 6 conditions
- Increase sway or loss of balance are recorded
- Subjective complaints & postural strategies are also documented
MOVEMENT STRATEGIES FOR BALANCE
1. FIXED SUPPORT
- Ankle Strategy
- Hip Strategy
- Muscles
a. Anterior
- Gastrocnemius, hamstrings, Errector spinae
b. Posterior
- Tibialis Anterior, hamstrings and quadriceps
EXAMINATION OF MOVEMENT STRATEGIES
- Know first the ROM, MMT, POSTURAL
CONTROL
a. STANDING CONTROL
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- Movement coordination test
- Symmetry in weight distribution, latency of response and strategies used.
b. SEATED CONTROL
- Position in seating position
c. ANTICIPATORY POSTURAL CONTROL
- Anticipation of/for pertuberations
d. DUAL TASK CONTROL
- Balance+Other Task (if patient can do this task)
DOCUMENTATION
GRADING
1- Present and Normal
2- Present but Delayed
3- Present but inappropriate
4- Abnormal
5- Absent
FUNCTIONAL AND BALANCE GRADES
STATIC AND DYNAMIC
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STANDARDIZED INSTRUMENTS
1. BERG BALANCE SCALE (BBS)
- 14 functional task, grading of 4-0
- Maximum Score: 56
- 45 or below: Higher risk for falls
2. PERFORMANCE ORIENTED MOBILITY
ASSESSMENT (POMA/T-POMA/TINETTI-POMA
- Balance test & Gait Test
- Until 2/3
- <19 score: High Risks for fall
- 19-24: Moderate score/risk
REACH TEST
FUNCTIONAL AND MULTIDIRECTIONAL REACH TEST
- 1 meter stick
- Should not have a change in BOS upon
reaching
SCORING
GET UP AND GO TEST
- 3 meters from chair
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- Check if stable: standing, walking and turning
TIMED UP AND GO
- Healthy individuals: 10 seconds
- Elderly and with disabilities: 11-20 seconds
- >30 seconds either healthy or none: Higher risk for fall
TIMED WALKING TEST
- Usually 10m; check if there is deviation while walking
- 1.2-1.5m/s: Healthy
- 0.9-1.3 m/s: Elderly
- Slower: Higher risk for fall
DISTANCE TEST
- 3 or 6 or 12 min. walk test
- Observe the patient’s gait
- While walking, change the instruction
3 – (N)
2- MILD
1- MODERATE
0- SEVERE
MAXIMUM SCORE: 24
INCREASE RISK OF FALL: <19
DUAL TASK TEST
a. Walkie-Talkie Test
- Walk and talk at the same time
- Complicated questions
b. Sitting Balance Tests
c. Perceived Balance Confidence
d. Activities-specific balance Confidence
e. Balance Efficacy Scale
PULMONARY REHABILITATION
I. STRUCTURAL RESPIRATORY SYSTEM
A. Upper Respiratory System
- Consists of nose, pharynx and larynx
a. Nose
- Contains nasal hair (vibrissae)
b. Larynx
- Contains the voice box
- Contains 9 cartilages
- Align at C4-C6 vertebra
- 3 Paired: Corniculate, Arytenoid and
Cuneiform
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- 3 Unpaired: Epiglottis, thyroid and Cricoid (Align at the level of C6 vertebra/Level of
Tracheostomy)
B. Lower Respiratory System
- Consists of trachea, bronchi and lungs
a. Trachea
- AKA: Windpipe
- Contains the carina
- The last ring of trachea is the most sensitive part
- Extends from C6-T5/T6 vertebra
b. Bronchi
- Common Problem in the ® bronchi: It may lead to Aspiration Pneumonia due to its
orientation
- Common Problem in the (L) Bronchi: It may lead to Pneumocystic Carinii Pneumonia
(PCP)
- Prone HIV →AIDS
BRONCHIAL TREE
1. LOBAR/SECONDARY BRONCHI
- Right Lung has 3 Lobes
- Left Lung has 2 Lobes
2. SEGMENTAL/TERTIARY BRONCHI
- Right Lung has 10 Lobes
- Left Lung has 8 Lobes
3. TERMINAL BRONCHIOLES
4. RESPIRATORY BRONCHIOLES
5. ALVEOLI
- This is where gas exchange takes place
- “ACINUS” – Functional Unit of Respiratory System
II. FUNCTIONAL RESPIRATORY SYSTEM
A. CONDUCTING ZONE
- Extends from the nose up to your terminal bronchioles (specifically in your dead
space)
B. RESPIRATORY ZONE
- Extends from the Respiratory Bronchioles up to Alveoli
RESPIRATION
- Process of gas exchange in the body
a. EXTERNAL/PULMONARY RESPIRATION
- Exchanges of gases between the alveolar capillary membrane and pulmonary
capillaries
b. INTERNAL/TISSUE RESPIRATION
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- Exchange of gases between pulmonary capillaries and surrounding tissue cell
VENTILATION/BREATHING
- Movement of air during inspiration (inflow) and expiration (outflow)
FORCED VITAL CAPACITY
- Uses forced expiratory maneuver
FLOW RATE
- Measure volume of air that moves over time
EXPIRATORY FLOW RATE
- Volume of expired air over time required for
the air to be expired
FEV1
(Forced Expiratory Volume in 1 second)
- Healthy: 70% or more than the total of FVC
RESPIRATORY ASSESSMENT
PATIENT HISTORY
1. CHIEF OF COMPLAINT
- Common: Shortness of Breath/Dyspnea; cough (sputum/type of breathing)
2. WHY?
3. OCCUPATION/WORK
- Metro Aide (Exposure to air pollution)
- Cigarette Smoker
SMOKE PACK YEARS
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- Number of packs per day multiply by number of years smoked
APPEARANCE OF PATIENT
1. GENERAL APPEARANCE
a. LEVEL OF CONSCIOUSNESS (LOC)
- No O2?
- Drowsy/Sleepy
b. BODY TYPE
- Endomorph
- Ectomorph
- Mesomorph
c. CYANOSIS
- Centrally (Lips)
- Peripheral (Nail Bed)
- Patient can have digital clubbing and reduce cardiac output
d. FACIAL SIGN/EXPRESSION
e. JUGULAR VEIN ENGORGEMENT
f. HYPERTROPHY OF ACCESSORY MUSCLE
g. PERIPHERAL EDEMA
- Usually ® CHF
PRIMARY MUSCLE FOR RESPIRATION? Diaphragm
2. CHEST SYMMETRY
- Normal AP: Lateral (1:2)
a. BARREL CHEST
- 1:1
- Upper chest appears to be larger than lower chest
- Sternum are prominent
- AP Diameter is greater than normal
- AKA: “Upper Chest Breather” COPD
b. PECTUS EXCAVATUM/FUNNEL CHEST
- Funnel Breast
- Lower Sternum depressed
- Lower Ribs flares out
- Excessive abdominal protrusion, little upper chest movement
- AKA: “Diaphragmatic Breather”
c. PECTUS CARINATUM/PIGEON CHEST
- Commonly seen in pediatric rehabilitation
- Pigeon Breast
- Sternum is prominent and protrudes anteriorly
3. POSITION OF COMFORT
- A patient who has difficulty breathing as the result of chronic lung disease often leans
forward on hands or forearms to stabilize and elevate the shoulder girdle to assist with
inspiration (Diaphragm descends in this position)
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SLEEP POSITION
- 2-3 pillows
- Increase pillow will lead to the tightening muscle of the back (forward headed)
- A patient with cardiopulmonary dysfunction often prefers to sleep in a head-up rather
than a fully recumbent position.
MNEMONICS: “SOPUTS”
Supine = Orthopnea; Platypnea= Upright;
Trepopnea = Sidelying position
PULMO/PT PROBLEMS
1. DYSPNEA
2. IMPAIRED AIRWAY CLEARANCE
- “CASH” (Cough Assessment Sputum Hydration)
3. RISK FOR COMPLICATIONS OF DECREASE
MOBILITY
- ROM, MMT and ADL’s Respiratory Rate / VS
- Always check before, during and after treatment Oxygen Saturation (Pulse Oximeter)
- Pulse Oximeter measure PR and Oxygen Saturation
- (N): 90-100%
KARVONENS
AKA: Heart Rate Reserve (HRR)
Formula:
EXAMPLE:
A 21-year-old patient who has a resting heart rate of 68 bpm, wanting to know his
training heart rate for the intensity level 60-70%
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SOLUTION:
HIS MINIMUM TRAINING HEART RATE:
220-21(Age) = 199
199-68 (Resting Heart Rate) = 131
131 x .60 (Minimum Intensity) +68 (Resting Heart Rate) = 146.6
HIS MAXIMUM TRAINING HEART RATE 220-21(Age) = 199
199-68 (Resting Heart Rate) = 131
131 x .70 (Maximum Intensity) +68 (Resting Heart Rate) = 159.7
His Training Heart Rate Reserve will therefore be 147-160 bpm
PSOB/BORG SCALE
- Ask patient where does she/he feel the shortness of breath
O2 Supplement
- To prolong survival rate
- If Partial Pressure of O2= <60mmHg
- Absolute indication for long term use= <55mmHg
MECHANICAL VENTILATOR MODE
A. Assist Control (AC): Constantly assisted by ventilator
B. Synchronized Intermittent Mandatory
Ventilation (SIMV): Patient breaths on his own but rest period is given wherein assisted
by ventilator
C. Spontaneous: Breaths on his own
BREATHING PATTERN
- Rate, regularity, Location of ventilation at rest and with activity
- INSPIRATION: EXPIRATION
- (N) at rest 1:2
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- With Activity: 1:1
- COPD: 1:4 at rest
Normal Sequence of Inspiration
- Abdomen Rises: Diaphragm descends
- Ribs move out and up
- Upper Chest rises
BREATHING PATTERNS
MMT OF DIAPHRAGM
- Diaphragm performs 70-80% of the effort of quiet inspiration
PRELIMINARY EXAMINATION
1. Uncover the patient’s chest and abdominal area so that the motions of the chest and
abdominal walls can be observed.
2. Watch the normal respiration pattern and observe differences in the motion of the
chest wall and epigastric area and note any contraction of the neck muscles and the
abdominal muscles.
3. Epigastric rise and flaring of the lower margin of the rib cage during inspiration
indicate that the diaphragm is active.
4. The rise on both sides of the linea alba should be symmetrical.
5. During quiet inspiration, epigastric rise reflects the movement of the diaphragm
descending over one intercostal space.
6. In deeper inspiratory efforts, the diaphragm may move across three or more
intercostal spaces.
7. An elevation and lateral expansion of the rib cage are indicative of intercostal
activity during inspiration.
8. Exertional chest expansion measured at the level of the xiphoid process is 2.0 to 2.5
inches (the expansion may exceed 3.0 inches in more active young people and athletes)
ALL GRADES (5-0)
Patient Position: Supine
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Position of PT: Standing next to patient at approximately waist level. One hand is
placed lightly on the abdomen in the epigastric area just below the xiphoid process.
Resistance is given (by same hand) in a downward direction.
Test: Patient inhales with maximal effort and holds maximal inspiration.
Instructions to Patient: “Take a deep breath … as much as you can … hold it. Push
against my hand. Don’t let me push you down.”
GRADING
Grade 5 (Normal): Patient completes full inspiratory (epigastric) excursion and holds
against maximal resistance. A Grade 5 diaphragm takes high resistance in the range of
100 pounds.
Grade 4 (Good): Completes maximal inspiratory excursion but yields against heavy
resistance.
Grade 3 (Fair): Completes maximal inspiratory expansion but cannot tolerate manual
resistance
Grade 2 (Poor): Observable epigastric rise without completion of full inspiratory
expansion.
Grade 1 (Trace): Palpable contraction is detected under the inner surface of the lower
ribs, provided that the abdominal muscles are relaxed. Another way to detect minimal
epigastric motion is by instructing the patient to “sniff” with the mouth closed
IMPAIRED AIRWAY CLEARANCE (CASH)
A. COUGH ASSESSMENT
- Phases of Cough
a. Deep Inhalation
b. Breath Hold (1-3 seconds)
c. Forced Exhalation (2 times)
- 1- raise of sputum
- 2- release
GRADING
FUNCTIONAL: Normal or Slight Impairment
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- Strong pain, loud and crispy
- >2 Tablespoon of sputum
- Able to clear airway of secretion
WEAK FUNCTIONAL: Moderate Impairment that affects the degree of active motion or
endurance.
- Shallow, soft and throaty
- Appears labored
- Can cough but can’t expel significant amount of sputum or expel cough
NON-FUNCTIONAL
- No clearance of airway
- No expulsion of air
- Cough attempt may be nothing more than an effort to clear the throat
ZERO
- Cough is absent Auscultation
Upper Lobe
Middle Lobe/Lingula
Lower Lobe
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RISK FOR COMPLICATIONS OF DECREASE MOBILITY CHEST MOBILITY
(COSTOVERTEBRAL EXPANSION)
- Symmetry of chest movement
PROCEDURE:
1. Place your hands on the patient’s chest and assess the excursion of each side of the
thorax during inspiration and expiration.
a. TEST FOR UPPER LOBE EXPANSION
- Face the patient; place the tips of your thumbs at the midsternal line at the sternal
notch.
- Extend your fingers above the clavicles.
- Have the patient fully exhale and then inhale deeply
b. MIDDLE LOBE EXPANSION
- Continue to face the patient; place the tips of your thumbs at the xiphoid process and
extend your fingers laterally around the ribs. Again, ask the patient to breathe in deeply
c. LOWER LOBE EXPANSION
- Place the tips of your thumbs along the patient’s back at the spinous processes
(lower thoracic level) and extend your fingers around the ribs.
- Ask the patient to breathe in deeply
EXTENT OF EXCURSION (2 METHODS)
1. Measure the girth of the chest with tape measure at 3 Levels. Document change in
girth after maximum inspiration and expiration.
a. AXILLA
- For Upper Lobe
b. XIPHOID
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- For Middle Lobe
c. LOWER COSTAL
- For Lower Lobe
2. Place both hands on the patient chest or back. Note the distance between your
thumbs after a maximum inspiration
PALPATION
Tactile (Vocal) Fremitus
- Vibration felt while palpating over the chest wall as patient speaks
PROCEDURE (Upper, Middle and Lower Lobe)
1. Place the palms of your hands lightly on the chest wall and ask the patient to speak
a few words or repeat “99” several times or tres tres.
2. Normally, fremitus is felt uniformly on the chest wall.
3. Fremitus is increased in the presence of secretions in the airways and decreased
orabsent when air is trapped as the result of obstructed airways
CHEST WALL PAIN
PROCEDURE:
1. Firmly press against the chest wall with your hands to identify any specific areas of
pain potentially of musculoskeletal origin.
2. Ask the patient to take a deep breath and identify any painful areas of the chest
wall.
3. Chest wall pain of musculoskeletal origin often increases with direct point pressure
during palpation and during a deep inspiration
MEDIASTINAL SHIFT
- Position of trachea is normally oriented centrally in the suprasternal notch
PROCEDURE:
1. To identify a mediastinal shift, have the patient sit facing you with the head in
midline and the neck slightly flexed to relax the sternocleidomastoid muscles.
2. With your index finger, gently palpate the soft tissue space on either side of the
trachea at the suprasternal notch.
3. Determine whether the trachea is palpable at the midline or has shifted to the left or
right
*NOTE: Add = C/L; Subtract=I/L
MEDIATE PERCUSSION
- Examination technique designed to assess lung density, specifically, the air to solid
ratio in the lungs
PROCEDURE:
1. Place the middle finger of the non-dominant hand flat against the chest wall along
an intercostal space.
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2. With the tip of the middle finger of the opposite hand, firmly tap on the finger
positioned on the chest wall.
3. Repeat the procedure at several points on the right and left and anterior and
posterior aspects of the chest wall.
4. This maneuver produces a resonance; the pitch varies with the density of the
underlying tissue.
NOTE IN MEDIATE PERCUSSION:
a. RESONANT
- Indicates normal lungs
b. HYPERRESONANT/TYMPANIC
- Greater amount of air in the area
- May indicate emphysema
c. DULL
- Liver is percussed
d. FLAT
- Muscle is percussed
BREATH SOUNDS
1. INSIDE THE LUNGS
a. AIR
- Decrease sound
b. SOLID/LIQUID
- Increase sound
2. OUTSIDE THE LUNGS
a. ANYTHING
- Decrease sound
Vocal Sounds
Normal Transmission
- Loudest near the trachea & main stem bronchi
- Softer & less clear at the more distal areas of the lungs.
Abnormal Transmission
- Heard loud on distal lung field through
a. Fluid-filled areas of consolidation
b. Cavitation lesion
c. Pleural effusions
a. Egophony
- nasal or bleeting sound; “E” sounds are transmitted to sound like “A”
b. Whispered Pectoriloquy
- increased loudness of whispering; pt whispers “one, two, three”
c. Bronchophony
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- Voice remaining loud at the periphery of the lungs or sounding louder than usual; pt
repeats the phrase “99” or “66”
NORMAL BREATH SOUNDS
PLEASE TAKE NOTE: ALWAYS CLEAN YOUR
STETHOSCOPE
ADVENTITIOUS BREATH SOUNDS
ATELECTASIS
- Absence of air and collapse of an area of lung tissue.
SPUTUM ASSESSMENT
MNEMONIC: COAT
1. COLOR
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a. Clear
b. Yellow
- Infection to be clear
c. Green
- All secretion/stasis/acute infection, pus
d. Blood-Stained
- Too much coughing or hemoptysis
e. Frank Blood
- Massive hemoptysis
f. Gray
- Abscess/Emphysema
g. Rust
- Pneumonia
h. Purple
- Neoplasm
i. Pink/white, frothy
- Pulmonary Edema, CHF
2. ODOR
a. Sweet
- Like pseudomonas
b. Foul
- Indicates infection
3. AMOUNT
- 2 tablespoon or 30 mL per day indicate normal
4. TEXTURE
a. THIN
- Indicate normal saliva
b. THICK/VISCOUS
- Check the patient if she/he is hydrated
CAUTION: Do not treat patient if there is a lot of blood during coughing
a. BLEB
- Burst (putok) during inhalation
b. BULLAE
- Bubble formation
HYDRATION
ROM
- Please read shoulder and neck movement range of motion
MMT
- Grading and Procedure for MMT of pectoralis minor and major; SCM
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Hand Evaluation and Anthropometry
Muscle Strength
- MMT
- Hand-held dynamometer (HHD)
Grip Strength
- Assessment Tools: Hand dynamometer
- 5 adjustable handle spacings
- Test each hand alternately
- Do not fatigue patient
- There should be a 5% to 10% difference between the dominant and non dominant
hands.
- Three trials
- Discrepancies of more than 20% in a test-retest situation indicate that the patient is
not exerting maximal force
- Alternative method: BP apparatus
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Pinch Strength
- Pinch meter
- Pulp-to-pulp
- Lateral prehension
- Three trials
- Thumb: - The thumb is the most important digit. Because of its relation with the
other digits, its mobility, and the force it can bring to bear, its loss can affect hand
function greatly.
- Index Finger: the 2ndmost important digit because of its musculature, its strength,
- and its interaction with the thumb. Its loss greatly affects lateral and pulp-to-pulp
pinch and power grip
- In flexion, the middle finger is strongest, and it is important for both precision and
power grips
- The ring finger has the least functional role in the hand.
- The little finger, because of its peripheral position, greatly enhances power grip,
- affects the capacity of the hand, and holds objects against the hypothenar eminence.
Functional Wrist & Hand Scan
Functional Impairment of Hand
- Loss of:
a. Thumb: 40-50% of hand function
b. Index finger: 20%
c. Middle finger: 20%
d. Ring finger: 10%
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e. Little finger: 10%
- LOSS OF HAND: 90% loss of UE function
Types of Grips
1. Power Grips
- Requires control of greater flexor asymmetry to the hand
- Ulnar side of the hand works with the radial side
- Is used when STRENGTH or FORCE is the primary consideration
- Digits maintain objects against the palm
- Thumb may or may not be involved
- Extrinsic ms are more important
- Power Grips: hook grasp, cylinder grasp, fist grasp or digital palmar prehension,
spherical grasp, ulnar side of the hand works with the radial side to give STRONGER
STABILITY
2. Precision Grips
- Requires control of greater flexor asymmetry to the hand
- Ulnar side of the hand works with the radial side
- It is used when STRENGTH or FORCE is the primary consideration
- Digits maintain objects against the palm
- Thumb may or may not be involved
- Extrinsic ms are more important
3 Types of Pinch Grip
1. 3-point chuck, three fingered, or digital prehension, in which palmar pinch, or sub
terminal opposition, is achieved.
- With this grip, there is pulp-to-pulp pinch, and opposition of the thumb and fingers is
necessary (e.g., holding a pencil).
- This grip is sometimes called a precision grip with power.
2. Lateral key, pulp-to-side pinch, lateral prehension, or subtermino lateral opposition.
- The thumb and lateral side of the index finger come into contact. No opposition is
needed.
- An example of this movement is holding keys or a card.
3. Tip pinch, tip-to-tip prehension, or terminal opposition.
- With this positioning, the tip of the thumb is brought into opposition with the tip of
another finger. This pinch is used for activities requiring fine coordination rather than
power.
Other Hand Functional Testing Methods
1. Jebsen-Taylor Hand Function Test
- This easily administered test involves seven functional areas:
a. writing;
b. card turning
c. picking up small objects
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d. simulated feeding
e. stacking
f. picking up large, light objects; and
g. picking up large, heavy objects.
- The subtests are timed for each limb.
- This test primarily measures gross coordination, assessing prehension and
manipulative skills with functional tests.
- It does not test bilateral integration
2. Minnesota Rate of Manipulation test
- This test involves five activities:
a. placing,
b. turning,
c. displacing,
d. one-hand turning and placing, and
e. two-hand turning and placing.
- The activities are timed for both limbs and compared with normal values.
- The test primarily measures gross coordination and dexterity
3. Purdue Pegboard test
- This test measures fine coordination with the use of small pins, washers, and collars.
- The assessment categories of the test are:
a. right hand,
b. left hand,
c. both hands,
d. right, left, and both, and
e. assembly
- The subtests are timed and compared with normal values based on gender and
occupation.
4. Crawford Small Parts Dexterity Test
- This test measures fine coordination, including the use of tools such as tweezers and
screwdrivers to assemble things, to adjust equipment, and to do engraving
5. Simulated Activities of Daily living
Examination
- This test consists of nineteen subtests, including standing, walking, putting on ashirt,
buttoning, zipping, putting on gloves, dialing a telephone, tying a bow, manipulating
safety pins, manipulating coins, threading a needle, unwrapping a Band-Aid, squeezing
toothpaste, and using a knife and fork.
- Each subtask is timed
6. Moberg’s Pickup test
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- An assortment of nine or ten objects (e.g., bolts, nuts, screws, buttons, coins, pens,
paper clips, keys) is used.
- The patient is timed for the following tests:
a. Putting objects in a box with the affected hand
b. Putting objects in a box with the unaffected hand
c. Putting objects in a box with the affected hand with eyes closed
- The examiner notes which digits are used for prehension. Digits with altered
sensation are less likely to be used. The test is used for median or combined median
and ulnar nerve lesions.
7. Box & Block Test
- This is a test for gross manual dexterity in which 150 blocks, each measuring 2.5 cm
(1 inch) on a side, are used.
- The patient has 1 minute in which to individually transfer the blocks from one side of
a divided box to the other.
- The number of blocks transferred is given as the score.
- Patients are given a 15-second practice trial before the test
8. 9-hole Peg Test
- This test is used to assess finger dexterity. The patient places nine 3.2-cm (1.3-inch)
pegs in a 12.7 × 12.7 cm (5 × 5 inch) board and then removes them.
- The score is the time taken to do this task. Each hand is tested separately.
Anthropometric Measurements
Leg Length Measurement
1. True Leg Length
- Site: ASIS to medial malleolus
- If patient is obese, use lateral malleolus as landmark
- Must set the pelvis,
- Legs should be 15-20 cm (4-8in)
- if 1-1.5cm difference N but may cause sxs
- Iliac crest to greater troch coxa vara, gr troch to lateral knee jt line femoral shaft,
medial knee jt line to medial mall tibial length
2. Apparent Leg Length
- Site: Xiphesternum or Umbilicus to medial malleolus
- d/t pathology or contracture somewhere in the spine, pelvis or lower limbs.
Muscle Bulk Measurement
- Most common points
a. 20 cm above MJL
b. 10 cm above MJL
c. 9 cm below fibular head
- Effusion & atrophy/hypertrophy
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-
Select areas where mm bulk or swelling greatest and measures circumference
Common knee, leg, thigh – how far above or below the apex or base of patella
Note if swelling or mm bulk
Can use lateral jt line than patella
Normal Value for Athlete: 5-8cm
Extensor Lag
- AKA: Heel height difference
- The patient lies prone on the examining table with the lower limbs supported by the
thighs.
- The difference in heel height is measured.
- Normal Value: 1-1.5 cm
Limb-Girth Measurement
- Edema, swelling, effusion
- Swelling/Effusion: Bony landmarks and every 4cm/2 in. proximal or distal depending
on the extent
Upper Extremity
1. UE fingers
- base, PIP together, DIP together
2. Wrists
- +MCP, thumb webline, wrist joint at radial styloid
3. FA/elbow
- + radial styloid every 4cm/2 in proximal
4. Arm/shoulder
- + lateral epi, every 4cm/2 in proximal
Figure of eight measurement of the hand
- The examiner places a mark on the distal aspect of the ulnar styloid process as a
starting point.
- The examiner then takes the tape measure across the anterior wrist to the most
distal aspect of the radial styloid process
- From there, the tape is brought diagonally across the back (dorsum) of the hand and
over the 5th metacarophalangeal joint line, across the anterior surface of the
metacarpophalangeal joints
- then diagonally across the back of the hand to where the tape started
Lower Extremity
1. LE toes
- base, PIP, DIP
2. Ankle
- + MTP then every 4cm/2in prox
3. Leg/knee
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- + lateral mall then every 4
4. Thigh/hip
- lateral knee jt line then every 4
Figure of Eight Measurement in Ankle
- The patient is positioned in long sitting with the ankle and lower leg beyond the end
of the examining table with the ankle in plantigrade (90°)
- the examiner places the end of the tape measure on the tibialis anterior tendon,
drawing the tape medially across the instep just distal to the navicular tuberosity
- The tape is then pulled across the arch of the foot just proximal to the base of the
5thmetatarsal across the tibialis anterior tendon, and then around the ankle joint just
distal to the tip of the medial malleolus, across the Achilles tendon, and just distal to
the lateral malleolus, returning to the starting position
- Repeat 3 Times then average
Volumetric Measurement
- Volumeter
- Generalized Edema & local swelling, atrophy irreg (distal ext)
- 10-mL difference L & R hand, dominant & nondominant hands
- Swelling 30-50 mL difference
Skin Fold Measurements
Skin Fold Sites
✓ Triceps
✓ Biceps Brachii
✓ Subscapular
✓ Iliac crest
✓ Supraspinal
✓ Abdominal
✓ Front thigh
✓ Medial calf
Body Fat Measurements
- body composition (mm, fat, bone mass)
- Used to determine the individuals body type (mesomorphic, endomorphic,
ectomorphic
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-
Sufficient Sites
Males <12-15% body fat
Endurance athletes <7%
No one should below 5% body fat
M >14% and F >17% weight loss program or weight training inc lean body mass
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