DR.
CHOWN
SPRING
2022
Midterm Study Guide
OT 590: Clinical Competency
WEEK 1: RANGE OF
MOTION & GONIOMETRY
OF THE UE
EVALUATION
• First, check orders to see what type of motion is allowed
(i.e. AROM, PROM, AAROM).
• Next, if cleared for range of motion (ROM), recommend
AROM before PROM to gauge how far the client can move
independently.
TYPES OF ROM
• AROM
• PROM
• Observe for compensatory
movements
• Tone
• Check for coordination
• Guarding
• Motivation
• Pain
• Pain
• Crepitus
• Position and stabilize the joint correctly
ERROR
REDUCTION
• The same goniometer should always be used to reduce
the chances of instrumental error
• Move a body part through its appropriate ROM
• Determine the joint's end of the range of motion and
end-feel
• Palpate the appropriate bony landmarks
• Align the goniometer with the landmarks
• Read the measuring instrument properly
• Record measurements correctly (both active and passive
range of motion should be measured and recorded
respectively).[1]
• The range of motion of each joint should be measured in
isolation, to avoid trick movement (simultaneous
movement of another joint) and muscle
insufficiency which may alter the reading.
FACTORS THAT MAY AFFECT ROM
OUTCOMES
Edema
Pain
Adhesions
Capsular
tightness or
laxity
Tendon
excursion
Strength
deficits
FACTORS
THAT IMPACT
RELIABILITY
Size and design of goniometer
Type of ROM
Amount of force applied
Method of documentation (time during
day, positive and negative numbers)
Placement of goniometer
FREQUENCY OF TEST ADMINISTRATION
• American Society of Hand Therapists (ASHT) endorses American Medical Association's
(AMA) use of plus and minus signs
• + is equal to hyperextension, surplus
• - is for extension lag, lagging or missing extension
• Total Active Motion (TAM) – Sum of active MCP, PIP, and DIP arc of motion in degrees of
an individual digit.
1. Subtract total active flexion (TAF) of the MP, PIP, and DIP joints from the total extension (TAF)
deficit of the same joints in unaffected and affected hand.
2. Calculate TAM% by dividing the TAM of the injured finger by the TAM of the contralateral finger
GONIOMETR
Y
• Center – placed on axis
• Stationary arm – placed on
stationary limb
• Moving arm – placed over
moving limb (i.e. line of travel)
• Black numbers for ROM of all
extremities; red numbers for
foot, only.
• Note. When reading degrees,
read to the left, not right.
Always start at 0 degrees!
GONIOMETRY
EXAMPLES
• Left: Shoulder flexion and extension
• Practice: Find shoulder flexion 0-115 degrees
• Right: Elbow flexion and extension
• Practice: Find 40-110 degrees elbow AROM
WEEK 2: GONIOMETRY
OF THE LE
GONIOMETR
Y EXAMPLES
• Top: Knee flexion and
extension
• Practice: Find knee flexion
110 degrees
• Bottom: Hip flexion and
extension
WEEK 3: MANUAL MUSCLE
TESTING (MMT) OF THE UE
MMT OF THE UE
•
Manual muscle testing is used to assess function
and strength of various muscle, most commonly the
UE.
•
Two techniques:
•Break Technique: apply pressure until pt breaks position
•Make Technique: resistance through the whole
motion/range
•
No standard scale, as depicted on the right.
•
0 – 5 is an ordinal scale, which means there are
disproportional distances between grades.
•
Example: Grade 4 is not twice as strong as grade 2.
Note. 3 is full ROM, >4 is subjective
•
Note. Use a cupping motion when performing
MMT.
• 0 = flaccid, nothing would happen
MMT OF
ELBOW
• 1 = flicker or trace movements
•
Might get a little flicker, look at biceps – can slap to give stimuli
• 2- = partial ROM, no gravity (so you are holding their arm)
•
Horizontal plane
•
Can only go halfway while being supported
• 2 = full ROM, no gravity
•
Can get full ROM, but gravity is still eliminated
• 2+ = against gravity position, goes through less than 50% of ROM
•
Arm is hanging, can only flex 20 degrees
• 3- = more than 50%, but not full ROM
•
About 120 degrees
• 3 = full ROM; holds test position
• 3+ = slight pressure, two fingers, don’t let me break you, resist
• 4- = slight to moderate pressure, about the palm of hand with slight
resistance, anything heavier will break
• 4 = moderate pressure, resisting with some force
• 4+ = moderate to severe, push more
• 5 = pushing really hard
SOURCES OF
ERROR RELIABILITY
Compensatory movements
Pain
Contractures
Tone
Deformities
Contraindications
Lack of understanding
Lack of effort
Therapist training
Different techniques
Different amount of resistance
Point and line of force applied
Speed of resistance
Duration of contraction
Fatigue
Motivation of therapist
MMT QUICK
SCREEN
AROM
PROM
MMT of shoulder (up/down),
biceps (pulling/pushing),
squeeze fingers
UE MUSCLES
EXAMPLES
• Abductor Pollicis Brevis (APB)
• Function: abduction thumb
CMC joint
• To test: supinate hand, put your
index finger on the volar side of
their proximal phalanx, try to
have them oppose their thumb
while you resist, muscle will try to
fire and pop
UE MUSCLES EXAMPLES
• Flexor Pollicis Longus (FPL) - very strong flexor
•
•
•
Function: flexion of the thumb at the
interphalangeal joint
•
To test: block below IP joint of thumb, have
them flex the tip
•
If thumb is in hyperextension, tendon is
gone; natural position is slightly flexed
Flexor Digitorum Superficialis (FDS)
•
Function: flexion of the middle phalanges of the
four fingers (excluding the thumb) at the proximal
IP joints
•
Isolate or flex at the PIP joint
Flexor Digitorum Profundus (FDP)
•
Function: flexion of the fingers at the MCP and IP
joints
•
Isolate or flex at the DIP joint
UE MUSCLES
CONT.
• Extensor Pollicis Longus (EPL)
• Function: extension of the thumb at
the MCP and IP joints
• To test: Put hand flat on table in
pronation, have them lift their thumb
off table, EPL will pop
UE MUSCLES CONT.
• Interossei
• Palmar/Volar –
ADDUCT
• Put your fingers in
between theirs and
have them squeeze
• Dorsal – ABDUCT
• Wrap your hand
around theirs, have
them abduct
UE MUSCLES CONT.
• Lumbricals
• Flex MCP and IP joints – wave
goodbye
• To test: put your hand on volar
side of hand while they are in
tabletop, have them try to pull
their fingers down
HAND ANATOMY:
LUMBRICAL
MUSCLES
DORSAL INTEROSSEL
MUSCLES (DAB)
FUNCTION:
ABDUCT FINGERS
PULL FINGERS AWAY FROM
MIDLINE (NOT PINKY)
NERVE: ULNAR
HAND ANATOMY:
LUMBRICAL
MUSCLES
ADDUCTOR POLLICIS
MUSCLE
FUNCTION:
THUMB ADDUCTION
HAND ANATOMY:
LUMBRICAL
MUSCLES
PALMAR INTEROSSEI
MUSCLES (PAD)
FUNCTION:
ADDUCT FINGERS
NERVE: ULNAR
UE MUSCLES CONT.
• Extensor Digitorum Communis (EDC)
• Function: extends medial four digits at
the metacarpophalangeal joints and
secondarily at the interphalangeal joints.
It also acts to extend the wrist joint
• Have them make a claw with their hand,
put your hand on their fingertips, apply
pressure and have them try to extend, EDC
will pop on dorsal side
•
Flexor Carpi Ulnaris (FCU)
• Function: Allows you to ulnarly deviate
• Test: elbow at 90, supinate hand, go
into flexion and ulnar deviation (up and
away)
UE MUSCLES CONT.
• Biceps Brachii
• Function: flexion and supination
(outward rotation) of the forearm
• Test: supinated, push their forearm down
while they flex
• Brachialis
• Function: flexes the forearm at the elbow
• Test: pronated, resist flexion
• Brachioradialis
• Function: flexes the forearm at the elbow
• Test: neutral, thumb up, resist flexion
UE MMT: TESTING
UE MUSCLES CONT.
• Supinator
• Biceps are the main muscle responsible for this
• To test: elbow at 90, hold their hand like you're giving them a shake, support their
elbow, have them try to supinate as you resist
• Triceps
• Stand up, lean on table, and kick back arm | or seated, bring arm back, support
humerus, have them going into extension and resist
• Difficult for older adults, or individuals with rotator cuff injuries
UE MUSCLES CONT.
• Empty Can Test
• Tests the supraspinatus (important muscle of rotator
cuff)
• Arms up like superman
• Position: elbow extended, shoulder in horizontal
abduction, turn hand down like holding a can one hand
on shoulder, push down at wrist, if you ask them to
hold and arm slowly goes down = injury
• Lift Off Test
• Hand on back, palm facing out, try to lift hand off
back, can gently resist
• Tests for subscapular – STRONGEST muscle of
rotator cuff (responsible for internal rotation)
• Arm hides like a submarine
HAND
ANATOMY:
JOINTS
Click to add text
HAND
ANATOMY:
INTRINSIC
MUSCLES
Function:
fine motor, grasp
Click to add text
HAND ANATOMY:
THENAR MUSCLES
ABDUCTOR POLLICIS BREVIS
(APB)
FLEXOR POLLICIS BREVIS (FPB)
OPPONENS POLLICIS (OP)
FUNCTION:
APB - ABDUCT
FPB - FLEX
OP - OPPOSE
HAND ANATOMY:
HYPOTHENAR
MUSCLES
ABDUCTOR DIGITI MINIMI (AND)
FLEXOR DIGITI MINIMI BREVIS
(FDM)
OPPONENS DIGITI MINIMI (ODM)
FUNCTION:
ADM – ABDUCT LITTLE FINGER
FDMB – FLEX LITTLE FINGER AT
MCJ
ODM – FLEX AND LAT ROTATE
LITTLE FINGER AT CMC JOINT
HAND
ANATOMY:
INTRINSIC
MUSCLES
Function:
fine motor, grasp
Click to add text
HAND
ANATOMY:
EXTRINSIC
MUSCLES
Function:
gross motor of
hand and wrist
HAND
ANATOMY:
EXTRINSIC
MUSCLES
Function:
gross motor of
hand and wrist
HAND
ANATOMY:
EXTRINSIC
MUSCLES
Function:
gross motor of
hand and wrist
HAND
ANATOMY:
EXTRINSIC
MUSCLES
Function:
gross motor of
hand and wrist
WEEK 4: MMT OF THE LE &
PINCH/GRIP TESTING
MMT OF LE
• Evaluation:
• Testing:
• PVD
• Dorsiflexion MMT
• History of diabetes
• Plantar Flexion MMT
• Weight bearing status
• Hamstring MMT
• Fall risks
• Quadriceps MMT
• Consult with PT
• Thomas Test – Measure the flexibility of
the hip flexors
• Mobility equipment
• Energy level
• Any wounds or deformities
DORSI/PLANTAR FLEXION
MMT
• Dorsi flexion
• Have patient lay supine, stand at the end of the bed or next
to it, put one hand on their tibia, other hand on the top of
their foot, ask them to point their toes to their face and resist
• Plantar flexion
• In the same position, move your hand to the bottom of their
foot and ask them to point their toes to the floor and resist
DORSI/PLANTAR FLEXION
ANATOMY
HAMSTRING/QUADRICEPS
MMT
• Hamstrings
• Function: Flex knee, ext hip
• While patient is laying supine, have them
lift their knee, place your left arm
underneath their knee and your right hand
on posterior side of tibia, tell patient to try
to bring their foot to their butt while you
resist
• Quadriceps
• Function: Ext knee, flex hip
• In the same position, move your hand to
the anterior side of tibia, tell patient to
kick the soccer ball while you resist
PINCH TESTING
• Pinch strength is tested utilizing a
pinch gauge, as depicted on the left.
• Types of pinch:
A.Tip pinch
B. 3-jaw chuck
C. Lateral/key pinch
GRIP TESTING
• Grip testing is completed using a dynamometer, as depicted on the right.
• Positioning:
• The client is seated with shoulder adducted, elbow flexed to 90
degrees with the forearm and wrist in neutral.
• When ready the subject squeezes the dynamometer with maximum
isometric effort, which is maintained for about 5 seconds. No other
body movement is allowed.
• The mean value of three trials is recorded, and both hands are
compared.
• Jamar testing measures hand-eye coordination as well as manual
dexterity of the arm and hand for manipulative work.
• Research has shown a link between Jamar testing, depression, and
malingering
• Position: 2
WEEK 5: HAND THERAPY
ASSESSMENTS
SEMMES–
WEINSTEIN
• Evaluation
MONOFILAMENTS
• Environment
• Quiet room, normal temperature, good light
• Materials
• Monofilaments and hand map/colored pencils
• Client History
• Thorough history can help guide where to focus the test
• Reference Area
• Find an unaffected area and establish what is “normal”
for the patient
• Application
GIANT BOOBS PULL
REDRECKS
• Begin with normal threshold filaments and progress
filaments until the patient can identify the touch (1/3
trials is considered an affirmative response)
• Filaments are applied 1.0-1.5 seconds at a time, lifted off
the skin 1.0-1.5 seconds
TWO-POINT DISCRIMINATION
• Ability to perceive the difference of 1 or 2 stimuli
• A light application of the tool using one or two points.
• Must be longitudinal, not horizontal or crooked.
• The hand or UE is comfortable and vision is occluded
• Testing is performed in a randomized sequence and points are in a longitudinal
fashion, perpendicular to the skin
• 7/10 responses are considered accurate!
• Scoring (Note. Document fingers, size, and number of trials)
•
Normal is 0.5 cm or less
•
Fair is 0.6 cm to 1.0 cm
•
Poor is 1.1-1.5 cm
• Always start at 0.5 cm; Testing is discontinued at 1.5 cm
•
Note. Quickest assessment
STEREGNOSIS
• Stereognosis - the ability to perceive and recognize the form of an object in the absence of
visual and auditory information, by using tactile information to provide cues from texture, size,
spatial properties, and temperature, etc.
• Steps
• Choose about 5 common household items
• Explain and demonstrate the test
• With vision occluded, place object in the client’s hand (you should test both hands for reference)
• Record how many objects they are able to identify and record
Note. Typically used for CVA patients
NERVE
INNERVATION
NERVE IMPINGEMENT TESTS
Pronator Syndrome
Carpal Tunnel
• Median nerve
impinged just below
the elbow
• Test: Shake hands
with patient, tell
them to pronate, add
resistance:
• pain = positive sign
• Median nerve
impinged at wrist
level
• You need medium
strength to lay down
the carpet
• Test: Tinel’s test –
tap directly down the
center of the forearm
elbow to wrist on the
palmer side: pain =
positive sign,
Phalen’s test – prayer
position: pain =
positive sign,
Durkan’s test – apply
compression by use
of fingers over the
wrist for 30 seconds,
numbness of fingers
= positive sign
Cubital Tunnel
• Ulnar nerve
entrapment at the
elbow
• Test: Elbow flexion
held for 30 seconds,
numbness of pinky
and ring finger =
positive sign
Radial Tunnel
Syndrome
• Radial nerve
impinged directly
below the lateral
epicondyle of the
elbow
• Test: apply resistance
to ring finger
extension, pain =
positive sign
Cervical / Double
Crush Syndrome
• Bilateral hand
numbness = positive
sign
CARPAL TUNNEL
Median Nerve
TESTING
RADIAL NERVE
DAMAGE
• Cannot make a thumbs up
• Wrist Drop
• Unable to extend wrist
• Radial Tunnel Syndrome
• Can be misdiagnosed as tennis elbow/lateral epicondylitis
• A few cm distal from the lateral epicondyle, palpate over
epicondyle and if it doesn't hurt, move down to radial tunnel,
pain = +
• To test: shake their hand and have them try to supinate as you
resist, pain = +
• Middle finger test – put finger on back side of distal
phalanx, have them try to extend as you resist, pain = +
MEDIAN NERVE
DAMAGE
• Cannot make an "OK" sign (tip to tip)
• Hyperthenar Atrophy
• Take your two hands, look straight down, make sure
the thenar eminence looks meaty/concave,
not convex/flat
• Ape Hand
• Thumb is flat against index finger, cannot abduct
thumb
• Benediction/Preacher's sign (can be median or ulnar)
• RF and SF flexed, thumb, IF and MF extended, can't
make a fist
• AIN Syndrome
• Anterior Interosseus Nerve; presents like an "L" shape,
FPL of thumb and FDP of index do not work
MEDIAN
NERVE
DAMAGE
• Hyperthenar Atrophy
• Take your two hands,
look straight down,
make sure the thenar
eminence looks
meaty/concave,
not convex/flat
MEDIAN NERVE DAMAGE (CONT.)
• Pronator Syndrome
• Located right below the elbow, due to repetitive movements
• To test: Tell patient to shake your hand, have them try to pronate while you resist, pain = +
• Carpal Tunnel
• Between the hypo and thenar eminence
• Phalen's sign – prayer stretch
• Reverse Phalen's – dorsal side of hands
• Tinel's sign – tap over median nerve; start proximal to distal
• Durkan's Test – push down and hold on carpal tunnel, fingers go numb = +
ULNAR NERVE DAMAGE
• Cannot cross their fingers
• Froment's Sign
• Take a piece of paper, tell client to pretend they are texting, slide paper
under their thumbs, have them try to hold the paper as you pull it away, if
their thumb IPs hyperflex = positive
• Adductor pollicis brevis is not working, thumb will cheat and FPL will
kick in to help
• Wartenberg Sign
• SF sticks out to side and floats in space, cannot adduct their finger
• Intrinsic muscles are not working, missing adduction – ulnar nerve fires
the intrinsics
• Benediction/Preacher's Sign (can be ulnar or medial)
• RF and SF flexed, thumb, IF and MF extended, can't make a fist
POSITIVE:
FROMENT'
S SIGN
Texting FROM your phone
to get an umbrella
POSITIVE:
WARTENBER
G'S SIGN
Drinking tea under an
umbrella with Dr. Penny
in Wartenberg
tea = pinky out
Umbrella = ulnar nerve
Wartenberg = name
ULNAR NERVE DAMAGE (CONT.)
• Claw Hand
• SF and RF MCP joints are hyperextended, IP joints are flexed (can affect all digits)
• 1st Dorsal Interosseous Atrophy
• Thumb webspace – atrophy, no fleshy area; may see wasting in between the metacarpals
• Guyon's Canal
• Located off the pisiform, bottom of wrist and ulnar side; SF and RF will go numb
• Tinel's Sign
• Activity that aggravates it: cycling, weightlifters
• Cubital Tunnel
• Wraps around posterior side of elbow, very superficial, "garden hose"
• When you flex your elbow for 30 seconds and SF & RF go numb, but goes away after you straighten =
positive
GUYON'S
CANAL
1ST DORSAL INTEROSSEOUS
ATROPHY
ULNAR
NERVE
MEDIAN
NERVE
RADIAL
NERVE
THORACIC OUTLET SYNDROME
• If they have symptoms in hand, look proximal
• Symptoms coming from neck? Cervical problem?
• 90% of the time it comes from the neck
• If symptoms are bilateral = RED FLAG!
NERVE
LOCATION
S
LEFT
HAND
WEEK 6: TRANSFERS AND
STAIRS
CASE SCENARIO
36-year-old female in MVA 2 weeks ago. Sustained right tibial plateau fracture. On best rest for 2
weeks because of sepsis and DVT in right leg. ORIF performed on day of admission. OT/PT
evaluate and treat and up to chair.
• What to do first: HPI, past medical history, premorbid functions
• Testing:
• Physical: AROM, PROM, MMT
• Neuro: Sensory testing
• Cognitive: Observe
WEEK 9: KINESIOTAPE
SKIN AND ITS SENSORY RECEPTORS
THE ENDOGENOUS ANALGESIC SYSTEM
• Pain is modulated by Kinesio Tex Tape’s effect on the skin and
superficial fascia
• Compressive forces may stimulate mechanoreceptors
• Decompressive forces may decrease inflammation and unload
mechanoreceptors
• Either force can relieve pain
APPLICATION
• I Strip: Tension focused within the
therapeutic zone directly over target issue
• Y Strip: Tension is dispersed through and
between two tails over target issue
• X Cut: Tension is focused directly over
target issue and dispersed through tails at
each end
• Fan Cut: Tension is dispersed over target
issue through multiple tails
KINESIO
TAPING®
TENSION
PERCENTAG
E
GUIDELINES
• Super Light 0-10%
• Paper off 10-15% (stretch already in
tape)
• Light 15-25% (see fibers)
• Moderate 25-35%
• Severe 50-75% (looking through and
see pattern)
• Full 75-100%
• 0% tension anchor or end
BASIC
KINESIO
TAPING
MUSCLE
APPLICATIO
N
CONCEPTS
D to P (I to O)
• Distal  Proximal
• To inhibit overused muscle – acute conditions, muscle spasm
• 15% to 25% tension
•
DIP
P to D (O to I)
• Proximal  Distal
• To facilitate weak muscle-chronic conditions, rehabilitation
• 15% to 35% tension
•
PDF
Therapeutic Direction is the recoil of the tape
toward the anchor
Therapeutic Zone is the region of tape applied to
targeted tissue
WEEK 10: NEURO TESTING
UE TESTING
Finger-to-thumb Test
 Each tip to thumb
 Looking for: Fluidity of movement, overflow (other hand mirrors
when patient does one hand, heavy concentration
 Test: bilaterally, one hand at a time, eyes open, then eyes closed
Finger to nose
 Looking for: fluidity of movement (smooth and coordinated), hitting
target (dysmetria: no sense of distance; overshoot, or miss target),
weakness, tremors
Rapid alternating movements
 Dysdiadochokinesia: cannot copy movement
 Looking for: smoothness of movement
 Difficult for individuals with brain lesions
Pronator Drift Test
 Lesion on opposite side of drift
 Test: eyes close, arms out elbows straight with palms up
UE TESTING
Rebound phenomenon
 Test: Pretend you are arm wrestling, resist, then let go
 Positive sign: overshoot, hit him/herself
 Negative sign: can prevent themselves from hitting themselves
Archimedes spiral
 Draw spiral circle going outward, then pt has copy it
Testing tone
 Tone: amount of resistance to passive range of motion; velocity dependent,
needs to be fast, fluctuate speed
o Hypertonia: more resistance
 cogwheeling (a jerky feeling in your arm or leg that you can sense
when moving or rotating your affected limb or joint)
o Hypotonia: floppy, Jell-O; range is greater than expected
Proprioception
 Test: seated with arm on table, pt closes eyes, “tell me if my pushing your
thumb up or down”, about 3 times, mix it up
 Looking for: speed of response, hesitation/confidence of response
TREMOR
TESTING
Intention tremors
• Definition: involuntary, rhythmic muscle contractions (oscillations) that
occur during a purposeful, voluntary movement; tremor when you are
intending to do something
• Common for MS
Resting tremors
• Definition: occurs when the muscle is relaxed, such as when the hands
are resting on the lap
• With this disorder, a person's hands, arms, or legs may shake even when
they are at rest
• Common for Parkinson’s
• Pill rolling
Essential tremors
• Definition: a nervous system (neurological) disorder that causes
involuntary and rhythmic shaking
• affect almost any part of your body, but occurs most often in your hands
• especially when you do simple tasks, such as drinking from a glass or tying
shoelaces
***tremors: different rhythmic frequencies
OTHER
MOTOR
SYMPTOMS
Dysmetria: a condition in which there is improper measuring of distance in muscular
acts (overshooting)
o hypermetria: overreaching (overstepping)
o hypometria: underreaching (understepping)
Bradykinesia: lowness of movement
o It is one of the cardinal symptoms of Parkinson's
Ataxia: uncoordinated movement
o look/move drunk
Clock drawing test
• Test: tell pt draw the face of a clock (cue based on needs: “draw circle then fill in
the numbers”; “start with the 12 at the top”
• Next (grade up), tell them to put the hands in a certain time
• tests for: left/right side neglect; stroke patients
• left side neglect is more common
Apraxia: Difficulty with skilled movements even when a person has the ability and
desire to do them
• IdeationalNo idea or concept of a task; can’t start a task, or think of the steps
• Ideomotor
• Understands the concept, but motor-wise is wrong
• Can perform spontaneously, but can’t on command
OTHER
MOTOR
SYMPTOMS
Dressing
• Dressing task/sequencing of dressing doesn’t make
sense
• Test: dressing assessment, initial eval
Constructional
• inability of patients to copy accurately drawings or
three-dimensional constructions
• Test: jenga, pyramid
LE TESTING
Heel-to-shin Test
• Slide heel straight down opposite shin
• Looking for: smooth, coordinated movement; pure coordination
Toe taping
• Looking for: Coordination
• Tape foot in rhythmic fashion
Arm swing
• Looking for: rhythmic swinging of arms
Romberg test
• Proprioceptive test
• Test: standing, ability to catch them/they can be supported; eyes open,
have hands on their side, then, pt closes eyes (observe)Positive: lean or fall
to one side; relying on eyes to keep balance
TYPES OF
GAIT
Hemiplegic gait: one side; hike hip and swing leg due to weakness (could have foot
drop)
o UE could be clenched to body
o Overcompensating techniques
Diplegic gait (spastic gait): bilateral side
o
o
o
o
Walk on tippy toes
Adductors are very tight, feet rotated inward
UE constructed to body
Cerebral palsy
Neuropathic gait (steppage gait)
o High stepping to clear foot due to foot drop
o Common in foot drop
Ataxic gait (uncoordinated walking)
o Wide stance to stay balanced to avoid following
o Drunk walk home from troopers
Sensory gait (stomping gait)
o Common with: sensory seeking, diabetic due to lose of sensation/neuropathy
Parkinsonian gait
o
o
o
o
Narrow BOS, shuffling gait; no steppage or arm swing
Universal flexion (UE, trunk, etc)
Heavy leaning forward to start walking
Very stiff and rigid movement
WEEK 11: MODALITIES
Frequency
ULTRASOUND
• Superficial: 3 MHZ
• Deep: 1 MHZ
Intensity
• Thermal: greater than 0.8
• Nonthermal: 0.8 or less
Pulse versus continuous
• Thermal: chronic, improve elasticity
• Nonthermal: acute, healing
• Turning stove on and off = water never boils
Time
• Lots of tissue = more time
• Less tissue = less time
ULTRASOUND DECISION MAKING GUIDELINE
Non-thermal
Inflammatory or Acute
Phase
0.2 w/cm²
20% duty cycle
Mild heating
Proliferative or
subacute phase
0.2 to 0.8 w/cm²
50% duty cycle
Therapeutic heating
Remodeling or chronic
phase
0.8 to 2.0 w/cm²
100% duty cycle
TENS
1. Types of TENS
a. TENS used for Pain control
i. Acute pain or chronic pain
ii.High rate: frequency is really
high (acute)
1. Sensory setting
iii.Low rate: frequency is low
(chronic)
1. Motor setting
2. Chronic = 3 months or
more
iv.Noxious is rarely used
b. Order of recruitment
i. Sensory -> motor -> noxious
TENS
Sensory is always first, then early motor, then motor (contraction)
*Inverse relationship between the amplitude and the pulse duration (if one goes up the other goes down)
Remember:
• Black – smoke over fire = Motor Point (NMES Only)
• Increased rate = increased muscle fatigue
• Ramp time: Normal = 2.0 seconds
• We are now trying to fire ‘motor’ units vs sensory.
- Thus compared to TENs, rate, pulse and intensity may be slightly higher
• Red electrode = positive (anode)
• Black electrode = negative (cathode)
• Frequency = require approximately 35 to 50 pps to produce smooth tetanic contraction
• Pulse Duration = 150 to 350 microseconds to stimulate motor nerves
• Farther apart the deeper it does (pads)
• Chronic pain = low rate (thumping sensation)
NMES
a. Muscle strengthening/muscle re-education
b. Know terms:
i. Pulse rate
ii. Pulse width/duration
iii.On/Off time (rest breaks)
1. Goal oriented
a. Ex. Going to the gym: no rest between sets = exhausted, cannot
continue
b. Start with long rest and slowly decrease break time
iv.Ramp up ramp down
1. Kicking door open = scared response (rapid, painful reaction) vs. slowly
opening the door = comfortable response (gentle, functional reactions)
v. Modulation: solution to the problem
vi.Accommodation: feeling, what is happening to the physical
vii.Asymmetrical biphasic = small muscles
viii.Symmetrical biphasic = large muscles
WEEK 13: COGNITIVE
SCREENING
MINI
MENTAL
The Mini-Mental State Exam (MMSE) is a widely
used test of cognitive function among the elderly; it
includes tests of orientation, attention, memory,
language and visual-spatial skills.
GLASGOW
COMA SCALE
Categorization
Coma: No eye opening, no ability to follow
commands, no word verbalizations (3-8)
Head Injury Classification
Severe Head Injury----GCS score of 8 or less
Moderate Head Injury----GCS score of 9 to 12
Mild Head Injury----GCS score of 13 to 15
EXECUTIVE FUNCTION
Attention
Memory
Calculation
Abstract
thought
Visual and body
perception
(agnosia)
Mini Mental
State Test
Orientation
Concentration
Problem-solving
Reaction time
Sequencing
Spatial (copy a
design, clock
face)
Judgement and
insight
LOBE FUNCTIONS
Lobe
Alteration in Higher Function
Frontal
Apathy, disinhibition
Temporal
Memory
Parietal
Calculation, perceptual & spatial orientation (nondominant hemisphere)
Occipital
Perceptual & spatial orientation
LOBE FUNCTIONS
WEEK 15: VITALS
VITALS!!!
PR
Less than 60 BPM = bradycardia
More than 100 BPM = tachycardia
RR = 15 – 20 breaths per minute
BP = 120/80
O2 = 95-100%
Temperature
<94 hypoxia (blue)
<90 medical emergency
BLOOD PRESSURE
Measure of pressure exerted
by blood as it flows through
the arteries
Blood pressure is recorded in
millimeters of mercury and is
recorded as a fraction
Pulse Pressure
Systolic pressure is written over the
diastolic pressure
• Example: 136/72
The difference between the systolic
and diastolic blood pressures
• Example: 110/70
• Pulse pressure is 40
DETERMINANTS OF BLOOD
PRESSURE
Cardiac Output
Peripheral Vascular
Resistance
• Weak heart = 
volume with each
contraction = 
C. O. =  BP
• Strong heart = 
volume with each
contraction = 
C. O. =  BP
• Vasoconstriction
(smaller lumen) =
increased
resistance =  BP
• Vasodilatation
(larger lumen) =
decreased
resistance =  BP
Blood Volume
Blood Viscosity
(thickness)
• Decreased
volume =
Decreased blood
pressure
• Increased volume
= Increased blood
pressure
• Increased RBC
(more RBC/less
plasma)
• Measured by
hematocrit (> 6065% = elevated
BP)
FACTORS AFFECTING BLOOD PRESSURE
• Age
• Older person: Elasticity/ flexibility
of the arteries decreases, and BP
rises
• Stress and Emotions
• Race
• Sex
• Exercise
• Diurnal Variations
• Medications
• Environment
• Disease Process
• Lifestyle
• Smoking
• Alcohol
• Cholesterol
FACTORS
AFFECTING
BODY
TEMPERATUR
E
Age
Basal metabolic rate (BMR)
Diurnal Variations
Hormones/ Catecholamines
Stress
Exercise
Environment
TAKING A PULSE
Use radial artery most of the time
Don’t use neck pulses
Count one full minute
Should be strong and easy to feel
Reported as “P= 85”
Gender
FACTORS
AFFECTING
PULSE RATE
Exercise
Fever
Medications
Hypovolemia (high blood volume)
Stress, fear, & pain
Position changes (supine, sit, stand)
Pathology
RESPIRATION
Observe while patient is at rest
Don’t let them observe you counting (they can
unconsciously change their rate)
Up, down = one cycle
Count for one full minute
Reported as “RR=16”
Anxiety/stress/pain
FACTORS
AFFECTING Activity
RESPIRATION
Increased environmental temperature
Decreased environmental temperature
Increased altitude
Medications
Increased intracranial pressure
Age
During anaesthesia the oxygen saturation
should always be 95 - 100%. If the oxygen
saturation is 94% or lower, the patient is
hypoxic and needs to be treated quickly.
A saturation of less than 90% is a clinical
emergency (WHO, 2011, pg. 8)
Normal 95%-100%
ORTHOSTATIC/ POSTURAL
HYPOTENSION
• BP that falls 20 mm Hg or more when a patient sits or stands
• Orthostatic hypotension
• Blood leaves the central organs (esp. the brain) and moves to
periphery causing the person to feel faint
• BP 3x: assess by taking BP while lying, sitting, then standing
NORMAL VITAL SIGNS CHANGE WITH AGE, SEX,
WEIGHT, EXERCISE TOLERANCE, AND
CONDITION
Temperature
97.8 - 99.1 °F/ average 98.6°F
36.1–37.8 °C / average 37°C
Pulse
60 - 100 beats per minute
Respiration
12 - 18 breaths per minute
Blood Pressure
90/60 mm/Hg to
120/80 mm/Hg