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Physical Therapy Examination

PTP 565: Fundamentals of Tests and Measures

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Physical Therapy Examination

• Examination: gathering of data: history, systems review, selecting and administering tests and measures. Comprehensive screening and specific testing process. Leads to a diagnostic classification.

• APTA Guide to Physical Therapy Practice

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PHYSICAL THERAPY EXAMINATION

• Important to develop a system for examination

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Organizational Structure of an Orthopedic Exam

I. History

II. Systems Review

III. Scanning Exam

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IV. Tests and Measures• Observation/Posture/Gait• Active ROM• Passive ROM• Resisted movements • Neuro Screen• Functional Assessment• Special Tests• Joint Play• Palpation

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I. History

Benefits from obtaining a history:1. report from the patient of their condition2. assists in formulating a working hypothesis for differential diagnosis3. gives clinical signs and symptoms4. assists with formulating an examination plan.5. assists in setting functional goals for the patient

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• General Demographics– Gender/Age/Height/Weight

• Social History• Occupation, Employment, Work• Functional Status, Activity Level• Growth and Development• Living Environment• Red Flags

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Other Significant Information

• Past Medical History

• Past Surgical History

• Medication

• Review of Systems: Questionnaire information about Heart, Lungs, Other organs.

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Red Flags

• Definition:• Constitutional Signs and Symptoms

– Fevers, chills, night sweats– Malaise or Fatigue– Unexplained Nausea or vomiting– Recent unexplained weight changes– Unilateral, bilateral or quadrilateral paresis or paresthesia– Shortness of breath– Bowel or bladder dysfunction

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Red Flags: continued• Insidious onset of pain

• Multiple levels of neurological symptoms

• Pain at night

• Increase in pain intensity over time

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Red Flags:

• No Red Flags? Continue with the Exam• Red Flags exist: Clinical Decision• What do you do with the patient?

– Refer– Consult– Send to the ER– Call an ambulance– Make an appointment for the Primary Physician

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Pain

• Onset– Sudden– After 24 hours– Gradual or insidious onset

• Intensity – Visual Analog Scale– Verbal Analog Scale– McGill-Melzack pain questionnaire– Thermometer Pain Rating Scale

• Pain Perception– Acute– Subacute– Chronic

• Pain Progression– Better– Worse– No Difference

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• Quality of Symptoms– Location of Symptoms

– Aggravating Factors

– Easing Factors

• Pain Descriptors– Sharp– Shooting pain– Aching – Burning– Pins and Needles– Numbness– Stiffness– Twinges

How Acute is the injury?• In terms of pain

• Time since onset of symptoms

• Length of Time pain lasts

• Acute• Sub-acute• Chronic

• Other Symptoms

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Signs/symptoms of acute conditions

• Inability to maintain any position for any length of time.

• Verbal and nonverbal expressions of pain while moving, slow guarded movements,

• Pain Scale that is very high 9-10 on a scale of 1-10

• Recent injury like within 1-2 days

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Examination for acute conditions: Key Points

Don’t try and complete the examination

Move into an intervention designed to relieve acute symptoms

Re-examine at a later date when the individual is able to tolerate the activity

Goal: interrupt the pain cycle

Injury not in acute phase:

• Continue with the examination process.

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II. Systems Review

• Cardiovascular System

• Integumentary System

• Musculoskeletal System

• Neuromuscular System

• Psychological Status

III. Screening Examination

• Purpose: decide area of involvement so that the examination can be directed to the appropriate area

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Scanning exam is especially helpful when:

• No history of trauma• Radicular signs are present: referred pain

along a specific spinal nerve root distribution (dermatome)

• History of trauma along with radicular signs are present

• Patient reports pins and needles sensation (paraesthesia) or complete numbness (anesthesia) in the region.

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• “long track” signs (spinal cord or UMN lesions) are present (flaccidity or spasticity)

• patients signs and symptoms don’t reveal any clear pattern

• ? psychological factors, secondary gain or patient is a poor historian

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Scanning Exam: Upper Quadrant

• Upper Quadrant: areas to scan include the joints above or below the patient’s dysfunction.

• Cervical spine: must screen the thoracic spine, TMJ, and shoulder

• Shoulder: must screen the cervical spine, thoracic spine, elbow and hand

• Elbow: must screen the shoulder, thoracic spine, hand

• Hand: must screen shoulder and elbow

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Thoracic Spine Scan

• Thoracic Spine: in particular must be aware of the systemic dysfunctions which show up as thoracic pain, rib pain, and or/shoulder pain

• Upper: cervical spine, shoulder, ribs• Lower: lumbar spine, ribs

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Lower Quadrant:

• Lumbar spine: must screen the thoracic spine, ribs, sacroiliac joint, hip, sometimes knee and feet

• Sacroiliac joint: lumbar spine, hip, knee, ankle• Hip: lumbar spine, SI, knee, ankle• Knee: lumbar spine, hip, ankle• Ankle/Foot: lumbar spine, knee

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What do you check during a scanning exam?

• Observation/Posture• Active ROM• Passive ROM with Overpressure• Muscle Strength• Sensory: myotome, dermatome and reflexes

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After the Screening Exam

Clinical Decision

Keep Refer Keep and Refer(Consult)

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Keep/Refer/Consult

• Keep: Patient is appropriate for Physical Therapy

• Refer: Patient’s signs and symptoms do not have a musculoskeletal origin

• Consult: Patient can be treated by physical therapy but also needs another medical professional for assistance

Specific Joint Examination

• Investigative hat

• Ruling out or confirming hypothesis for the dysfunction

• Determining the facts: muscle weakness, loss of range etc.

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Observation:

• Done before any hands on activities.

• Looking phase of exam

• Observe/Inspect for Visible defects, dysfunctions, alignment abnormalities

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Observation

• Gait: quick observation noted while the patient is walking from the waiting room to the examination room.

– Will note gait deviations that are really obvious like an antalgic pattern.

– Can also get an idea of balance by looking at base of support, position of arms, waddling gait

• Assistive devices used by patient

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Transitional movements• Sit to stand, walking, back to sitting• Guarded movements, stiffness, willingness to

move• Ability to maintain a position like sitting or

standing

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• Facial expression during history taking, affect of patient – anxious, flat etc.

• Patient’s willingness to move, substitute movements noted

• Medicated? Too much or too little?

• Posture: review standard alignment; sagittal and A/P views, look at symmetry and determine if the findings are related to the dysfunction.

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• UE: head, shoulder position in relation to acromian, thoracic spine position, Q angle of elbows, previous fractures for example a clavicular fracture,

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• Obvious deformities are noted during the posture exam such as scoliosis, or presence of bony abnormalities in the LE

• LE – may observe patella positioning in relation to the LE alignment, Varus or valgus position of knees, genu recurvatum

• Ankle position

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Other Observations:• Muscle wasting

• Scars and color of scars. If red these are recent, pale, they are old and well healed.

• Note any joint noise such as crepitus, snapping or grinding sounds made with movement

• Skin changes, nail changes can be observed

http://www.cdaarthritis.com/images_slides/images_slides_29e_larger_slides.htm

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Purpose of HANDS ON examination:

• To rule out or confirm a hypothesis developed by the therapist during the history and observation as to the patient’s cause of pain.

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Active ROM

• AROM– Patient’s willingness to move– Joint mobility/limitations– Muscle control– Muscle power– Movements which cause pain

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AROM: What to observe

• When/where pain occurs during movement• Does the movement increase the intensity of the

pain• Reaction of the patient to pain• Amount of observable restriction/limitation• Pattern of movement• Willingness of the patient to move the limb• Quality of movement

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2. Passive movement:

• This is done with overpressure after the patient has moved through their available range.

• Determines end feel at that particular joint with that physiological movement.

• End feel: quality of resistance to movement at the end of a physiological movement

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Normal end feels

• Hard: Bone to bone

• Firm: Capsular end-feel, Tissue Stretch

• Soft: Soft tissue approximation

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Abnormal end feels• Muscle spasm: Sudden and abrupt stop to movement• Capsular: similar to tissue stretch, it doesn’t occur at

end range• Bone to bone: similar to the normal bony end feel

but the restriction in range occurs earlier than it should in the normal range.

• Empty: pain is produced with movement• Springy Block: elastic resistance to further movement

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Definitions:

• Gonia: Angle

• Metron: Measure

• Definition: Measurement of the angles created by rotary motion of two bones around a joint

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Goniometry Purposes:

1. Joint Position

2. ROM Active ROM Passive ROM

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Other Aspects

1. Only motions occurring in a single plane are measured with few exceptions.

2. Measures osteokinematic motion NOT arthrokinematic motion

3. Flexibility Measurement

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4. Degrees of freedom: freedom of movement around a plane of motion– Motion occurs around one plane – one degree of

freedom– Motion occurs around two planes – two degrees

of freedom– Motion occurs around three planes – three

degrees of freedom

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Purposes of Joint ROM Examination

1. Database: Establish the existing ROM available in the joint Compare this with the normal ranges given in

the literature Compare with the other side. Beginning data base for treatment

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2. Aids in diagnosing and determining joint functiona. Hypomobility: less than normal ROM

when compared to established norms or the patients other side.

b. Hypermobility: greater than normal ROM when compared to established norms or the patients other side.

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C. Capsular Pattern: – Cyriax: pattern of limitation in range of motion at a joint

which predictably occurs when the capsule of the joint is tight due to capsular fibrosis or extended due to swelling.

– Fixed proportional loss of range of motion, it is not all inclusive as he never considered flex/extension when determining the shoulder’s capsular pattern.

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D. Orthotic fabrication: Many splints and orthotics rely on goniometric measurement to fabricate the devices

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3. Reassessment:

4. Acts as a motivational tool:

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5. Document results from treatment regimes

6. Research– Validity

• Evidence that a test will measure what it is suppose to measure

– Reliability• How reproducible are the results? Is the

measurement consistent and free from error?

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Validity of Joint Angle Measurements

• Validity: Evidence that a test measures what it is suppose to measure

• Goniometric Measurements– Content Validity:

– Criterion Validity: Gold Standard

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Reliability of Joint Angle Measurements

• Degree of consistency between goniometric measurements

• Intratester reliability is better than Intertester reliability, generally there is about a 5dg measurement difference between testers.

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• Universal goniometer is the most reliable of joint measurement tools

• Good to excellent reliability found in the numerous studies.

• UE measurement is more reliable than LE measurement

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• No real difference in reliability between using the mean of several measurements and one measurement once you are experienced in goniometry

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Factors which improve reliability in goniometric measurement

1. Consistent test position: if done antigravity position, should always be tested in the antigravity position

2. Consistent anatomical landmarks for movement and stationary arm alignment

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3. Consistent testing situation: if always evaluate in the morning, should continue in this manner.

4. Inexperienced PT’s may want to take the mean of several measurements while experienced PT’s will be reliable with only one measurement

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5. Same amount of manual force applied to the joint when measuring PROM

6. Consistent Tester: Due to intertester reliability (5 Dg difference between testers)

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Factors influencing Joint ROM

1. Age

2. Gender

3. Occupation or pattern of activity:

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4. Joint Structures: Anatomical Variance Disease Processes Posture Genetics

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5. Hand Dominance:

6. Types of Motion:

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PROCEDURE

1. Knowledge required to be competent in goniometry

a. Optimal testing positionb. Alternative Testing Positionsc. Stabilization required for

measurementd. Joint structure and functione. Normal end feelsf. Anatomical bony landmarksg. Instrument alignment

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2. Skills required to be competent in goniometrya. position patient and stabilize correctlyb. move a body part through an appropriate

ROMc. determine the end feel of the joint ranged. palpate appropriate landmarkse. align measuring instrument with landmarksf. read measuring instrumentg. record measurements correctly

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Positioning for joint measurement

1. The muscles surrounding the joint must be as relaxed as possible to get a true joint measurement

2. Position must place the joint in the starting position of 0

3. Position must permit complete ROM4. Provide stabilization for the proximal joint

segment

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Alternative testing positions:

• Need to accurately describe the position in records so that the same position is used in subsequent measurements.

• Reliability issue

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Stabilization:

1. Stabilize the proximal segment

2. Substitute Movements

3. Force of stabilization

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4. End Feel: Noted at end of the PROM – Quality of resistance to movement at the end

of a physiological movement– Normal End Feels

• Soft: Soft tissue approximation • Firm: Capsular end-feel, Tissue Stretch • Hard: Bone to bone

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MEASUREMENT TOOLS:

• Visualization: – Very subjective, not the best method to use. – Can be used for a quick reference but not for

objective measurements needed in charts. – Unreliable

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Electrogoniometer:

• Dynamic joint measurement used in research. – Developed in 1959, – The two arms of the goniometer are attached to a

potentiometer which is attached to an EMG machine.– The change is joint position will cause resistance in the

potentiometer which is then recorded as the amount of joint motion.

– Problem: time consuming

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Inclinometers: 2 types

1. Gravity dependent inclinometer: pendulum

2. Fluid or “bubble” goniometer: carpenter’s level, 360 dg scale, relies on gravity

– Has proven most effective in spinal mobilization so far

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Other Types of Measurement Tools

• Tape Measures/Rulers– Primarily used for trunk and scapular mobility

• Radiographs• Tracings• Motion Analysis with videotaping

– markers are placed over bony landmarks and then the angles are drawn

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Universal Goniometer:

• Gold Standard for joint measurement outside of radiographs

• Most commonly used, versatile• Measures joint position/range at nearly all

joints of the body, most effective in the extremities

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Basic Design:

• Protractor: full or half circle, center of which is the fulcrum, placed over the approximate location of the axis of motion of the joint being measured, axis will move during motion so must be adjusted at end range

• Stationary Arm: aligned parallel to the longitudinal axis of the proximal segment of the joint

• Moving arm: aligned parallel to the longitudinal axis of the distal segment of the joint

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Principle of Concurrent Lines

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Principle of Parallel Lines

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Sources of Error in reading a goniometer

1. Distortion of the scale as the examiner is not at eye level

2. Reading the wrong scale: 0 – 180 or 180 – 0

3. Misinterpreting the intervals on the scale

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NOTATION SYSTEMS

1. Anatomical position is the reference or 0 position for all movements EXCEPT

• Supination/pronation of the forearm• Glenohumeral joint internal/external

rotation• Thumb movements

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Recording in the patient’s chart:

1. ROM: number of degrees at beginning and at end of the motion

2. Passive or active ROM3. Subjective information4. Objective information5. Position of patient is not in the

recommended position

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RECORDING SYSTEMS

1. 0-180 dg. System is most widely used. Method of the American Academy of Orthopedic Surgeons

• Describes one specific motion, arc of motion is based on 180 dg. Numbers are all positive.

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2. 180 dg to 0 dg– System is used but is more difficult to interpret.

– 180 dg is the reference or starting point for measurement, measurement moves toward 0 dg

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3. 360 dg system – Anatomical position is 180 dg

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(+) and (-) numbers:

• Used to indicate hyper and hypo mobility of the joint, can also create confusion

1. Works well when: there is no motion past 0 dg. A minus number would indicate that the 0 position was not reached

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2. Confusion exists when the movement is past 0 dg

3. Creates problems when dealing with soft tissue approximation

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3. Isometric Resistive Movements

• Spine first than the extremities• Movement strength exam, not a specific manual

muscle test• Break Test• Myotomal distributions: 5 Second holds for

endurance/fatigue• Myotome: muscle innervated by a particular nerve

root, pattern of weakness if nerve root is entrapped• Shoulder abduction: C5 cervical nerve root

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Muscle Strength Testing

• Only one factor in determining muscle function

• MMT is only one form of strength testing• Consider factors of velocity of contraction,

power, endurance

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Principle of MMT

• Muscle strength required to hold a test position must be equivalent to the muscle strength required to complete the test movement (Kendall)

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Measurement Purposes

• Diagnostic – Cyriax Exam• Patient Improvement or Patient Worsening• Predictive Capabilities• Functional Loss• Outcome Measures

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Definitions: Muscle Performance

• Capacity of a muscle to do work. Incorporates the properties of strength, power and endurance

• W = F x D

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Muscle Strength

• Measurable force exerted by a muscle or group of muscles to overcome a resistance. Occurs with one maximal effort

• F

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Power

• Work produced per unit of time, Rate of work• P = F x D T• One isometric contraction, maximal resistance

with movement occurring throughout the range

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Endurance

• Ability of muscle to contract repeatedly over a period of time

• F x D x T• Number of repetitions a muscle can perform

before fatigue sets in

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Fatigue

• Inability to maintain torque over a period of time or a set number of muscle contractions

• Describes the amount of power maintained over time

• Fatigue is a loss of power and less range noted during a muscle contraction

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Types of Muscle Contraction

• Isometric

• Isotonic– Concentric– Eccentric

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Factors influencing Contractile Force

1. Size of muscle – length and cross sectional area

2. Muscle type – slow twitch, fast twitch3. Cyto-architectural factors

Arrangement of muscle fibers Angle and pull of the muscle

4. Muscle Vascularization5. Muscle Innervations

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6. Recruitment Order: controlled by the motor unit

– Recruited from weakest to strongest– Slow fatigue resistant fibers are recruited first– Fast fatigue resistant– Fast fatigue fibers recruited last

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Factors Influencing Power

1. Neurological stimulation2. Fuel storage3. Fuel delivery4. Balance5. Timing6. Recruitment order

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Factors influencing muscle endurance

1. Cytoarchitectural factors– Muscle mass– Capillary density– Percent of slow resistant fibers

2. Recruitment of muscle mass within a muscle3. Recruitment of other muscles

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Biomechanical Factors Influencing Muscle Strength

1. Cytoarchitectural Factors– Pennate versus parallel muscles

– Muscle fibers arranged in series (pennate) rather than parallel

– Pennate muscles have larger physiologic cross sectional area (and muscle force) but smaller length and shortening velocity than parallel muscle fibers

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Cytoarchitectural factors cont.

2. Aponeurosis and tendons: Have a series elastic component

3. Passive tension of muscle

4. Elastic Energy

Specific Tests and Measures: Mechanical Means

• Weights: lift or move a specific weight and maintain this against gravity

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Springs

• Compress or pull out on a spring, force will vary in the range

• Not very accurate at end range

• Inexpensive

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Air Cylinders

• Compress air and force• Equal pressure on all

sides• Read the pressure

guage to determine the force

• Myometers

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Hydraulics

• Pressure on a gauge• Hand grip dynanometer• tensiometer

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Strain Gauge or Force Plates

• Electronic ways of reading contractility

• Research approach

Isokinetic testing

• Dynamic muscle strength through range

• Constant velocity with variable resistance

• Advantage: can reproduce results, reliable

• Disadvantage: big piece of equipment, costly, tests in open chain

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Manual Muscle Test

• Developed over 80 years ago by Dr. Lovett

• Measure of impairment not function

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Fundamental Aspects

• Muscle has a specific Action on a joint• Patient is positioned in such a way that one muscle

or group of muscles are primarily responsible for active movement

• Grading is based on – an arc of movement produced by the muscle and – the amount of external resistance to motion

Grading System

Numerical Score Qualitative Score

5 Normal N

4 Good G

3 Fair F

2 Poor P

1 Trace T

0 Zero, no activity 0110

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+ and – in MMT

• + and – are unreliable above a 3+• In MMT, + and – are discouraged except for

– 3+– 2+– 2-

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Test Procedures: Break Test

• Manual resistance applied at end range or mid range of muscle

• Patient holds position• Therapist gives resistance and assigns strength

grade

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Active Resistance test

• Application of manual resistance against a contracting muscle

• Resistance increased during the range until it reaches maximal level and motion ceases

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Measurement Principles

1. Reliability: changes when the muscle grades are above fair

2. Sources of variability within the muscle test– Measurement device– Intertester versus intratester– subject

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3. Functional Threshold UE: LE:

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Issues and Concerns

1. Single muscle, group of muscles, movement testing

2. Prime movers and Accessory movers

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3. Factors which limit motion

4. Fixation

5. Stabilization

6. Substitution

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7. Muscle Imbalances

8. Point of Application Break test

One joint muscles Two joint muscles

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9. Demographic Factors Age Gender

10. Pain Inhibitory muscles Excitatory muscles

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Examination

• TEST THE NORMAL (UNINVOLVED) SIDE FIRST1. Establishes a base line for comparison2. Allows the patient to know what you are

going to do to the involved side before touching that side. Helps to decrease the patient’s apprehension

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EXAMINATION

• ACTIVE MOVEMENTS ARE TESTED BEFORE PASSIVE MOVEMENTS THEN FOLLOWED BY RESISTED MOVEMENTS.

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EXAMINATION

• PAINFUL MOVEMENTS ARE DONE LAST – TO HELP PREVENT OVERFLOW OF PAIN INTO THE NEXT MOVEMENT.

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EXAMINATION

• IF ACTIVE RANGE OF MOTION IS NOT FULL, OVERPRESSURE IS STILL APPLIED TO DETERMINE END FEEL.

• MUST BE CAREFUL AS THIS WILL / MAY CAUSE AN INCREASE IN THE PATIENTS SYMPTOMS.

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EXAMINATION

• WHEN OVERPRESSURE IS APPLIED, YOU ARE ESSENTIALLY DOING PASSIVE RANGE OF MOTION AT THE END RANGE. A MORE FORMAL PASSIVE RANGE OF MOTION TESTING IS NOT NEEDED.

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Examination

• Repeat each active, passive or resisted isometric movement test several times or hold for a certain amount of time

• Results: symptoms increase, – Decrease– change pattern of movement – increase in weakness – or if there is possible vascular insufficiency

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Examination

• Resisted isometric tests are done with the joint in a neutral or resting position so that stress on the inert tissues is minimal

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Examination

• For passive ROM or ligamentous tests, it is the degree AND the quality of end feel that is important.

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Examination

• When testing the ligaments, apply stress gently and repeat several times.

• Stress is up to but not beyond the point of pain.

• Stress joint to the maximum but avoid muscle spasm.

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Evaluation Process: (after the exam)

• Dynamic Process

• Clinical judgments based on data gathered during the exam

• May identify possible problems requiring consultation with another health care provider.

• APTA Guide to Practice

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Capsular Patterns

• Pattern of limitation or restriction of movement noted during range of motion testing. Specific for each joint.

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Non-Capsular patterns:

• There can be limitations or restrictions to movement caused by structures other than the capsule.

• 3 types of non-capsular patterns– 1. ligament adhesion – 2. internal derangement – 3. Extra-articular lesion

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Inert structures

• Non-contractile structures: ligaments, nerves, blood vessels

• Within the body are evaluated by the degree of pain which occurs, and the type of limitation that occurs in the body.

• Cyriax : four classic patterns

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1. Normal:

• ROM is full • no pain • no lesion in the inert tissue tested • may be a lesion elsewhere

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2. Abnormal

• Limited PROM in some directions • painful with an abnormal end feel• Movements that stretch or move the affected

structure cause pain.• Could indicate a first or second degree strain

of the ligament, local adhesion, internal derangement, extra-articular limitation

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3. Abnormal

• Limited PROM, pain free• abnormal end feel• end feel is generally bone to bone• Indicates symptomless OA• Don’t treat unless painful as it could cause

more of a problem.

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4. Abnormal

• Limited PROM • pain in all directions• abnormal end feel• Entire joint is affected• Capsular pattern is present and in correct

proportions.

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Contractile tissue:

• Musculotendinous tissue• Active contraction of muscle is painful• passive stretch of the muscle will also be

painful.

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• Only one resisted test will cause pain unless: – 1. psychogenic component, emotional

hypersensitivity or problems– 2. Acute lesion where everything is painful– 3. fatigue

• 4 classic patterns

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1. Strong and painfree:

• no lesion of muscles being tested

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2. Strong and painful:

• local lesion of muscle or tendon• 1st or 2nd degree strain • no primary limitation of PROM but can

develop secondary joint stiffness

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3. Weak and painful:

• severe lesion around the joint• weakness or reflex inhibition of the muscles

around the joint• ? fracture

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4. Weak and pain free:

• rupture of the muscle/ third degree strain • involvement of the nerve supplying the

muscle

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References

• Norkin CC, White DJ. Measurement of Joint Motion: A Guide to Goniometry, 2nd ed. 1995

• Greene WB, Heckman JD. The Clinical Measurement of Joint Motion. American Academy of Orthopaedic Surgeons, 1994.

• Dutton M. Orthopaedic Examination, Evaluation, and Intervention. 2004