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• • no true passive movements but provoking or stress tests goal: look for reproduction of patient` s symptoms!!!!
LIMB LENGTH TEST
Leg length test: • perform if you expect SI joint lesion • usually if iliac bone on one side is lower the leg on that side is longer (????page 590) • supine position • SIASs level • Distance SIAS to med or lat malleolus • Normal difference 1 – 1, 3cm Functional test: • Patient standing relaxed • palpate SIASs and SIPSs, note differences Sign of buttock test: • supine • passive unilat straight leg raising • if resistance: flex knee while holding thigh in same position • if u can go further: hamstring, or lumbar spine problem • if u cannot: patho of buttock, e.g. bursitis, tumor, abscess Trendlenburg` s sign : • stand or balance on one leg • pelvis on nonstance leg raises : neg • palvis drops : positive Functional Hamstring Length • sit on table with knees flexed to 90° • spine neutral • sit behind p and palpate SIPS with one thumb, other parallel on sacrum • patient asked to extend knee • normally possible without post pelvic rot or flex lumbar spine
tight hamstrings would cause pelvis post rot or spine flex
Thoracolumbar fascia length • patient sitting on table, knees 90° flexed • PT stands behind patient • Patient asked to rot left and right fully • Note ROM • Patient then asked to flex forward arms to 90° • To lat rot, add arms, so little fingers touch each other • Holding this rot left and right • Restricted ROM: fascia or lat dorsi are tight Straight leg raise test ....
JOINT PLAY – SEE MODULE 1!!
Swing = if movement is taking place the angle changes
REFLEXES AND CUTANEOUS DISTRIBUTION
• • after special test WHEN?: If examiner is unsure wheather there is neurological involvement Can be diminution (hyporeflexia) or loss (arereflexia) of stretch reflex Upper motor neuron lesions: spasticity, hyperreflexia, hypertonicity, extensor plantar responses, reduced or absent superficial reflexes, weakness of distal muscle Lower motor neuron lesion: involve nerve roots, peripherial nerve produce findings of flaccidity • WHY? / AIM: To find out if there is neurolog. Involvement Test reflexes and sensation (s.b.) Deep tendon reflexes are performed to test the tegrity of spinal reflex
• 1) • • •
HOW? / DEMANDS: deep tendon reflexes: muscle and patient must be relaxed tendon put into light stretch drop reflex hammer 5-6 time onto tendon to uncover any fading reflex response 2
if difficult to elicit: patient asked to clench teeth or squeeze hands together (Jendrassik maneuver) when testing lower limb – the legs, when testing upper limb à increase facilitative activity of spinal cord and accentuate minimally active reflexes
2) superficial reflexes: • stroking skin with sharp object • • • • • • • REFLEX Upper abdominal Lower abdominal Cremasteric Plantar Gluteal Anal • NORMAL RESPONSE • CENTRAL NERVOUS SYSTEM SEGMENT • T7 – T9 • • • • • T11 – T12 T12 – L1 S1 – S2 L4 – L5; S1 – S3 S2 – S4
• Umbilicus moves up and towards area being stroked • Umbilicus moves down and toward area being stroked • Scrotum elevates • Flexion of toes • Skin tenses in gluteal area • Contraction of anal sphincter muscles
l 3) • • • • • •
pathological reflexes indicate upper motor neuron lesions if present on both sides indicate lower motor neuron lesions if present on one side Hyporeflexia or areflexia indicates lesion of peripheral nerve or spinal nerve roots Hyporeflexia or areflexia can be seen in absence of muscle weakness or atrophy because of involvement of efferent loop Hyperreflexia indicates upper motor neuron lesion If cervical enlargement is involved some reflexes are exaggerated, some decreased
SENSORY SCANNING EXAMINATION
WHEN?: • same time as reflex tests WHY? / AIM: • to check cutaneous distribution of various peripheral nerves and dermatomes around joint being examined • determine the extent of sensory loss • determine whether loss is caused by nerve root lesions, peripheral nerve lesions or compressive tunnel syndromes • determine degree of functional impairment HOW?: 3
• • • • • • • • • •
Examiner must be able to differentiate between sensory loss involving a nerve root (dermatome!) or a peripheral nerve! Quick scan: examiner runs relaxed hand over skin to be tested bilaterally; ask patient whether there are any differencesin sensation Patients eyes may be open If there is difference: detailed sensory assessment: Distal and proximal sensitivities should be compared Patient`s eyes closed WHY? / AIM?: to mark out or delinate specific area of altered sensation !! altered sensation does not necessary come from the indicated nerve root or peripheral nerve à referred pain may come from any structur supplied by that nerve root HOW?: • Superficial tactile sensation: Tasted with wisp of cotton, soft hairbrush,.. Light tapping with at least 2 sec elapsed between each stimulus to avoid summation Tested: group II afferent fibres • Sensitivity to temperature ( lat. Spinothalamic tract) Tested: group III fibres 2 test tubes: cold, warm water normal response doesnt mean normal temperature sensation à p. can distinguish between hot and cold but not between different degrees of hot and cold Deep pressure pain: Tested: group II Aß fibres Squeezing achilles tendon, trapezius, web space between thumb and index fingers Proprioception and motion: Tested: group I and II fibres Patient`s fingers or toes passively moved and p. asked to indicate direction of movement à important: test digit grasped between thumb and index finger to ensure that pressure on p. skin cannot be used as clue to direction Cortical and discriminatory sensations: Tested: stereognostic function ( identification of familiar obj. In hand) Recognition of letters or numbers written with finger on skin: also tests integrity of dorsal column and lemniscal systems
JOINT PLAY ( ACCESSORY )MOVEMENTS
• • • • Definition: small ROM that can be obtained only passively by examiner Joint dysfunction signifies a loss of joint play movements Normally less than 4 mm in any one direction May be similar to passive movements 4
WHEN?: • if there are capsular patterns WHY / AIM?: • ???
HOW • • • • • • • •
/ DEMANDS: 1) patient should be relaxed and fully supported 2) examiner should be relaxed and should use a firm but confortable grasp 3) one joint should be examined at a time 4) one movement should be examined at a time 5) the unaffected side should be tested first 6) one articular surface is stabilized while the other is moved 7) movements must be normal and not forced 8) movements should not cause undue discomfort
LOOSE PACKED (RESTING) POSITION When / why?: • joint s.t. in this position • joint under least amount of stress • position in which capsule has greatest capacity • minimal congruency between articular surfaces and joint capsule with ligg. • Advantage: joint surface contact area reduced and always changing to decrease friction and erosion in the joints • Position also provides proper joint lubrication and allows spin, slide and rolling JOINT Facet (spine) Temporomandibular Glenohumeral Acromioclavicular Sternoclavicular Ulnohumeral (elbow) Radiohumeral Proximal radioulnar Distal radioulnar Radiocarpal (wrist) Carpometacarpal Metacarpophalangeal Interphalangeal Hip Knee Talocrural (ankle) POSITION Midway between flexion and extension Mouth slightly open 55° abduction, 30° horizontal adduction Arm resting by side in normal physiolog. Position Arm resting by side in normal physiolog. Position 70° flexion, 10° supination Full extension, full supination 70°flexion; 35° supination 10° supination Neutral with slight ulnar deviation Midway: abduction – adduction, flex – extension Slight flexion Slight flexion 30° flexion, 30° adduction, slight lat rotation 25° flexion 10° plantar flexion,. Midway: max inversion – 5
Subtalar Midtarsal Tarsometatarsal Metatarsophalangeal Interphalangeal
exversion Midway: extremes of ROM Midway extremes of ROM Midway: extremes ROM Neutral Slight flexion
CLOSE PACKED ( SYNARTHRODIAL) POSITION When / Why ?: used to stabilize the joint if an adjacent joint is being treated • Should be avoided as much as possible : joint surfaces under max tension • Two joint surfaces fit together • Ligg and capsule max tight • Cannot be achieved if joint is swollen • No accessory movement possible JOINT Facet ( spine) Temporomandibular Glenohumeral Acromioclavicular Sternoclavicular Ulnohumeral (elbow) Radiohumeral Proximal radioulnar Distal radioulnar Radiocarpal (wrist) Metacarpophalangeal ( fingers) Metacarpophalangeal ( thumb) Interphalangeal Hip Knee Talocrural (ankle) Subtalar Midtarsal Tarsometatarsal Metatarsophalangeal Interphalangeal POSITION Extension Clenched teeth Abduction and lat. Rotation Arm abduction 90 ° Max shoulder elevation Extension Elbow flexed 90° ; forearm supinated 5° 5° supination 5° supination Extension with radial deviation Full flexion Full opposition Full extension Full extension, med rotation Full extension, lat rotation of tibia Max dorsiflexion Supination Supination Supination Full extension Full extension
WHEN?: Only after tissue at fault has been identified WHY / AIM? : Palpation for tenderness used to determine the exact extent of lesion within that tissue Only if tissue lies superficial and within easy reach of fingers
1) discriminate differences in tissue tension and muscle tone: spasticity, collapse of muscletone during testing, rigidity = involuntary resistance during passive movement without collapse flaccidity = no muscle tone differences in tissue texture direction of fibres presence of fibrous bands shapes, structures, tissue types tissue thickness, texture pliable, soft, resilient edema swelling: à comes on soon after injury à blood à comes on after 8 – 24 hours à synovial à boggy, spongy feeling à synovial à harder, tense feeling within warmth à blood à taugh, dry à callus à leathery thickening àchronic à soft, fluctuating à acute à hard à bone à thick, slow – moving à pitting edema
5) 6) 7)
joint tenderness by applying firm pressure to joint variations in temperature tremors, fasciculations => contraction of number of muscles innervated by a single motor axon pulses: ARTERY LOCATION Carotid Anterior m. sternocleidomastoideus Brachial Med. of arm midway shoulder – elbow 7
Radial Ulnar Femoral Popliteal Post. Tibial Dorsalis pedis
Wrist lat m. flex. Carpi radialis tendon Wrist between m.flex. digitorum superficialis and flex. Carpi ulnaris tendons Femoral triangle: sartorius, add. Longus, lig. Inguinale Post aspect of knee, deep and hard to palpate Post aspect of med. malleolus Between first and sec metatarsal bones superior
pathological state of tissue in and surround joint thickening tenderness dryness, excessive moisture of skin gouty joints tend to be dry septic joints tend to be moisty abnormal sensation: dysesthesia (diminished sensation) hyperesthesia ( increased sensation) anesthesia ( absence of sensation) crepitus
loud, snapping, pain free noises of tendons usually caused by cavitation in which gas bubbles form suddenly and transiently owing to negative pressure in joint!
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