1. health and fitness
2. disease

PNE Written Component
Prepared by PABC Members:
Jason Shane ([email protected], www.facebook.com/shanephysiotherapy and
Amanda Mrsic ([email protected]), for the FREE distribution to whomever may
benefit from its use. Our way of paying it forward.
Hopefully the time (let’s be honest, a ridiculous amount of time) we spent making this will help
you studying for the national exam. As we used to say “you’re going to rock it!”
(p.s. go to the end of the document...we have a goodbye note...and a page count, yikes!)
SAMPLE LIST OF AREAS OF PRACTICE EVALUATED BY THE PCE
01.01. Neuromusculoskeletal (50%±5%) (This list is not
necessarily exhaustive.)
01.01.01 Muscle contusions/strains/tears/weakness
Mm Strains: majority occur in bi-articular mm at the mm-tendon jx, most occur during
eccentric loading;
Rx:
- Acute Phase: PRICE, crutches if in LE;
- Repair Phase: modalities, DTF’s, strength, stretching;
- Remodeling phase: strength (incr loading and velocity), stretching (static and
dynamic)
01.01.02 Pelvic floor dysfunction
Can be assessed via: digital, EMG, manometric, dynamometer, RTUS real time ultra
sound, MRI & biofeedback.
Rx: isolate PFM during exercise, avoid accessory mm use, eg. Glutes, abs; overload
the mm by holding longer with shorter rest periods; weakness or laxity of PFM can
occur during pregnancy or childbirth, further loss of elasticity and mm tone later in
life (or even after pregnancy) can lead to:
- cystocele=herniation of bladder into vagina,
- rectocele= rectum into vagina,
- uterine prolapse = uterus into vagina;
Sy’s of pelvic pain: pain down post thigh
Add in more info from patho lecture - female reproductive pathology
Jason Shane and Amanda Mrsic Apr 2015
01.01.03 Ligament sprains/tears
Grade 2 syndesmotic ankle sprain (high ankle sprains):
Rx:
- Phase 1 (protection phase 2wks) Goal to protect and decr inflam, PRICE, NWB
with crutches, modalities to decr edema, light ROM;
- Phase 2 (management phase 2-4weeks) goal is normal mobility, incr strength
and fx ambulate (PWB w/o P), bilateral stance training, joint mobs, strength
training;
- Phase 3 (management) goal to incr function and unilateral balance and
strength;
- Phase 4 Return to sport
01.01.04 Tendonopathy, tendon ruptures/tears, tendonosis
Achilles tendonopathy, Rx-eccentric heel drop program, footwear/orthoses,
stretching/mobs
De Quervain’s Tenosynovitis = a tendinosis of the sheath or tunnel that surrounds
the tendons of EPB (O: lower post 1/3rd of radius, I: base of prox. Phalynx of thumb)
& APL (O:ulna, radius, interos. Memb, I: base of 1st metacarpal) (mm which radially
deviate the thumb).
To test for it: tuck thumb in fist and ulnarly deviate wrist, look for P along area of
distal radius
APL, EPB, fray of sheath, scar tissue forms (inflamm, repair)
Lateral Elbow P = 90% involve ECRB (O:lateral epi, I: post base of 3rd metacarpal,
Fx:extends and abducts hand at the wrist), other 10% are b/w common extensor
tendon and origin (tenoperiosteal Jx) and origin of ECRL (O: lateral supracondylar
ridge, I: dorsal surface of base of 2nd metacarpal on radial side, Fx: extensor at the
wrist joint, abducts the hand at the wrist; usually symptomatic with activities involving
wrist and/or finger extension and/or gripping); Test for it: P w/ resisted extension of
D3; Rx: Acute-control P and inflame, rest, ice, US, tennis strap, TENS, Pt ed,
maintain mm length and mobility, AROM for elbow, wrist, and hand; Repair-gently
stress collagen via DTFM and eccentric strength training, cont with stretches
01.01.05 Fasciitis, fascial tearing, myofascial restriction
P59 O’Sullivan
Fascia - found in ligaments, tendons, bone and muscle
Rx: soft tissue work, needling, exercises
01.01.06 Joint derangements/dysfunction (e.g., loose bodies, hypermobility,
hypomobility)
Loose body: free floating piece of bone or cartilage; often result of OA or chip
fracture; typical symptom is locking or catching
Hypermobility: spondylosis (OA of joints in spine and narrowing of foramina),
listhesis (fracture and slip of cranial vert anteriorly), lysis (fracture of pars)
Jason Shane and Amanda Mrsic Apr 2015
Hypomobility: capsular patterns, O’sullivan pg 4
01.01.07 Fractures, dislocations, subluxations
Fractures: K&C (Kisner and Colby) pg 321-325
Comminuted fracture = fracture with more than 2 fragments
Subluxations:
- AC joint, K&C pg 494; clavicle post and sup on acromion,
- Shoulder (GH joint) dislocation: Rx-scapular stabilization/posture, rotator cuff
strengthening/functional rehab
SLAP lesion = Superior Labral tear Anterior to Posterior
Bankart lesion = injury to ant/inf portion of glenoid labrum
01.01.08 Osteoporosis/osteopenia
Depleted BMD
Women 10X more than Men esp post. menopause
Fracture of: Tsp, Lsp, Femoral neck, Prox humerus, prox tibia, pelvis, distal radius
NORMAL = WITHIN -1 SD FOR BMD
OSTEOPENIA = -1 TO -2.5 SD BMD
OSTEOPOROSIS = -2.5 SD AND BELOW
01.01.09 Tumour/pathological fractures
Primary malignant tumors of soft tissues and bone are rare but may occur in youth
Osteosarcoma = occur at either end of long bones, produce jt pain,
Agg: activity,
X-ray: moth eaten appearance,
Rx = surgery (Terry Fox had this)
Primary malignant tumors are rare in bone, usually are secondary
Synovial sarcoma = usually in larger joints, P (often at night or w/ activity), swelling
and instability,
Rx: Sx +/- chemo/rad
Malignant tumors=may metastasize to bone
Mets from breast, lung, prostate, kidney, thyroid cancers
Osteoid osteoma = benign bone tumor, exercise related bone P and tenderness
(often mistaken for bone #), characterized by presence of night P and abolition of
Sy’s with aspirin, CT scan shows a central focus point,
Rx: ablation, ethanol, laser
01.01.10 Degenerative joint disease
Mechanical change, jt disease and jt trauma
Degeneration of articular cartilage: hypertrophy of subchondral bone and ht capsule
Jason Shane and Amanda Mrsic Apr 2015
(wt bearing jts)
Meds: corticosteroids and NSAIDS
OA: decreased jt space, dec cartilage height, osteophytes
PT goals: jt protection, improve jt mechanics, aquatics
01.01.11 Mechanical spinal abnormalities (e.g., low back pain, scoliosis,
postural dysfunction)
REMEMBER THIS PICTURE, it can be useful!!!
Posture: RSPT 518 Oct 8th
Posture and LBP: RSPT 544 Oct 13 (May Nolan lecture)
01.01.12 Inflammatory/infectious conditions of the neuromusculoskeletal
system (e.g., osteomyelitis)
Osteomyelitis = Inflamm response in bone caused by infection; O’Sullivan pg 37,
usually a staph aureus infection
Goals: maintain joint function, cast care
More common in kids and immune supressed, M>F, antibiotics to treat: Sx if in the jt
Tendonitis = Inflammation due to micro trauma
Tendinosos = Chronic tendon dysfunction: common sites supraspinatus,
common
extensor tendon of elbow, patella
Jason Shane and Amanda Mrsic Apr 2015
Bursitis -caused by overuse, trauma, gout, infection; S and S is pain with rest, active
and PROM are limited; Rx-flexibility, mobs, thermal agents
01.01.13 Amputations
Causes: diabetes mellitus, PVD, trauma, congenital/correction of deformity, tumors,
infected TKR
Sites of amputation (the tricky ones): toe (ray resection), ankle (symes)
Effects of:
1)Toe amputation
- decreased power for push off, decrease balance d/t decreased proprioception
and BOS
2)Partial foot
- lose forefoot lever, decrd balance, risk for tissue breakdown secondary to incrd
pressure on remaining WB surface
- prosthesis: shoe filler, carbon fiber afo, complete prosthesis
3)Ankle (Symes): goes through the jt, distal end of tip and fib intact
- long lever, bulbous end, better than transtibial
- high risk of skin breakdown
- prosthesis: similar to trans-tib, trap door to fit over malleoli, can have partial
patellar WB
4) Transtibial
- can’t WB through the end, some ppl can achieve a normal gait pattern
- Prosthetic sockets: total surface bearing, patellar tendon bearing
- Pressure sensitive: anterior/distal end of tib, fibula - head and end, bottom of
stump
- pressure tolerant: post mm mass, patellar tendon, medial/lateral flares
- suspension: supracondylar, suprapatellar cuff, sleeve (req lots of hand
strength), locking pin, suction (1 way valve)
gait deviations:
stance: foot flat or foot slap, knee hyperextension or buckling, early heel rise,
swing: inc/dec stride length, toe drag, lat/med whip, vaulting
5) knee disarticulation
- thigh mm preserved, potential to WB through the stump, prosthetic: trap door
for condyles
6) transfemoral
- no WB on end, takes 60% more energy to ambulate with prosthesis compared
to able body walking, may require a gait aid, often asymmetrical gait, WB
through Ischial Tuberosities and hydrostatic loading, pressure sensitive areas=
end of residual limb, adductor tendon
- Knee prosthesis: manual lock, mechanical/friction,
hydraulic/pneumatic/microprocessor
gait deviations:
Jason Shane and Amanda Mrsic Apr 2015
stance: ABduction, lat trunk shift, excessive trunk lordosis, hip flex, dec stance time,
swing: medial or lateral whips, circumduction, hip hike, vaulting with good leg
7) hip disarticulation
- probs require gait aid, asymm gait pattern 210% energy expenditure
8) hemipelvectomy
PT education:
- contracture prevention, knee or hip flex contracture >20% will prevent
prosthetic use, pain management, edema control, shaping, fall prevention, foot
care of remaining limb, falls prevention (risk @ night)
- NO PILLOWS under legs in supine or between legs for transfemoral
- Socket-supports body wt
- Liner-interface b/w socket and limb
- Suspension-system used to keep prosthesis on the residual limb
- Socks-ensure proper fit
- Shank/pylon-connects socket to foot, provides ht
01.01.14 Congenital malformations (e.g., talipes equinovarus, hip dysplasia)
Duchennes Muscular Dystrophy: X-linked recessive
mm weakness proximal to distal, die as late adolescents, +ve gowers
Talipies Equinovarus = CLUB FOOT-plantar flexed (talocrural), adducted, inverted
(subtalar, talocalcaneal, talonavicular, calcaneo-cuboid), supination at midtarsal
joints
2 types:
1) Talipes Equinovarus - abnormal equinovarus - abnormal development of head
and neck of talus - hereditary or neuromuscular disorders;
2) Postural - feet squished in utero; Rx: casting and splinting or Sx
Equinus = PF foot; Etiology = congenital bone deformity, CP, contracture of calf mm
01.01.15 Nerve compression (e.g., Carpal Tunnel Syndrome, radiculopathy,
spinal stenosis)
Radiculopathy = Si’s & Sy’s depend on degree of compression and may include: P,
tingling, numbness, loss of N conduction, mm weakness, decrd skin sensation, and
loss of reflex
Spinal Stenosis = hypertrophy of spinal lamina, ligamentum flavum, facets; vascular
or neural compromise; (also see May Nolan L-Spine lecture pg 15)
Rx: joint mobs, flexion bias exercises, avoid extension, traction
Thoracic Outlet- subclavian artery vein, brachial plexus, vagus/phrenic N,
sympathetic trunk
compress at: sup thoracic outlet, scalene triangle, clavicle and rib 1, pec minor and
Jason Shane and Amanda Mrsic Apr 2015
thoracic wall
Rx: restore mm imbalance, Sx
NERVE ENTRAPMENT1) ulnar nerve-normally occurs in cubital tunnel, could be d/t trauma,
compression, thickened retinaculum in FCU, Sy’s medial elbow pain, +ve tinnel
sign
2) median nerve-occurs in pronator teres, and under FDS, occurs with repetitive
gripping activities; aching pain, forearm pain
3) radial nerve-entrapment of distal branches (post interosseous nerve) occurs in
radial tunnel
Carpal Tunnel: can do Phalen’s test, long term compression of median nerve can
cause atrophy of thenar mm
01.01.16 Peripheral nerve injuries
Wallerian Degeneration - transection results in degen or axon and sheath distal to
site of injury
Segmental Demyelination -axons are preserved but are demyelinated; remyelination
restores fx, ex GBS
Axonal Degeneration- axonal degeneration of axon cylinder and myelin, distal to
proximal, “dying back of nerves,”, ex-peripheral neuropathy
NEUROPATHY: any disease of nerves characterized by deteriorating neural function
TRAUMATIC: Expect to see motor, sensory, and potentially autonomic changes (ex), and pain; an MRI or nerve conduction test is used to confirm a peripheral nn injury
Neuropraxia= just a compression of the nerve, causes a transient disruption, good
recovery w/good prognosis which could take minutes to weeks
Axonotemesis= disruption of axon but myelin sheath is still intact, may cause
paralysis of the motor, sensory, and autonomic. Mainly seen in crush injury. Longer
recovery with fair prognosis which can take months
Neurotemesis=completely severed axon and sheath; recovery is only possible with
surgery with variable success; i.e. it may never recover
Charcot Marie Tooth Disease =a hereditary motor and sensory neuropathology
causing extensive demyelination of motor and sensory nerves of the foot
Presentation: slow progression of symmetric mm weakness, atrophy of foot
intrinsics, diminished deep tendon reflexes, pes cavus/hammer toes, weak
dorsiflexors and pronators
PT Rx: contracture management (stretching mm), management/education on foot
care
Bell’s Palsy=d/t latent herpes virus, days before onset Pt reports pain around
Jason Shane and Amanda Mrsic Apr 2015
mastoid; virus causes inflam response over facial N
Facial N innervates-mm of facial expression, stapedius mm of inner ear, sensory and
autonomic fibers for taste (ant aspect of tongue), tears, salivation
Clinical manifestations-unilateral facial paralysis
Rx: corticosteroids, estim?, protect eye
Thoracic Outlet Syndrome=an entrapment syndrome caused by pressure on
brachial plexus
Risks for getting it-posture, growth, trauma, body comp
Pathology-chronic compression of N roots results in edema and ischemia of N
roots→ neuropraxia and wallerian degen can occur
presentation-paraesthesia, weakness and pain in arm, neck pain may radiate into
face, scapula, ant chest; coldness, edema, raynaud’s, fatigue in hand, distension of
veins
Rx: correct posture, surgical mngmt if vasculature gets compromised
Diabetic neuropathy=peripheral nn disorder in diabetes that occurs w/o any other
cause for neuropathy
Pathology-chronic metabolic disturbance affects nn and schwann cells-->loss of both
myelinated and unmyelinated axons
Presentation-symmetric, distal pattern of sensory loss, painless paraesthesia with
minimal motor weakness
Rx:control hyperglycemia, skin care, amputation
01.01.17 Neural tissue dysfunction/neuro-dynamic dysfunction
Dural Tension
Double Crush - compression of N along several sites proximal and distal
SLR, PKB, ULTT, SLUMP etc.
01.01.18 Scars
Keloid scar: thick scar that goes beyond the margins of the original wound
Hypertrophic: thick scars that do not extend beyond the boundary of the original
wound but has an excess amount of tissue in relation to what is needed to replace
the damaged dermis
01.02 Neurological (20%±5%) (This list is not necessarily
exhaustive.)
01.02.01 Cerebral Vascular Accident/transient ischemic attack
Jason Shane and Amanda Mrsic Apr 2015
Stroke: Ischemic (80%) or Hemorrhagic (20%)
TIA: brief blockage of circulation
01.02.02 Acquired brain injury
TRAUMATIC =change in brain fx d/t external force; forces can include blunt (MVA,
fall, accel/decel), contusion, shearing, bruising, axonal tearing, rotational forces,
penetrating, blast
Hematomas:
Epidural-outside the dura, 90% assocd with skull fractures, most often in temporal
or temproparietal region, arterial bleed
Sub-dural-brain collects between brain and dura, often requires surgical
intervention (burr holes or craniotomy), venousl bleed
Intracranial-most common, blood within the brain
Diffuse axonal injury=shearing of the brain’s long connecting nerve fibers; usually
causes a coma, can’t see on MRI; can affect grey/white matter interfaces
Secondary brain injuries=cerebral blood flow is 50% less than normal post injury,
bruising, inflammation, incrd ICP
Intracranial pressure: normal is 0-10mm Hg, >20mm Hg is BAAAD
Physio problem list:
Resp complications (decrd tidal volumes, small airway, atelectasis), ICP, abnormal
posture, mobility, contractures, confusion/agitation, fatigue
Decerebrate posturing=indicates brain stem damage (lesions or compression in
midbrain) and lesions in cerebellem
Decorticate posturing= arms flexed, legs extended, damage to areas including
cerebral hemisphere, thalamus, cord, corticospinal tract
Rx:
Initial medical management=prevent hypoxia, maintain adequate BP, adequate
fluids to maintain Mean Arterial Pressure, HOB 30 degrees
Nutrition: hypermetabolism, energy expenditure may be doubled for up to 4 weeks
Other complications: 40% get post traumatic epilepsy; DVTs, and PE’s
Basal skull fracture=signs are blood or CSF out of nose or ears, raccoon eyes,
bruising over mastoid (battle sign)
Coma=altered state of consciousness so that no amount of stimulus or only pain will
cause Pt to respond
Frontal lobe injury=disinhibition, memory impairment, anosmia (can’t smell),
seizures, expressive aphasia)
Temporal lobe= receptive aphasia, dyslexia, dysgraphia, amnesic syndromes,
Jason Shane and Amanda Mrsic Apr 2015
epilepsy
AND NON TRAUMATIC BRAIN INJURY
STROKE
ischaemic = 80% of strokes; could be d/t a thrombus (slower sy’s to evolve) or
embolism (occurs rapidly w/o warning); risk factors are atherosclerosis, HTN, cardiac
disease, diabetes,
TIA=sudden onset, last 24hrs, warning sign of stroke; majority have full stroke w/in 1
year
hemorrhagic = 20%, aneurysms and AV malformations, HTN, head trauma, illicit
drugs, bleeding disorders
S’s and Sy’s = confusion, headache, trouble speaking, understanding speech,
numbness or weakness on one side, can’t see, trouble walking, dizziness, loss of
balance or coordination, sudden severe headache
Rx: thrombolytic agents, Tissue Plasminogen Activator (TPA)=activates plasminogen
to digest fibrin which breaks down the clot, TPA can salvage penumbral tissue if
given within 3 hours; mechanically widening an artery
White matter is NOT plastic, grey matter is
Lacunar strokes (infarcts)-subgroup of ischemic strokes, small but deep in the
brain; assocd with HTN and diabetes, correlation with decreased cognition
What causes a stroke:
Arterial factors - artherosclerotic plaques, aneurysms, pressure on artery walls
Venous factors - tendency for person’s blood to clot quickly, irritation or inflammation
of lining of vein, DVT’s
Penumbra = an area of the brain at risk for dying; is located between an area of
perfusion and necrosis
Progression of and Risk for a Stroke: ABCD Score; Age, Blood pressure, Clinical
features (hemi-weakness, speech problems), Duration
Brain Stem stroke = not very common v. disabling b/c it can take out ALL the
ascending and descending tracts
Prevention of recurrent of stroke: anticoagulants (aspirin), lipid lowering agents,
lifestyle changes
cortex=grey matter and capable of neuroplasticity
Cortico-spinal tract-made up of white matter, is not plastic
CONCUSSION = a complex pathological process affecting the brain, induced by
traumatic biomechanical forces.
Jason Shane and Amanda Mrsic Apr 2015
-mild form of brain injury (most common TBI)
-loss of consciousness may or may not be present
-diagnose with signs, behavioral change, cognitive impairment, sleep disturbance
-baseline cognitive Ax: SCAT 2
-second impact syndrome- rare/fatal uncontrolled swelling of brain, minor 2nd blow
before initial symptoms are resolved
-post concussion syndrome: persistent symptoms: headache, dizzy, irritable,
memory, vision, concentration
- 3+ concussions = 5X greater risk Alzheimer's, 3x memory deficits
- coup, contre-coup
- grade 1: does not lose consciousness, dazed
- grade 2: no LOC, period of confusion, does NOT recall event
- grade 3: loss of consciousness for short time, No memory of event, requires eval
asap
risk: contact sports, anti-coagulants, prior events
S&S: dizzy, headache, vomit, sudden weakness, nystagmus, change in pupil size,
emotional lability, memory loss, drowsy, confused
TBI ***head down positioning is CONTRAINDICATED! for those with traumatic brain
injury******
positioning: limit neck flex and rotation
suctioning: pre/post oxygenation at 100%O2
resting splints 6-8hrs to prevent contractures
aspiration risks: turn feed tube off 20mins prior to Rx
01.02.03 Spinal cord injury We recommend you look over this section....
Jason Shane and Amanda Mrsic Apr 2015
Causes of SCI:
Traumatic; 40% are cervical incomplete
Types of traumatic injuries: Hyperflexion, hyperextension, axial load, rotation,
penetrating injury
Non-traumatic: cancer, infection and inflammation, motor neuron disorders, vascular
diseases (spinal cord infarcts); most are paraplegic
Reasons for Sx: unstable # or soft tissue injury, neuro sy’s getting worse
Benefits of Sx: realignment, stabilization, early mobilization, early rehab, less medical
complications, decrd hospital stay
Myelopathy = refers to pathology of the spinal cord. When due to trauma, it is known
as spinal cord injury
Lumbar laminectomy=helps to decompress the cauda equine/roots
Cauda equina syndrome:
Jason Shane and Amanda Mrsic Apr 2015
-affects more than one nerve root, surgical emergency
-Usually presents with: bilateral leg pain/numbness, sacral root problems, urinary
retention, stool incontinence, absent reflexes
Mobility orders from doctor:
“Spine stable” = column is assumed unstable, +/- neuro deficits, at risk for additional
injury; Pt must: 1)maintain neutral spine at all times, 2) bedrest, 3) HOB at zero
degrees; 2-3 person turns at all times
“Spine stable” - requires protection = confirmed spinal column, +/- neuro deficits, Pt
must maintain neutral spine at all times, Pt can turn independ with neutral alignment,
mob and rehab begins
“Spine stable-no restrictions ”= injury decided stable by surgeon, patient may do all
mvmts of spine w/I comfort limits; Pt may be taught to log roll with neutral spine
Important to classify SCI b/c: to define level and extent of injury, gives a baseline, used
for prognosis and outcome measure
ASIA:
Sensory exam: light touch and pin prick tested;
- Grade 0: Pts does not reliably report being touched,
- Grade 1: Pt correctly reports being touched and differentiating b/w sharp and
dull BUT describes feeling of sharpness as different,
- Grade 2: Pt normal
Hyperpathia=everything feels sharp
Deep Anal Pressure (DAP): if present, Pt has a sensory incomplete injury ASIA B
Voluntary Anal Contraction=if present indicates motor incomplete (AIS C)
Motor exam: 10 bilateral myotomes
C5 ABD/elbow flexors, C6 wrist extensors, C7 elbow ext, C8 thumb ext/ ulnar dev,
long finger flexors, T1 finger abductors
Level of lesion = defined as the most caudal segment of the spinal cord with normal
sensory and motor Fx on BOTH sides of the body
- Sensory level-most caudal segment w/bilateral score of 2 for BOTH light touch
and pin prick
- Motor level-most caudal segment with a grade greater than or equal to 3
provided ALL segments above are grade 5
Clinical syndromes:
Complete injury = no sensory or motor Fx is preserved in the sacral segments S4-S5;
there may be dermatomes below the sensory level and myotomes below the motor
Jason Shane and Amanda Mrsic Apr 2015
level that remain partially innervated…KNOWN as Zone of Partial Preservation, the
most caudal segment with some sensory defines extent of ZPP
Anterior Cord Syndrome=loss of motor Fx, P and temp below injury level; dorsal
column is spared (i.e. kinesthesia, proprioception, vibration)
Central Cord Syndrome=upper motor and sensory Fx more impaired than LE; often
associated with spinal canal stenosis
Brown Secard= one side of cord more damaged than the other; IPSILATERAL loss of
motor Fx and dorsal column Fx (reason is they cross in medulla); CONTRALATERAL
loss of P and temp sensation a few levels below the lesion
Conus and Cauda Equina=spinal cord terminates at L1-L2; injuries at conus can
affect both conus and root resulting in a varied neuro picture; i.e. mixture of UM and
LMNL
Prognosis for neuro injuries: pinprick preservation (LE and sacral) w/i 72hrs is good
prognosticator of motor function to return and ability to walk
SCI Effects on Resp Fx:
● C4 is normally the level Pt’s need to breathe independently
● T11 and below, normal vital capacity
● Cough Fx: C1-C3 absent, C4-T1 non functional, T2-T4 poor, T5-T10 weak, T11
and below is normal
● C2-C7 innervate accessory mm of breathing
● T1-T11 innervate intercostals
● T6-L1 innervate abdominals
Levels of injury:
C1-C4:
Patterns of weakness - paralysis of trunk and UE, probably diaphragm
Possible mvmts: neck mvmts, slight sh retraction and add
Role of PT: ROM, spasticity management, neck strengthening, chest physio, prevent
contractures
Major mm innervated:
FULL: C1-C3 SCM, neck extensors, neck flexors
C2-C4 traps
PARTIAL: C3-C5 Lev scap, diaphragm, supraspinatus, infraspinatus
C4-C5 rhomboids
C5:
Patterns of weakness - sig imbalance around sh girdle, absence of elbow ext, wrist
pronation, ext, flex or any hand/finger movement
Possible mvmt - sh abd, flex, ext, elbow flexion and supination, scapular add and abd
Jason Shane and Amanda Mrsic Apr 2015
FULL: all of the C4 mm plus diaphragm, rhomboids (C4-5 dorsal scapular), levator
scapula (C3-4 and dorsal scapular)
PARTIAL: Deltoid, biceps, brachioradialis, teres minor (C5-6)
Hand Fx-use wrist splints and universal cuffs
C6:
Patterns of weakness - no wrist flexion, elbow ext, hand movt
Possible mvmt - radial wrist ext, some horiz adduction, can extend elbow in some
positions using ER of shoulder; have tenodesis grip which permits a weak grasp w/o
any hand mm
Slide board transfer possible, manual W/C possible, FIRST LEVEL OF SCI to have
potential to live in community w/o care
PT role: maximize strength for transfer to functional tasks, teach “trick” mvmt
strategies, ROM and stretching, prescribe equipment
C7-C8:
Patterns of weakness - limited grasp and release dexterity d/t lack of intrinsic mm of
hand
Mvmt possible - elbow ext (C7), wrist ext, DIP/PIP flex, MP flex (C8)
Triceps allow independent transfers, manual W/C, indep with most/all ADL’s
Hand function - C8 gives finger and thumb flexors (which are weak) and no lumbricals
Thoracic paraplegia - intact UE Fx, mainly use W/C
Lumbar paraplegia-more motor sparing more efficient gait, possible to have
functional gait, if conus or cauda equina may have flaccid bowel and bladder
2 tests for spasticity: Modified Ashworth, Tardieu
Lat spinothalamic - P and temp
Ant spinothalamic - crude touch and pressure
Dorsal columns – fine touch, stereognosis, vibration
Lateral corticospinal - the 90% that cross in the pyramid motor
Anterior corticospinal - the 10% cross at the level of innervations motor
Autonomic effects of SCI on Heart and Lungs:
Sympathetic NS - Chain T1-L1, fight or flight, increases HR and BP and blood flow to
skeletal mm, RELAXES bronchial mm (one would think it would contract them BUT if a
bear was chasing you, you would want the mm to relax to incr O2 supply)
Parasympathetic NS-craniosacral, primary interest in Vagus nerve; decreases HR and
contractility, decr blood flow to smooth mm, contracts bronchial mm
Jason Shane and Amanda Mrsic Apr 2015
With Level of injury T6 and above: (in general)
- Sympathetic influence is dependent on level of injury (b/c it goes from T1-L1)
- Parasympathetic influence remains intact and UNOPPOSED via the vagus
nerve in injuries T6 and higher
- Limits cardiac output and shunting of blood from inactive to active ones
- Blunting of heart rate often to only110-120bpm
- Heart response is d/t vagal withdrawal rather than sympathetic drive (normally
sympathetic would drive up HR but it is no longer intact there must rely on
removing parasymp)
Spinal Shock = temporary suppression of all reflex activity below the level of injury
(24-48 hrs)
Neurogenic shock (T6 and above) = body’s response to sudden loss of symp.
control, therefore parasymp dominance, loss of vasomotor control;
3 clinical signs are: 1) bradycardia, 2) hypotension, 3) Hypothermia
Rx for hypotension: volume resuscitation (saline), vasopressors (to counter loss of
sympathetic tone)
Health risks with SCI: DVT, pulmonary embolus, HO (2 main contraindication for Rx
are forced PROM and serial casting), osteoporosis AND
Post traumatic syringomyelia=a formation of an abnormal tubular cavity in the spinal
cord; the dura tethers/scars to the arachnoid blocking CSF flow, CSF is forced into the
spinal cord progressively enlarging the cyst which compresses the cord and its
vascular supply
Spastic bladder = injuries above the conus, messages will continue to travel b/w
bladder and spinal cord since reflex arc is still intact, may be triggered by “tapping”,
bladder can be trained to empty on its own, bladder mngmt is either intermittent
catheters or condom/foley drainage
Flaccid bladder = in conus and cauda equina injuries, messages don’t travel b/w
spinal cord and bladder since the reflex centre is damaged, bladder loses ability to
empty reflexively, bladder will continue to fill AND must be catheterized
Misc info:
- CVD is major cause of death in people surviving 30 years+
- L ventricular myocardial atrophy seen in SCI
- 100x higher rate of bladder cancer in people with SCI
- Spasticity, common clinical characteristics: incrd mm tone or firmness, incrd
stretch reflex, uncontrolled mvmts
01.02.04 Tumour (Can you believe it, they put tumors on the blueprint twice! Bah!)
tumor = neoplasm, benign or malignant, soft tissue or bone, develop from or within
tissue in a localized area - later they can spread (mets)
Jason Shane and Amanda Mrsic Apr 2015
-
epithelial = carcinoma
mesenchymal (type of undifferentiated loose connective tissue from the
mesoderm)= sarcoma
glial = glioma - most common site of tumors in the brain
lymphoid = lymphoma
hematopoietic = leukemia
melanocytic = melanoma
LUNG carcinoma = squamous metaplasia, squamous diplasia, carcinoma in situ,
invasive carcinoma
COLON cancer = 2nd cause of death
BREAST = hormonal and genetic risk factors, axillary node disection
PROSTATE = in men over 50 usually, Tx: surgery, external beam radiation,
brachytherapy, androgen deprivation therapy
etiology = viruses, chemical agents, physical agents (radiation, asbestos), drugs,
hormones, alcohol
Rx: surgery, radiation, chemotherapy (usually in kids), biotherapy, antiangiogenic
therapy, hormonal therapy
kids: acute lymphocytic leukemia, non-hodgkins, hodgkins, brain, small round blue
cell, sarcoma (bone based - osteosarcoma, ewing’s sarcoma)
Skin Cancer:
- Basal Cell Carcinoma (BCC) = most common form of skin cancer, low risk of
spreading, translucent and red in color
- Squamous Cell Carcinoma (SCC)=solid skin tumor, often volcano shaped, high
risk for mets
- Malignant melanoma = most dangerous form of skin cancer; high potential for
mets
- ABCD rule for melanoma- Asymmetry, Border, Color, Diameter
01.02.05 Degenerative neurological/neuromuscular disorders (e.g., muscular
dystrophies, amyotrophic lateral sclerosis, Parkinson disease)
ALS - amyotrophic lateral sclerosis (Lou Gerigs) = a motor neurone disease and
gradual deterioration of BOTH UMN and LMN (may have both flaccid and spastic
paresis), characterized by rapidly progressive weakness, muscle atrophy and
fasciculations, muscle spasticity, difficulty speaking (dysarthria), difficulty swallowing
(dysphagia), and decline in breathing ability.
Amyotrophy - mm fiber atrophy
Jason Shane and Amanda Mrsic Apr 2015
Lateral- lateral column atrophy
Sclerosis-sclerosis (harden/thickening) of those axons
Starts peripherally, moves central, mm groups are affected asymmetrically
sensory system, cognition, bowel and bladder are spared
Rx: resp difficulties, complications of immobility, sy relief
Parkinson disease = chronic neurodegenerative disease, reduction in dopamine
produced by substantia nigra
Possible causes: infectious/post encephalitis (irritation and swelling (inflammation) of
the brain, most often due to infections), drug induced
Dopamine normally inhibits Ach, without dopamine there is excessive excitatory
output
Motor disturbances: resting tremor, rigidity, akinesia/bradykinesia, postural
instability, impairments of voice, dexterity, balance, gait
Non-motor disturbances: pain, visual/spatial, proprioceptive, postural
hypotension,sleep disturbance, depression, anxiety, fatigue, dementia
Limiting factors and contraindications to exercise: cardiac or resp condition, MSK
problems, postural hypotension, severe dyskinesia
DMD = issue with mm CT, fat infiltration, hypertrophy (esp in calves) and weakness,
dystrophyn affected (protein), Gower’s sign (difficulty standing up, uses on hand on
leg to get up)
- mutation in single gene on X chromosome
- fail to produce dystrophin protein
- dystrophin links sarcolemma to actin
- mm cells replaced by fat and CT
- progessive symmetric mm wasting
- CK levels high (necrotic mm)
- normally diagnoses by 5, dead by ~20
- gowers and calf pseudohypertrophy
-prox mm weakness, waddling gait, toe walking, lordosis, freq falls, difficulty standing
up and climbing stairs, lower IQ
-pelvic girlde then shoulder, scoliosis
PT: work on strength, independence, advocate
01.02.06 Demyelinating disorders (e.g., multiple sclerosis)
Multiple Sclerosis = an inflammatory disease in which the fatty myelin sheaths
around the axons of the brain and spinal cord are damaged, leading to demyelination
and scarring
- typical onset 20-40yo
- Sy’s: fatigue, mm weakness, paraesthesia, optic neuritis or diplopia, vertigo,
Jason Shane and Amanda Mrsic Apr 2015
bowel and bladder, impaired cognition/memory, pain, depression
Types:
Relapsing remitting – new symptoms or old symptoms may resurface or worse and it
can be full or partial recovery relapses can be days weeks or months recovery can be
slow or instantaneous
Primary progressive there is a gradual worsening of symptoms overtime may stabilize
but no remission
Secondary progressive – starts off as relapsing remitting then steadily worsens
Progressive relapsing --there is a steady progression with attacks
PT Rx: treat vestibular dysfunction, posture, proprioception, core, stretches
Contraindications and precautions to exercise: heat, fatigue, pregnancy
01.02.07 Inflammatory/infectious conditions of nervous system (e.g.,
meningitis, Lyme disease)
Lyme disease: from a bacteria, Borrelia burgdorferi, through ticks
may occur in stages,
stage 1) localized presentation, erythema, flu like
stage 2) neuro (headache and neck stiffness) MSK and cardiac (tachy, brady,
arrythmia, myocarditis) , may have Bells palsy
3) final stage: long term neuro, with arthritis(1/3) and cognitive deficits
Info: mimics other diseases like MS, fibromyalgia, chronic fatigue syndrome, guillan
barre
Rx: antibiotics to treat
PT management: relieve pain, prep deconditioned patients for home ex, ed re FITT
w/out exacerbating symptoms, improve strength
meningitis: infectious disease that causes inflammation of meninges (all 3: pia,
arachnoid, dura)
Info: increased risk of infarctions, cortical veins may develop thomboses, may be
block of CSF secondary to scar tissue (can cause hydrocephaly - excess amount of
fluid in the brain) which causes headache (the CARDINAL SIGN!)
Presentation: can present as acute (hrs-days); sub acute (2wks plus); chronic (1mo
plus)
Types:
1) aseptic (fungus, virus, parasite, can also get with: herpes simplex 2, epstein barr,
lupus)
2) tuberculosis: abscess or edema
3) bacterial: in child or infant is considered a medical emergency
Physical test for meningitis: patient supine, passively flex neck, Brudzinski’s sign:
Jason Shane and Amanda Mrsic Apr 2015
knees and hips will flex
Creutzfeldt Jakob disease = caused by prions; is bovine spongiform
encephalopathy in cows (mad cow disease); occurs in young adults, is a movement
disorder/dementia; it is rapidly progressive and fatal
Pathology - contracted by ingestion or via the nose; incubates 5-8yrs
01.02.08 Post-polio syndrome (from Wikipedia)
- Poliovirus attacks neuron in brainstem + ant horn cells of spinal cord
- Motor neurons controlling skeletal mm die
- sprouting may occur = some recovery of movement = motor neuron
enlargement
- mm weakness and paralysis after years of metabolic stress on neuron
- ongoing denervation and reinnervation, with overall loss of motor units
01.02.09 Cerebellar disorders
-MS
- hereditary ataxia, Friedreich’s ataxia
-neoplastic, metastatic tumors
-infection
-vascular: stroke
-developmental: ataxic cerebral palsy, arnold chiari syndrome
-trauma: TBI
-drugs: heavy metals
-chronic alcoholism; acute alcohol poisoning, effects GABA receptors
1) archicerbellum lesions: central vestib system, gait and trunk ataxia
2) paleocerebellum lesions: hypotonia, trunk ataxia, ataxic gait
3) neocerebellum: intention tremor, dysdiadochokinesia, dysmetria, dyssynergia,
errors in timing
additional impairments: asthenia (generalized weakness), hypotonia, motor learning
impairments, cog deficits, emotional dysregulation
01.02.10 Vestibular disorders
cause of dizziness: cardiovascular, neurological, visual, psychogenic, cervicogenic,
meds, vestibular
3 functions of vestibular:
1) gaze stabilization - objects in visual field stay clear with head movement;
2) postural stabilization - maintain balance and equilibrium;
3)resolution of sensory motor mismatch (proprioception, vestibular and visual)= sea
sickness/motion intolerance
anatomy:
Jason Shane and Amanda Mrsic Apr 2015
semicircular canals x3; horizontal, anterior, posterior= GAZE/ angular displacement
of the head
otolith:
utricle- detects horizontal plane motion,
saccule- detects sagittal plane motion; together detect acceleration and deceleration=
POSTURAL
vertigo = the subjective experience of nystagmus (room spinning around you) - get it
with BPPV
dizziness = discrepancy between R and L side, patient can’t work out where they are
in space
oscillopsia = blurred vision
antibiotic → GENTOMYCIN = affects vestibular system
UVL-unilateral vestibular loss= peripheral dysfunction: cause- infection (vestib neuritis,
labyrinthitis, disease (Menieres- too much endolymph squishes structures in the ear
S&S: low freq hearing loss, tinnitis), trauma, BPPV)
presentation: dizziness, oscillopsia, imbalance
BPPV(UVL) = benign paroxysmal positional vertigo
- displaced otoconia go to the posterior canal
presentation: brief transient vertigo when looking up/down, rolling to that side in bed,
sitting to supine
-Dix Hallpike maneuver to test - head 45 deg to test ear, 30 deg ext, lower from sit to
supine and keep for 30 sec +ve test nystagmus- delayed onset, brief and rotary
CI’s arthritis, vertebral art insufficiency, 5D’s
Rx: modified Epley maneuver
BVL: causes: toxicity, bilat infection, vestibular neuropathy, otosclerosis
BVL presentation: very poor balance, NO DIZZINESS
vestibular occular reflex= maintain stable vision during movement; deficient with
unilateral and bilateral vestibular loss
Central vestibular disorders= TIA, Stroke, head injury, brain tumor, MS,
Ax: direction changing nystagmus
recovery dependent on cortical reorganization
motion sensitivity:
1) sensitivity to movement of the head - position change, repetitive movement, car
train or boat travel
2) sensitivity to moving visual field - visual vertigo, ocular dizziness, reading
Jason Shane and Amanda Mrsic Apr 2015
01.02.11 Neuropathies (e.g., peripheral neuropathies, complex regional pain
syndrome)
peripheral neuropathy = injury to peripheral N that may be due to injury or illness
-mononeuropathy, mononeuritis, polyneuropathy, autonomic neuropathy, neuritis
most common cause is from diabetes. can also be due to injury or other diseases like :
lyme, HIV, shingles, Gullian-Barre
Complex Regional Pain Syndrome (formerly known as Reflex Sympathetic
Dystrophy)= a chronic pain condition believed to be the result of dysfx in central or
peripheral NS
Typical features: changes in the color and temp of the skin over the affected limb or
body part, with intense burning pain, skin sensitivity, sweating, swelling, stiffness
Stage 1 (0-3 mo) puffy swelling, redness, warmth, stiffness, allodynia, pos bone scan
Stage 2 (3-6 mo) incrd P and stiffness, firm edema, cyanosis, atrophy, osteopenia on
xray
Stage 3 (6mo plus) tight, smooth, glossy, cool, pale skin; stiffness and contractures,
nail and hair changes; severe osteopenia
PT Rx: prevention and early detection → early ROM and use, P and edema mngmt
(desensitization, contrast baths, modalities), education
01.02.12 Developmental/birth injuries (e.g., cerebral palsy, myelomeningocele,
Erb’s palsy)
Cerebral Palsy:
CP: non progressive lesion of the brain that occurs before the age of 2, hearing and
speech problems, hydroencephalus, microencephaly, scoliosis, hip dislocation, mental
retardation
- anoxia, haemorrhage (intraventricular, periventricular leukomalacia - most common
ishcemic brain injury in premature babies) or brain damage
risk factors: of mom is older, low birth wt, IVF (invitro fertilization)
mono, di, tri, quad, hemi
spastic: mm stiffness, dec ROM, movements limited to synergies - primitive
movement patterns- trouble start/stop movement
athetoid: slow twisting wide amplitude movements, changing of mouth positions
ataxic: abnormal rate, range, force, duration of movements; difficulty with rapid move,
gait, fine motor, balance
dystonic: long sustained involuntary movements and postures
hypotonic: lack of tone, weakness
hip subluxation, spasticity of adductor longus and iliopsoas, dislocate posteriorly
Rx: seating, botox to adductors, surgery, baclofen pump, tendon release,
Jason Shane and Amanda Mrsic Apr 2015
PT: manage atypical mm, habituation, not rehab, positioning, orthotics, maintain ROM
Sitting modifications-put pummel between legs
Spina bifida: neural tube defect resulting in vertebral and/or spinal cord malformation
1) spina bifida occulta - no spinal cord involvement, may be indicated by hair tuft
2) spina bifida cystica - visible or open lesion
a)meningocele - cyst includes cerebrospinal fluid cord intact
b) myelomeningocele - cyst includes CSF and herniated cord tissue
-link between maternal decreased maternal decreased folic acid, infection, exposure to
teratogens (alcohol)
-hydrocephalus
- meningitis
-foot deformities -talipes equinovarus (club foot) esp with L4, L5 level
-latex allergy
Erb’s palsy (waiters tip)
- C5, C6, injury in infants, usually come out of birth canal
- can affect: rhomboids, levator scapulae, serratus anterior, delts, supraspinatus,
infraspinatus, biceps, brachioradialis, brachialis, supinator, long extensors of wrist,
fingers, thumb
Rx: immobilization initially, gentle ROM, play exercises
Klumke (claw hand)
-C8,T1
effect: intrinsic mm of hand, flexors and extensors of wrist and fingers
Median N palsy (ape hand)
- C6-8, T1 median N
- impairment of thenar mm
-can’t ABduct and oppose thumb
01.02.13 Dementia, affective and cognitive disorders
Dementia:
Impairment in: memory, language, visual spatial skills, cognition, personality
– Most pts die of pneumonia
-Mini Mental State Exam (MMSI) is most used outcome measure
PT concerns: prevent falls, retain motor activities, reduce restlessness improve
sleeping support for caregivers
01.02.14 Altered level of consciousness (e.g., coma, seizures)
Coma = lowest level of consciousness
- use GCS to assess; will not obey commands, open eyes, or interpret words
Jason Shane and Amanda Mrsic Apr 2015
● Epilepsy/ seizures - disturbances in CNS
S&S: altered consciousness, motor activity (convulsions), sensory phenomena,
autonomic, cognitive
1) primary generalized seizures - bilateral and symmetrical w/out local onset
● a) tonic-clonic (grand mal) - dramatic, whole body - 2-5 mins
● b) absence seizures (petit mal) - brief, almost imperceptible LOC, come back to
full conciousness, no change in posture, can be up to 100/day
2) partial seizures
● a) simple - usually one part of the body
- focal motor = clonic activity on specific area of body
- focal motor with march (Jacksonian) - orderly spread or march of clonic
movements; can progress to whole side
- temporal lobe seizure - episodic change in behavior, complex hallucinations,
● b) complex partial seizures - simple partial seizures followed by impairment of
consciousness
NEUROANATOMY (Admit it, this reminds you of coloring class, who doesn’t like colored pens
and pencils)
ASCENDING TRACTS:
Lat Spinothalamic - tests pain, hot/cold of limbs and trunk; receptors are free nerve endings
sharp P is A delta fibers, slow/dull are type C fibers; ascends in lateral white column of spinal
cord, crosses w/i 1-2 segments; finishes in parietal lobe (this lobe integrates sensory information
from different modalities); IF HALF THE CORD has lesion, at the level there is ipsilateral loss,
and contralateral loss below the lesion
Ant (ventral) Spinothalamic- crude touch and pressure; receptors are Merckel discs and
Ruffini corpuscles and free nerve endings; A delta and A beta; ascends in ant white column;
crosses w/i 1-2 segments; finishes in parietal lobe as well; IF HALF THE CORD has lesion, at
the level there ipsilateral loss, and contralateral loss below the lesion
Dorsal columns (medial lemniscus)- 2-pt discrimination, fine touch, stereognosis, vibration;
receptors are pacinian corpuscles (vibration), merckels’s disc, meissners (light touch); a beta;
fibers cross in the brain stem; lesion below medulla=ipsilateral loss; lesion above
medulla=contralateral loss; finishes in parietal lobe
Jason Shane and Amanda Mrsic Apr 2015
DESCENDING TRACTS:
Lateral corticospinal = primary motor tract; 90% cross in pyramids (part of the brain stem);
synapses in ant horn cell in grey matter of spinal cord, goes out on an alpha motor neuron,
terminates at the neuromuscular junction; LESION above level of medulla where they cross→
loss of vol mvmt contralateral to the lesion below level of medulla
Anterior corticospinal = primary motor; 10% that cross at level of innervation; target lower
motor neurons; start in frontal lobe; don’t cross in the pyramids; travel in ventral white column;
IF LESION is on one side of the cord→ loss of 10% voluntary mvmt contralateral to the lesion
CEREBRAL ARTERIES:
Internal carotid artery= collateral supply is possible thru ant. and middle cerebral arteries;
deficit=contralat. hemiplegia and hemisensory disturbance, global aphasia (if dominant side),
mentally slow, contralateral homonymous hemianopia, partial Horner’s syndrome, gaze palsy
(eyes to opp side); is the main supply for ant cerebral a., post CA, middle cerebral a.
Anterior cerebral artery=weakness and sensory loss of contralat limbs, self care problems,
emotional lability
Middle cerebral artery= contralat hemiplegia, hemisensory loss, hemianopia, contralat neglect,
aphasia(impaired language ability) if on dominant side, apraxia (disorder of motor planning,
can’t carry out purposeful movements), impaired hearing, difficulty dressing, may also produce
motor speech dysfunction (Broca’s area)
Vertebral artery= two join to form basilar artery; imp branches to watch for strokes PICA
(largest branch of vertebral a.), AICA, PCA
Post cerebral artery (PCA)= supplies occipital lobes; vision problems, CN III palsy,
contralateral hemiplegia, chorea (abnormal invol. mvmts, looks like dancing), hemiballismas
(involuntary flinging mvmts of extremities), hemisensory impairment, contralat homonymous
hemianopia, difficulty with naming and colors
Superior cerebellar artery= supplies cerebellum, limb ataxia, Horner’s syndrome (droopy
eyelid, red face), contralateral sensory loss
Ant inf cerebellar= supplies cerebellum, ipsilateral limp ataxia, ipsilateral horner’s, sensory
loss, facial weakness, paralysis of lateral gaze, and contralateral sensory loss of limbs and trunk
PICA=supplies cerebellum, disarthria (poor articulation while speaking d/t motor issues),
ipsilateral limb ataxia, vertigo, nystagmus, ipsilateral horners, sensory loss (p and temp) of face,
Jason Shane and Amanda Mrsic Apr 2015
pharyngeal and laryngeal paralysis, contralateral sensory loss (p and temp) of trunk, visual sy’s
(paralysis of vertical eye mvmts and decrd pupillary light reflex)
Broca’s(receptive) aphasia= Broca’s area is located in the left frontal lobe
Wernicke’s(expressive) aphasia= Wernicke’s area is located in the left temporal lobe
Primary somatosensory= located in both parietal lobes, resp for all sensation
Primary visual=located in both occipital lobes
Primary auditory=located in both temporal lobes
Olfactory area=located in both temporal lobes
LEFT CVA mean most muscles on R side of body are affected. Also aphasias, used more
reasoning, numerical and scientific skills, spoken and written language, sign language.
RIGHT CVA means decreased musical and artistic awareness, spatial and pattern perception,
recognition of faces, emotional content of language (speak in montotnous voice), discriminating
smells, damage to right brodmann’s area have difficulty differentiating smells
CRANIAL NERVES:
1) Olfactory - does smell; damage to can cause anosomia (inability to detect smells, seen with
frontal lobe lesions)
2) Optic - does vision; damage to can cause homonymous hemianopsia (hemianopic visual
field loss on the same side of both eyes. Hemianopias occur because the right half of the brain
has visual pathways for the left hemifield of both eyes, and the left half of the brain has visual
pathways for the right hemifield of both eyes)
3) Occulomotor - does pupillary reflexes; damage to can cause absence of pupillary
constriction or Horner’s syndrome (combination of drooping of the eyelid (ptosis) and
constriction of the pupil (miosis), sometimes accompanied by decreased sweating of the face on
the same side; redness of the conjunctiva of the eye is often also present)
4) Trochlear - turns adducted eye downwards
5) Trigeminal - V1 sensory on face, V2 opthalmic branch (touch with cotton), V3 motor mm of
mastication
6) Abducens - turns eye out
7) Facial - facial expression; damage to presents as inability to close eye, droopy corner of
mouth, difficulty speaking; innervates ant aspect of tongue
8) Vestibular - balance, gaze stability, auditory; damage to can cause vertigo, nystagmus,
deafness
9) Glossopharyngeal - phonation (voice quality), swallowing; damage to can cause dysphonia
(hoarse or nasal voice); innervates the back of the tongue
10) Vagus - elevates the soft palate and controls position of uvula, gag reflex
11) Accessory (spinal) - innervates traps and SCM; damage to will cause inability to shrug
ipsilateral shoulder (traps) or inability to turn head to opp side (SCM)
12) Hypoglossal - tongue movement; damage to can cause dysarthria or deviation of tongue to
the weak side
Jason Shane and Amanda Mrsic Apr 2015
SAMPLE LIST OF AREAS OF PRACTICE EVALUATED BY THE PCE
(continued)
01.03 Cardiopulmonary-vascular (15%±5%) (This list is not necessarily
exhaustive.)
01.03.01 Heart disease/malformation/injury (e.g., arteriosclerosis, blunt
trauma, tamponade, aortic aneurysm)
valvular heart disease: valves break; failure of valved to open completely
thereby impede forward flow (stenosis), regurgitations(insufficiency): fail valve to
close-reverse blood flow
dilated cardiomyopathy: heart with increased mass, heart has trouble pumping;
risks: third trimester, alcohol
hypertrophic cardiomyopathy: hypertrophied heart, abnormalities in filling ;
young athletes at risk of dying; S&S chest pain, SOB, sudden
cardiac tamponade: compression of the heart due to blood or fluid buildup in the
pericardial sac, may occasionally be the result of puncture wound through the heart
during a procedure
Sy’s-jugular distension, hypotension, muffled heart sounds
arteriosclerosis = stiffening of the arteries; thickening and loss of elasticity hardening of arteries
atherosclerosis: plaques into lumen and weakened underlying artery; heart attack,
stroke, aortic aneurism; atheromas (plaques, cholesterol or lipids) form within the
intima of artery
aortic stenosis = calcification due to age or lipid accumulation; consequences:
heart murmur, hypertrophy, angina, syncope
aneurism = localized abnormal dilation of the wall of a blood vessel, all aneurisms
may rupture
causes; atherosclerosis, trauma, congenital defects
most common site: abdominal aortic aneurism
aortic dissection: chest pain, dissecting aneurism
Blunt trauma to the heart:
Flail Chest=multiple rib fractures, free floating rib section; Inspiration-flail
segment sucks in→ lung, heart, mediastinum shift away, reducing air entry into the
unaffected lung; expiration - flail segments pushes outward→
lung, heart, mediastinum are pushed toward flail segment
Jason Shane and Amanda Mrsic Apr 2015
Rx-pain control, intubation/ventilation if necessary, O2, airway clearance,
occasionally Sx
pneumothorax= collapse of the lung due to air in pleural space; can be due to
puncture of chest wall or lung spont bursts; hyperresonant percussion; aspirate or
chest tube
1) open - stabbed- air into pleural space;
2) tension - v.serious! - open wound becomes sealed on expiration, air goes
from affected lung into pleural space - on inspiration air will stay in pleural
space, increase pressure on heart that can stop beating :(
spontaneous pneumothorax- spont rupture of air containing space of lungs
hemothorax- collapse of lung due to blood in pleural space ; less breath sounds
01.03.02 Myocardial ischaemia and infarction (including surgical
interventions)
Terrible Triad: (3 I’s)
1) Ischaemia= Inverted T waves, poor blood supply and hypoxia, occurs w/i
seconds of onset and is REVERSIBLE
2) Injury= Elevated ST segment, myocardial tissue injured during MI
occurs in 20-40mins, IS REVERSIBLE
Depressed ST segment: inj to myocardial tissue, can occur during angina
3) Infarction= abnormal Q waves and QS complexes, can also be tall R waves
NOT REVERSIBLE, occurs 2hrs after onset
BRADYcardia <60bpm
TACHYcardia >100bpm
Ventricular fibrillation= incompatible with life = requires defib (shock!)
- 1st degree AVblock= caused by prolonged conduction in AV node; P-wave
normal
Jason Shane and Amanda Mrsic Apr 2015
-
2nd degree AV block (2 types, mobitz 1 and 2) =block occurs at occurs at
AV node and is transient; PR lengthens until totally blocked then NO QRS
follows a P causing a missed beat (MOBITZ type 1)
MOBITZ type 2: block occurs at bundle branches/bundle of His; abrupt drop of
QRS, but PR interval normal
-
3rd degree AV block: block at AV node, bundle of His OR bundle branches;
complete disassociation between atria and ventricles, this produces
independent atrial and ventricIular rate (atrial faster)
-
bundle branch block: in bundle branches and QRS is longer
01.03.03 Heart failure,
CHF: congestive heart failure
- heart is unable to pump blood at a rate required by tissues of the body, or it
does so at elevated filling pressures
- marked by breathlessness and abnormal retention of sodium and water
resulting in edema with congestion of lungs or peripheral circ or BOTH
- two types: systolic; deterioration of contractile function
diastolic: can’t accommodate ventricular blood volume
Right sided heart failure: common cause: L sided heart failure; damming of
blood in periphery, congestion of the portal system: liver damage and enlarged
spleen, dec flow in periphery, kidney and brain issues, pitting edema
Left sided heart failure: due to: damming of blood in pulmonary circulation; SOB
when lying, nocturnal gasp of breath when sleeping, kidney and brain dec
perfusion
cor pulmonale: failure of the R side of heart; due to chronic severe pulm HTN:
emphysema and chronic bronchitis (COPD)
ischemic heart disease: caused by myocardial ischemia; S&S angina, MI,
sudden cardiac death 90% due to atherosclerosis
angina pectoris: paroxysmal (short and frequent) recurrent episodes of chest
discomfort caused by transient myocardial ischemia: stable, unstable,
prinzmetal(variant) occurs at rest
MI: release troponin and creatine kinase
01.03.04 Tumour (oh, sorry, tumors are on the blueprint THREE times!!!)
Jason Shane and Amanda Mrsic Apr 2015
LUNG CANCER:
2 types:
1)small cell: 20-25%: develops in bronchial cell mucosa, spread rapidly, and
metastasize early
2) non-small cell:
- 1) squamous cell - spread slow, arise in central portion near hilum, mets late
- 2) adenocarcinoma- 35-40%- slow to mod spread, early mets throughout
lungs brain and other organs
- 3) large cell - rapid spread, wide spread mets, kidney, liver, adrenals, poor
prognosis
risk: SMOKING OF COURSE!
PT management: manage fatigue
Brain tumours = 2nd to stroke, is #1 cause of death (in the brain)
50% chance of survival, kills more ppl than MS and lymphoma, sig cause of death
in kids (intra-tentorial)
1) intracerebral primary = tumors neurons don’t proliferate (other cells around
proliferate)
2) intracerebral metastatic = come from lung, breast, prostate - compensate by
dec brain tissue vol, CSF vol and blood flow vol
3) Intra-spinal- signs: N root pain, worse at night, pain with cough, radicular pain
Rx: surgery or radiation
low grade astrocytoma - benign, good survival if treated early
anaplastic astryocytoma - aggressive
medulloblastomas - freq metastasize to other spots in brain and spine
neuronomas: a) schwannoma - cranial N 8 (vestibular)
S&S headache and seizure, nausea, vomit, cognition and behavior
01.03.05 Pneumonia (primary or post-operative/preventive)
inflammation of parenchyma of lungs (lung tissue); could be caused by:
1) bacterial, viral or fungal,
2) inhalation of toxic chemicals (smoke, dust, gas),
3) aspiration; normally airborne pathogens
most are preceded by an upper respiratory infection followed by sudden and
sharp chest pain, coughs up green sputum, can also have dyspnea, tachypnea
Rx: antibacterials/antibiotics, airway clearance techniques, antifungals (if fungal
infection), oxygen support, positioning
- Hospital acquired pneumonia has a higher mortality rate than community
typical (sudden onset of symptoms - bacterial often, fever, sputum, physical sign of
consolidation) and;
atypical (walking- no symptoms, little sputum, min chest signs)
aspiration: impaired consciousness- alc abuse, after surgery, neuro disease
Jason Shane and Amanda Mrsic Apr 2015
01.03.06 Atelectasis (primary or post-operative/preventive)
Atelecatsis = collapse of normally expanded and aerated lung tissue at any
structural level involving all or part of the lung; can be patchy, segmental or lobar
distribution
can be due to:
1) blockage of bronchus/bronchiole, lung is prevented from expanding due to:
paralysis, diaphragmatic disorders, mucous or airway obstruction, hypoventilation;
2) compression due to pneumothorax, pleural effusion, space-occupying lesion
(tumor) which prevents alveoli from expanding;
3) postanesthetic - effects of anaesthesia and prolonged recumbency
Presentation: x-ray=shifting of lung structures toward collapse, if involves entire
lobe may show a shadow; quiet breath sounds, possibly dyspnea, tachypnea,
cyanosis
Rx: identify underlying cause, suctioning if d/t secretions, chest tube if d/t
pneumo/hemo thorax or extensive pleural effusion
01.03.07 Adult/infant respiratory distress syndrome (e.g., acute lung injury)
ARDS: acute respiratory failure with severe hypoxemia as a result of pulmonary
or systemic problem; lung injury characterized by increased permeability on
alveolar capillary membrane; leakage of fluid and blood into lung interstitium and
alveoli
INFLAMMatory reaction; alveolar edema and collapse
causes: severe trauma; aspiration; embolism; indirect- happen after viral infection
or pneumonia
key feature on x-ray = WHITE OUT
Rx: PEEP to keep airways open, tackle underlying cause, PRONE position
SARS: severe acute respiratory syndrome = viral resp illness; unlike the flu, will
get pneumonia if you have SARS
abscess: infection leading to necrosis of lung tissue and cavity formation
IRDS: occurs in infants whose lungs have not fully developed; lack surfactant
(helps lungs inflate with air and keeps the sacs from collapsing)
risks: prematurity, c-section, multiple preggers, blue baby, stop breathing, grunts
Rx: deliver artificial surfactant
hypoxemic resp failure (gas exchange failure): arterial hypoxemia - low blood
O2, no inc in CO2, due to: pneumonia, ARDS, obstructive lung disease,
pulmonary embolism
hypercapnic resp failure: too much CO2 in the blood, leads to dec O2 in the
blood, due to dec ventilation (depress of resp ctr by drugs), acute upper/lower
Jason Shane and Amanda Mrsic Apr 2015
airway obstruction, weak/impaired resp mm, SCI
01.03.08 Asthma
chronic inflamm of the lungs characterized by variable airflow limitation and hyperresponsiveness; chronic inflamm disorder of airways
- airway hyper-responsiveness: recurrent episode; wheezing, breathlessness,
chest tightness, coughing (often reversible unlike COPD), smooth mm contraction
gas exchange normal, hyperinflated during attack, normal elastic recoil, exercise
capacity reduced, allergic exposure- child or adults
2 categories:
1) extrinsic - allergic or atopic - normally due to allergen; mast cells release
mediators which cause bronchospasm and hypersecretion - KIDS more
2) intrinsic - non allergic- hypersensitivity to bacteria, virus, drugs, cold air,
stress - ADULTS more
Rx: prevent triggers, pharmacological - inhaled corticosteroids
exercise induced: smooth mm constrict - upright, lean forward and pursed lip
breathing
01.03.09 Chronic obstructive pulmonary disease (e.g., emphysema,
bronchitis, bronchiectasis)
COPD= chronic resp condition characterized by progressive airway obstruction
that is not fully reversible, gas exchange is normal, always hyperinflated,
decreased elastic recoil, age of onset middle aged to older adults
Rx: pharmacological 2 focuses, 1) smooth mm relaxation, 2) reduce airway
inflammation
O2 therapy, BUT NOT FOR Pts with pulmonary HTN, CHF
Bronchiectasis: irreversible destruction(necrosis) and dilation of the airways with
chronic bacterial infection; excess mucus, can be caused by CF, TB, and
endobronchial tumors; eventually alveoli replaced with scar tissue due to chronic
inflamm
Rx: bronchodilators, antibiotics, secretion clearance
Bronchitis: excess mucus production
Emphysema = pathological diagnosis, destruction of air spaces distal to the
terminal bronchiole with destruction of alveolar septa which causes merging of
alveoli into larger air spaces→ this reduces the surface area for gas exchange; loss
of airways and capillaries as well; Impact: hyperventilation put the diaphragm at
mechanical disadvantage (it’s flattened)
Jason Shane and Amanda Mrsic Apr 2015
01.03.10 Restrictive pulmonary disease (e.g., fibrosis)
interstitial lung disease:
stiff, less compliant lungs (not airway obstruction)
S&S dyspnea, severe O2 desaturation, finger clubbing, scarring on CT
Rx: O2 therapy, lung transplant, pulmonary rehab
pulmonary fibrosis: ⅔ no known cause; ⅓ TB, inhaling harmful particles, radiation
therapy, meds
idiopathic pulmonary fibrosis: scarring and fibrotic tissue
asbestosis: caused by inhaling harmful particles
pneumoconiosis (coal workers lung):
01.03.11 Tuberculosis
(mycobacterium tuberculosis)
- infectious, inflamm systemic disease that affects lungs and may disseminate
to involve kidneys, growth plates, meninges, avascular necrosis of hip jt,
lymph nodes and other organ
- airbourne particles
S&S: productive cough 3+wks, wt loss, fever, night sweats, fatigue, bronchial
breath sounds
TB skin test: inject in forearm: determine of body’s immune response has been
activated by TB before
medical management: 10 drugs
PT: thorough history and self protection (masks etc)
01.03.12 Pleural effusion
accumulation of fluid in the pleural space due to disease
- this can impair breathing by limiting expansion of the lungs
transudate: commonly due to heart fail - low protein, clear
exudate: formation of fluid by inflammation or disease, caused by infection or
Jason Shane and Amanda Mrsic Apr 2015
cancer of the pleura - opaque
symptoms: SOB, chest pain, percussion - dull, decreased or ABSENT breath
sounds, may hear a pleural rub
may cause mediastinal shift
01.03.13 Pulmonary edema
increased fluid in extravascular spaces of the lungs; may be increased hydrostatic
pressure due to heart or kidney failure - pushes fluid out of vessels, or increased
alveolar permeability (drug induced, ARDS, inhalation of noxious gas)
presents as stiffer lungs - incrd work of breathing, and dyspnea
classic symptom: cough that produces a frothy pink tinged sputum
on auscultation: FINE CRACKLES
Pulmonary embolus = bloody sputum, dyspnea, incrd RR, SOB, cyanotic,
01.03.14 Cystic fibrosis
- inherited autosomal disorder that affects all exocrine glands results in
defective Cl- excretion and Na+ absorption = THICK MUCUS
- can get: recurrent chest infections, consolidation, atelectasis and thickened
bronchial walls
- diagnose with fam history, sweat test - chloride content of sweat, 2 copies of
abnormal gene
- respiratory symptoms most common; also get: finger clubbing,
breathlessness, delayed puberty and skeletal maturity, infertility in males,
symptomatic steatorrhea, diabetes mellitus, liver disease, osteoporosis
Rx: airway clearance techniques, bronchodilators, aggressive antibiotics
01.03.15 Peripheral arterial disease
account for 95% of arterial occlusive disease; atherosclerosis is the underlying
cause
S&S -occur distal to site of narrowing or obstruction; intermittent claudication,
acute ischemia (pallor, pain paralysis, pulseless), ulceration and gangrene, skin
(shiny, thin, hairless); often occurs in feet
Outcome-decreased mobility d/t pain and loss of function or limb
PERIPHERAL VASCULAR DISEASE: (same as peripheral artery disease)
- artherosclerotic obstruction of iliac, femoral, and politieal arteries in the legs
- feel pain during physical activity, most often in the calf
- pathologic conditions of blood vessels that supply extremities and major
abdominal organs
underlying cause: atherosclerosis
S&S: intermittent claudication, dec pulses, ulcers, cool skin, limit mobility, pain or
loss of function of limb
Jason Shane and Amanda Mrsic Apr 2015
01.03.16 Venous disorders
THROMBOPHLEBITIS
- partial or complete occlusion of a vein by a thrombus with secondary
inflammation
- superficial or deep
DVT
- can become pulm emboli S&S: tender calf (d/t thrombus in calf vein), fever,
test with Homan’s; risk is it may become a PE
CHRONIC VENOUS INSUFFICIENCY
- inadequate venous return over a prolonged period
- cause: DVT trauma, obstruction by tumor,
- damaged or destroyed valves lead to venous stasis, can get edema,
thickening brown skin and ulcers
Varicose veins = faulty valves cause abnormal dilation of veins leading to twisting
and turning of the vessel; at risk for thrombosis
(Don’t even know how many times we’ve learned this diagram over the years)
Jason Shane and Amanda Mrsic Apr 2015
Volumes
TIDAL VOLUME (TV): Volume inspired or expired with each normal breath. (500mL)
INSPIRATORY RESERVE VOLUME (IRV): Maximum volume that can be inspired over the
inspiration of a tidal volume/normal breath. Used during exercise/exertion. (2-3L)
EXPIRATORY RESERVE VOLUME (ERV): Maximal volume that can be expired after the
expiration of a tidal volume/normal breath.(1L)
RESIDUAL VOLUME (RV): Volume that remains in the lungs after a maximal expiration.
CANNOT be measured by spirometry(1L)
Capacities:
INSPIRATORY CAPACITY ( IC): Volume of maximal inspiration:
IRV + TV (2.5L-4L)
FUNCTIONAL RESIDUAL CAPACITY (FRC): Volume of gas remaining in lung after normal
expiration, cannot be measured by spirometry because it includes residual volume:
ERV + RV(2L)
VITAL CAPACITY (VC): Volume of maximal inspiration and expiration:
IRV + TV + ERV = IC + ERV (3-4.5L)
TOTAL LUNG CAPACITY (TLC): The volume of the lung after maximal inspiration. The
sum of all four lung volumes, cannot be measured by spirometry because it includes
residual volume:
IRV + TV + ERV + RV = IC + FRC (4-6L)
DEAD SPACE: Volume of the respiratory apparatus that does not participate in gas
exchange, approximately 300 ml in normal lungs.
--ANATOMIC DEAD SPACE: Volume of the conducting airways, approximately 150 ml
--PHYSIOLOGIC DEAD SPACE: The volume of the lung that does not participate in gas
exchange. In normal lungs, is equal to the anatomic dead space (150 ml). May be greater
in lung disease.
FORCED EXPIRATORY VOLUME in 1 SECOND (FEV1): The volume of air that can be
expired in 1 second after a maximal inspiration. Is normally 80% of the forced vital capacity,
expressed as FEV1/FVC. In restrictive lung disease both FEV1 and FVC decrease , thus
the ratio remains greater than or equal to 0.8. In obstructive lung disease, FEV1 is reduced
more than the FVC, thus the FEV1/FVC ratio is less than 0.8.
CARDIAC REHAB
3 goals:
- 1) restore optimal function
- 2) prevent progression of underlying processes
- 3) reduce the risk of sudden death and re-infarction
S&S of cardiopulmonary disease: pain in chest, neck, jaw, arms; SOB at rest or
mild exertion; dizzy or syncope; orthopnea (SOB while lying flat) or nocturnal
dyspnea, ankle edema, palpitations or tachycardia, intermittent claudication,
known heart murmur, unusual fatigue
exercises to avoid: NO VALSALVA!; extensive upper body activity; isometric/
Jason Shane and Amanda Mrsic Apr 2015
static exercises;
PHASES:
phase 1: inpatient
phase 2: outpatient 12 week program
phase 3: in the community
cardiothoracic index = size of heart in relation to thorax
01.04 Multisystem (15%±5%) (This list is not necessarily exhaustive.)
01.04.01 Episodic disease (e.g., oncology, HIV/AIDS, autoimmune disorders,
rheumatic diseases, haemophilia)
Oncology: (the Alliance is being sneaky this time, they’re calling it “oncology”
instead of tumors)
Staging cancer:
- TNM: Tumor (extent/spread), Nodes (lymph), Mets (distant ones)
PT relevant Rx: PT’s can teach Pt’s to stretch mm when radiation therapy begins
to mitigate occurrence of contractures
Physical activity:
- During Rx - improves QOL, physical Fx, fatigue; Precautions-severe
anemia, immune compromised, severe fatigue
- Following Rx - goals are to have appropriate weight, be physically active,
healthy diet
- ACSM guidelines - prescription must be individualized according to cancer
survivors pre-Rx aerobic fitness, medical comorbidities, response to Rx, and
the neg side effects of Rx
Clinical presentation of cancer survivors: fatigue, myalgia, arthralgia, bone health,
peripheral neuropathy (impact on balance), deconditioning
Palliative Care: Goals are to provide comfort, support, maximize independence;
PT’s can help with respiratory, stress reduction, education
AIDS: acquired immunodeficiency syndrome
- caused by hiv1 or 2; loss of immune system function; can get pneumonia,
Tb, malignancy, encephalitis, meningitis, dementia, herpes zoster
- reduction of CD4+ helper T cells
- transmission through contact with infected body fluids: blood, saliva, semen
CSF, breast milk, vaginal/cervical secretions NOT: urine, sweat, vomit
diagnosed with clinical findings and systemic evidence
- AIDS - related complex (precursor to full blown AIDS)
- lab evidence: HIV -1 antibody test, CD4 cell count 200-500/ml (normal =
800-1200/ml
Jason Shane and Amanda Mrsic Apr 2015
-
no cure
med interventions = 1) multidrug antiviral therapy 2) symptomatic treatment:
maintain nutrition, maintain functional mobility, education,
- PT goals: use precautions when working, exercises- mod aerobic, strength,
avoid exhaustive, acute = reduce to mild levels, activity pacing, energy
conservation, stress management
Autoimmune disorders:
Guillan Barre Syndrome = antibody mediated demyelination of schwann cells;
see a generalized inflammatory response
Presentation: initially see a “socks and gloves” pattern of areas that initially go
numb; is perfectly symmetrical; maximal weakness occurs in 2-3 weeks and takes
months to recover; absent deep tendon reflexes
Rx: plasmapheresis, Iv administration of immunoglobulin (decreases the immune
response)
PT Rx: early on - prevent ulcers (posning), early PROM; later - mm strength
Connective tissue disorders that may involve skin as well as organs:
Lupus erythematosus - can involve kidney, CNS, cardiac, pulmonary; on skin
may find BUTTERFLY rash, localized erythema and edema, alopecia (loss of
hair), photosensitivity, mucosal ulcers, Raynaud’s (fingers are cold sensitive),
effusion in joints; associated with positive serum “antinuclear antibodies” (ANA)
Sclerodema-autoimmunity provokes massive fibrotic tissue response which may
lead to joint contractures, pulmonary fibrosis, GI dysmotility (esp esophagus)
Dermatomyositis and polymyositis=inflam connective tissue disorders
characterized by proximal limb girdle weakness, often w/o P.
Dermatomyositis- affects both skin and mm; is also assocd. w/ a photosensitive
skin rash, purplish erythematous eruption over face (esp upper eyelids), hands,
forearms
Polymyositis- mm only
Haemophilia:
Type A
- is the most common of hereditary clotting factor deficiencies
X-linked recessive (Males have the condition, and the gene that causes it is
carried by women)
- If the mother carries the haemophilia gene and the father does not have
haemophilia: A male child will have a 50:50 chance of having haemophilia. A
female child will have a 50:50 chance that she will carry the haemophilia
gene.
- If the father is affected by haemophilia and the mother is not a carrier: A
female child will be a carrier (she is known as an obligate carrier). A male
child will not be affected by the haemophilia gene and cannot pass
Jason Shane and Amanda Mrsic Apr 2015
haemophilia onto his future children.
Presentation: profuse post circumcision bleeding, joint and soft tissue
bleeding, excessive bleeding, operative and post-traumatic hemorrhage
Signs and Symptoms:
● Big bruises;
● Bleeding into muscles and joints, especially the knees, elbows, and ankles;
● Prolonged bleeding after a cut, tooth removal, surgery, or an accident.
● Serious internal bleeding into vital organs, most commonly after a serious
trauma
Bleeding in the joints is the most common problem.
The symptoms of a joint bleed are as follows:
● Tightness in the joint with no real pain.
● Tightness and pain before any bleeding
● Swollen and hot to touch, hard to move
● All movement lost, severe pain
● Bleeding slows after several days when the joint is full of blood
There can be disabling arthritis if this is not treated.
Rx: recombinant factor VIII infusion; note, before VIII available many Pts received
blood products in the 80’s and died of AIDS and many got Hep C
Desmopressin (or DDAVP) can be used for sufferers of mild haemophilia
-
Rheumatic diseases:
Rheumatoid arthritis: synovitis is the main feature; synovium becomes swollen
and cells proliferate→ a dense cellular membrane (pannus) spreads over articular
cartilage and erodes the underlying cartilage and bone; over time the pannus may
extend to the opposite articular surface creating:
1) fibrous scar tissue, 2) adhesions, 3) bony ankylosing; immobility and
consolidation (bones form a single unit) of a joint; bones can become osteopenic
and ligaments and tendons become damaged or ruptured; surrounding mm
deteriorate leaving joint unstable and prone to deformity
symmetrical pattern
Criteria for RA:
- morning stiffness >1hr (6 weeks), arthritis of >/= 3 joints (6 weeks), arthritis
of hand joints, symmetric arthritis (6 weeks), rheumatoid nodules, serum
rheumatoid factor, radiographic changes
Have an abnormal antibody HLA-DR4 in 80% of people with RA
Increased risk: after mother gives birth, cigarette smoking, pollution
Clinical features: pain, fatigue, stiffness (decreased ROM), swelling, joint
deformity, mm atrophy
Management: Meds (DMARDs, NSAIDs, tylenol, cortisone)
Jason Shane and Amanda Mrsic Apr 2015
Rehab:
Acute phase- energy conservation, ice, splints, gentle ROM,
NO STRETCHING as it may stretch the synovial membrane and cause
irreversible damage
Chronic phase- relieve pain, i.e. modalities, splints, exercise (gentle ROM),
relaxation/rest; Reduce stiffness-gentle ROM, aquatic ex, heat; functional ex’s,
prevent deformity
Inflam conditions: - pain worse in morning, morning stiffness greater than 1hr
Non-Inflam condition: - yes, after used, morning stiffness less than 30min
Joint count assessment = an indicator of the disease activity of RA
1) Joint effusion
2) joint line tenderness
3) stress pain
Commonly affected joint in RA:
1) atlanto-axial joint (esp transverse lig)
● S&S of atlanto axial subluxation - clunking in repositioning in Sharp Purser
test, dysphagia, dizziness, blurred vision
2) TMJ - end stage may result in fusion of open bite
3) Shoulder - humeral head moves superiorly
4) AC joint
5) elbow - loss of extension, i.e. flexion deformity; superior radioulnar joint
commonly involved→ erosion of radial head
6) hip (groin P, flexion deformity)
7) knee - baker’s cyst, flexion deformity, valgus deformity, quad wasting
RHEUMATIC Con’t:
Hallux valgus - 1st MTP synovitis, big toe is lateral, lig laxity and erosion,
sublux→ dislocation, prox phalanx drifts lat, causes pronation of midfoot
MTP subluxation - synovitis, displacement of the flexors, unopposed extensors
pull the prox phalanx into hyperext, metatarsal head prolapses and get dislocation
and lat drift of toes: Sign = callouses
Claw toe - MTP synovitis, MTP ext, PIP+DIP flex, often all toes except big toe
Hammer toe - MTP and PIP synovitis, usually involves 2nd toe, flex of PIP and
hyperext of DIP (similar to boutonniere)
Mallet toe - flex of DIP, affects longest toe
Swan neck - (rheumatoid) flex of MCP(not always), hyperext of PIP, flex DIP
Boutonniere - zig zag deformity - MCP hyperext (not always), flex of PIP,
hyperext of DIP
Jason Shane and Amanda Mrsic Apr 2015
Gout = Genetic disorder of purine metabolism, incrd serum uric acid
(hyperuricemia).
● Acid ▲ to crystals and deposits into jts,
● most= knee and great toe of foot
● Meds: NSAIDS, cox2-inhibitors, corticosteroids, ACTH
● PT goals: injury prevention ed, fast intervention
Osteoarthritis=release of enzymes and abnormal biomechanical forces cause
fibrillation and damage of articular cartilage leading to cartilage loss; increase in
bone turnover→ osteophytes
7 risk factors: 1) age, 2) sex (more women), 3) genetic, 4) obesity, 5) physical
inactivity, 6) injury, 7) joint stress(occupation)
Dx by x-ray finding:
4 main features 1) joint space narrowing, 2) osteophytes, 3) subchondral cysts,
4) subchondral sclerosis
Sources of pain in OA: - bone, soft tissue, inflammation, mm spasm
4 questions to diagnose OA: 1) pain most days in last month, 2) pain over the
last year, 3) worse with activity, 4) relieved with rest
3 tests indicative of OA of the knee: 1) flexion contracture, 2) abnormal gait, 3)
swipe test or patellar tap
Main joints it affects:
● Spine - osteophytes in facet jts of l-spine can cause stenosis
● Shoulder and Elbow - uncommon
● Wrist - uncommon unless scaphoid fracture or avascular necrosis
● Hand - PIP is Bouchard node, DIP is Hebernen’s node; CMC joints (esp
thumb)
● Knee - most common jt affected by OA, varus, flexion contracture, crepitus
● Hip - walk with trendelenburg, groin pain, osteophytes, flexion deformities
Types of FAI (femoral acetabular impingement):
Cam - decrease or absent waist of the jx of femoral neck and head; during hip
flexion the abnormal femoral head drives into acetabulum, most common in young
men
Pincer - d/t abnormal acetabulum that provides excessive cover of the femoral
head, retroverted or deep acetabulum; impingement occurs when femoral neck
pushes against overarching acetabulum; more common in women age 30-40
years
● Ankle - uncommon
Jason Shane and Amanda Mrsic Apr 2015
●
Foot - first metatarsal joint; osteophytes can form at this jt causing hallux
valgus and rigidus, may have bunions
Rx: First line-exercise, weight loss, acetaminophen
Spondyloarthritis: don’t have a rheumatoid factor, common in the spine
Common features - inflammation in the spine (spondylitis and sacroiliitis),
synovitis (affecting peripheral joints) typically unilateral, inflammatory of the eye
(iritis/uveitis and conjunctivitis), no rheumatoid factor (seronegative), can be
hereditary HLA-B27
Spondyloarthritis Rx:
Meds - DMARDs, NSAIDs, corticosteroids, biologics
Physical Management - control/decrease inflammation, P management, reduce
stiffness/increase ROM, posture correction, increase mm strength and endurance,
increase cardio
Psoriatic Arthritis:
Pt has psoriasis, M=F, can begin with kids,
Chronic, erosive, inflamm
most common = digit jts and axial skeleton
Dactylitis = sausage like fingers d/t swelling;
Enthesitis = usually in heels and back
Meds: acetaminophen, NSAIDs, DMARDs, corticosteroids, biological response
modifiers
PT goals: jt protections strategies, maintain jt mechanics, endurance
Enteropathic Spondylitis - assocd with ulcerative colitis (affects just the lower
half of the bowels) and Crohn’s disease (affects the whole digestive system, it’s
worse), may affect spine and SI joint
Reactive arthritis - triggered by infection (possibly STI) in bowel or GI tract, hot
swollen joints, may go away and come back
Ankylosing spondylitis
- stiffness/fusing of the spine by inflammation, disease of young adults;
associated with genetic marker HLA B27
- Features:
- MSK: sacroiliitis, enthesitis, synovitis; other signs-eyes, bowels, lungs, heart
- The hallmark sign is sacroiliitis; may also feel deep, dull pain in buttuck
area d/t inflammation of SI joint; fusion can occur over time
Jason Shane and Amanda Mrsic Apr 2015
Enthesitis - inflammation of entheses leading to bony erosion and overgrowth;
common sites are spine, hip, peripheral regions; syndesmophytes (bony spurs
on 2 sides of a joint) can also cause bony fusion and rigidity
(entheses = where tendons, ligs, and joint capsule attach to bone)
Synovitis - usually affects peripheral jts, commonly shoulders, hips, knees, ankles
Clinical criteria of AS = LBP and stiffness for more than 3 months that improves
with ex but is not relieved with rest, limitation of motion of L-spine (d/t pain, tissue
contractures, mm guarding, fusing), limitation of chest expansion (diaphragmatic
breathing pattern), decreased strength d/t disuse, joint effusion, and pain, flexion
posture, fatigue d/t disease process, cardiac involvement, decrd vital capacity
Quick overview: onset before 40, low back pain, sacroiliitis, kyphotic deformity
Csp, Tsp, dec lumbar lordosis, M>F
Meds: NSAIDS, corticosteroids, cytotoxic, tumor necrosis factor
Diagnosis – HLA-B27
PT goals: trunk flexibility, endurance, increase resp function (relaxation)
Physical Ax - posture (tragus to wall), lateral trunk flexion, trunk flexion (modified
schober's), trunk extension (smythe test), trunk rotation, chest expansion,
cervical mobility
Juvenile Idiopathic arthritis
- signs and Sy’s must be present for 6 weeks to make diagnosis, avoid
resisted ex’s with active disease, P does not indicate joint damage;
improved strength (non-active period of the disease) reduces P and
increases stability
- complete remission in 75% of kids if occurs before age 16
- Sy’s-joint pain, stiffness, warm swollen joints, eye issue (uveitis), HLA-B27,
fatigue, Erythrocyte sedimentation rate, rheumatoid factor
Inflamm back pain
- usually prolonged, >60min, max P and stiffness in early AM, chronic, age of
onset 12-40 years, radiographs show sacroiliitis, syndesmophytes, and
spinal ankylosis
Mechanical back pain
- minor <40min, max P and stiffness late in the day, activity worsens Sy’s,
acute/chronic, 20-65 yrs, radiographs show osteophytes, disc space
narrowing, misalignment
01.04.02 Metabolic disorders/conditions (e.g., diabetes)
Jason Shane and Amanda Mrsic Apr 2015
DIABETES
Hypoglycemia=dizzy, nausea, weak, sweating profusely (this rules out
orthostatic hypotension)
Hyperglycemia=blurred vision, fatigue, thirst, frequent urination
01.04.03 Chronic pain/fibromyalgia
Chronic pain = pain that persists past the normal time of healing
Chronic fatigue syndrome=may be viral
● Dx: by exclusion; persistent or relapsing fatigue for at least 6 months, not
resolved with bed rest, reduces daily activity by at least 50%
● Rx: Analgesics, anti-inflamm, NSAIDS, nutrition, psych support
● PT Rx: check ex tolerance
Fibromyalgia = chronic pain syndrome affecting mm and soft tissue (nonarticular rheumatism)
● Etiology: unknown
● Sy’s - headaches, sensitivity to stimuli, fatigue, myalgia (mm pain),
generalized aching, sleep disturbances
● Anxiety and depression are common; more common in women
● 11 of 18 points: 1) Occiput (suboccipital insertions), 2) low cervical (ant
aspects of intertransverse spaces at C5-C7), 3) Traps (mid-pt of upper
border), 4) Supraspinatus (at origin), 5) Second rib (lateral to 2nd
costochondral junction),6) lateral epicondyle, 7) gluteal, 8) greater
Jason Shane and Amanda Mrsic Apr 2015
●
●
trochanter, 9) knee (at medial fat pad proximal to joint line)
Rx: anti-inflamm, mm relaxants, pain meds, psychological support, nutrition
PT Rx: energy conservation, aquatic therapy
01.04.04 Lymphedema = lymph accumulating in tissues
2 types:
● Primary - rare, inherited condition caused by problems with the dvlpmt of
lymph vessels
● Secondary - d/t identifiable damage to or obstruction of normally functioning
lymph vessels and notes;ex-Sx, radiation, parasitic infections
Fx of lymph system:
- removal from body tissues of fluid, proteins, bacteria, viruses
- smooth mm in walls contract to move lymph
Risk factors: radiation, age, axillary node dissection, arm infection/injury, obesity,
weight gain since operation
Prevention: skin care (avoid trauma/injury to reduce infection), activity (and
maintain body wt), avoid limb constriction, avoid extreme temperatures
Role of PT’s: exercise (weight loss), education on what to avoid (BP cuffs),
educating on signs and symptoms
Rx: compression garments, manual lymph drainage, manage risk factors
[Cording = tight fibrous bands that go from axilla to elbow or wrist and restrict
ROM]
01.04.05 Sepsis
- body has severe response to bacteria or other germs; whole body
inflammatory state; have SIRS and a proven infection
- SIRS = systemic inflammatory response syndrome; whole body
inflammatory state
diagnose with body temp, HR, RR, WBC count
01.04.06 Obesity
Excess body fat; BMI=weight (kg)/height (m)^2
- overweight BMI= 25-29.9
- OBESITY= BMI > or = to 30
- morbidly obese > or = to 40
skin caliper test fat greater than 1 inch is excess
● health risks associated with obesity: HTN, hyperlipidemia, type 2 diabetes,
cardiovascular disease, glucose intolerance, gallbladder disease, menstrual
irreg, infertility, cancer
● abdominal obesity = independent predictor of morbidity and mortality
● causes of obesity: excess calorie intake, psych/enviro factors, genetic
factors, endocrine and metabolic disorders
Jason Shane and Amanda Mrsic Apr 2015
Rx: lifestyle modifications, behavior therapy, pharmacology, surgery;
exercise=moderate intensity 40-60% progress to 50-70% HRR, 5-7d/wk, 4560mins, circuits or aquatics
01.04.07 Pregnancy and post-partum conditions
● NORMAL = gain 20-30lbs
● postural changes = kyphosis, forward lean in Csp, lumbar lordosis, balance
change, lig laxity (hypermobile SI - teach jt protections
PT can teach: relaxation and breathing ex, provide ed, teach exercises to
maintain abdominal and pelvic floor mm
Diastasis recti abdominis = lateral separation or split of rectus abdominus;
separation from midline >2cm sig; ab wall decrd support; get back pain
pelvic floor disorders = due to stretching; can lead to partial or total organ
prolapse
- cystocele : herniation of bladder into vagina
- rectocele: herniation of rectum into vagina
- uterine prolapse: bulge of uterus into vagina
- pelvic pain, urinary incontinence, pain with sexual intercourse
PT Rx: pelvic floor mm ex, postural re-ed,
low back and pelvic pain
- PT Rx: teach body mechanics, balance activity and rest, massage,
modalities for Pain
SI dysfunction
- post pelvic pain, buttock pain, may radiate to leg, pain with sit, walk, stand
- PT Rx: external stabilization, ed on no single leg WB
varicose veins
- PT Rx: elevate extremities, elastic stockings
preeclampsia = preg induced, acute HTN after 24wks gestation
- PT evaluate for S&S: HTN, edema, headache, visual disturb, hyper-reflex
C- section
- PT Rx: TENS for incision pain, breathing ex, gentle ab ex, pelvic floor ex,
postural ex, ambulation, prevent incisional adhesions (scar massage)
01.04.08 Burns
Superficial
Jason Shane and Amanda Mrsic Apr 2015
Partial Thickness
Full thickness
Zones:
Zone of coagulation = point of maximum damage, irreversible tissue loss
Zone of stasis = decrd tissue perfusion, potentially salvageable
Zone of hyperemia = increased perfusion, will recover unless sepsis occurs
Effects of burns:
● CV: Increased capillary permeability->interstitial edema; peripheral
vasoconstriction; hypovolemia; myocardial depression->hypotension and
decreased organ perfusion
● Resp: bronchoconstriction, ARDS
● Metabolism: increased 3x
● Immune system: compromised
● Renal: b/c of loss of fluids, vasoconstriction, decrd GFR, incrd myoglobin
gets processed by kidneys and can block tubules
Signs of inhalation injury: singed eyebrows/nasal hairs/burnt face, black
oral/nasal discharge, swollen lips, hoarse voice, abnormal oxygenation, Hx of
being enclosed in closed room
- Inhalation injury process: w/i 24hrs upper airway obstruction/pul edema; 2448 just pulmonary edema; 48 hrs plus bronchiolitis, alveolitis, pneumonia,
ARDS
- Mngmt of inhalation injury: early mobilization, breathing ex’s, post drainage
Rx of burns: first 2-3 weeks AROM and PROM to maintain range, positioning,
edema management, encourage ambulation, scar management BECAUSE
as early as 1-4 days can get a scar tissue contracture
Contraindications to exercise: exposed joint, fresh skin graft, DVT,
compartment syndrome
Sx:
Split Thickness Skin Graft = uses skin graft, stitched, glued or sutured in place;
immobile for 5 days
Full Thickness Skin Graft=skin transplant
Skin graft Rx: scar massage, sun protection, ROM, pressure garments,
strengthening can begin in 3-4 weeks
Scar from burns:
3 stages
1) 0-4 weeks Fibroblastic/proliferative,
Jason Shane and Amanda Mrsic Apr 2015
2) 4-12 weeks early remodeling,
3) 12-40 weeks late remodeling/maturation
Factors influencing scar: age, smoking, type of tissue, nutrition
Therapeutic mngmt of scar: pressure garments, massage, moisture
01.04.09 Wounds/ulcers
Ulcers
Causes: Pressure (round sore), shearing (abrasion/scrape), friction (blisters can
be a sign), deep tissue damage from banging or bumping (purple or bruising)
4 Stages of wounds: 1) reddened (non blanchable), 2) skin is broken, small
crater, 3) deep crater,might be infected, may be black, dead tissue 4) deep
through mm to the bone or joint
01.04.10 Skin conditions (e.g., dermatitis, psoriasis)
Psoriasis = an autoimmune disease that affects the skin.
- occurs when the immune system mistakes the skin cells as a pathogen, and
sends out faulty signals that speed up the growth cycle of skin cells; i.e
profound cutaneous inflammation and epidermal hyperproliferation
- Plaques frequently occur on the skin of the elbows and knees, but can affect
any area, including the scalp, palms of hands and soles of feet, and genitals.
In contrast to eczema, psoriasis is more likely to be found on the outer side
of the joint.
- Fingernails and toenails are frequently affected (psoriatic nail dystrophy) and
can be seen as an isolated sign. Psoriasis can also cause inflammation of
the joints, which is known as psoriatic arthritis. Between 10—30% of all
people with psoriasis also have psoriatic arthritis
5 Cardinal morphologic features: 1) placque (raised lesions), 2) well
circumscribed margins, 3) bright salmon red color, 4) silvery micaceous (shiny)
scales, 5) symmetric distribution
- Complications: pruritus (desire to scratch), severe psoriasis is associated
with increased risk of CVD and shortened lifespan
- Rx: Topical creams containing glucocorticoids, tars, vitamin D or A;
phototherapy with UV light; systemic therapy with immunosuppressive drugs
such as methotrexate or cyclosporine; systemic prednisone usually not used
Eczema (means “boiling over) = is a form of dermatitis, or inflammation of the
epidermis (the outer layer of the skin); is an itchy, red, scaly disorder
Two types:
1) Atopic dermatitis (“endogenous” eczema) - is an intensely itchy
inflammatory skin disorder associated with “atopy” (predisposition toward
developing certain allergic hypersensitivity reactions): asthma, hayfever, and
Jason Shane and Amanda Mrsic Apr 2015
allergic conjunctivitis
Presentation: itchiness is the most outstanding feature; can also be erythema,
lichenification (thickening skin lines), excoriations (scratching or picking at skin)
3 Phases:
1) Infantile (2mo-2 years) - facial and extensor distribution
2) Childhood - dry skin, flexural distribution (popliteal and cuboid fossa)
3) Adult - atopic dermatitis generally improves with age, less flexural
distribution, primarily affect the hands
Rx: avoid irritating factors, moisturizers, topical glucocorticoids, oral
antihistamines, UV
2) Contact dermatitis (“exogenous” eczema)
a) allergic contact dermatitis-immune hypersensitivity to an allergen in contact
with the skin (e.g. nickel, poison ivy)
b) irritant contact dermatitis-contact of skin with something that primarily causes
direct local irritation (harsh detergents, chemicals)
Seborrheic dermatitis (dandruff)=occurs in areas of higher sebaceous gland
activity (oily areas) such as scalp, face, central chest and back; is probably due to
an excessive immune response to a yeast; Rx: antifungals
Associated disorders: seen frequently in PD patients and Pt’s with neurologic
disorders that decrease their mobility (eg stroke, TBI, SCI), as well as HIV
infection
01.04.11 Tumours (covered elsewhere)
01.04.12 Competing diagnoses (management of 1° diagnosis is changed by
2° diagnosis)
Graves disease = hyperthyroidism, autoantibodies stimulate the thyroid (TSH
receptor), T3 and T4 (these inhibit the secretion of TSH) will be high, affects
men>women
Sy’s: fever, wt loss, exercise intolerance, goiters, bulging eyes (exophthalmos),
tachycardia, decrd fertility
Rx: betablockers for HR, anti-thyroid drug therapy, radioactive Iodine, Sx removal of
thyroid
Hashimoto thyroiditis= hypothyroid, autoimmune destruction of thyroid gland, T3
and T4 are low, TSH is high; affects men>women
Sy’s: wt gain, cold intolerance, round puffy face, bradycardia, constipation,
depression
Rx: thyroid hormone replacement
Jason Shane and Amanda Mrsic Apr 2015
Addison’s=autoimmune process against the adrenal cortex, fatal if not treated,
great prognosis if treated
Sy’s: weakness, fatigue, anorexia, hyponatremia, hypoglycemia, hyperpigmentation
Rx: replace missing adrenal hormone with aldosterone and cortisol
Cushing’s disease=chronic glucocorticoid (cortisol) excess (usually iatrogenic in
Pts taking them for immunosuppression, can also get from cancer of adrenal gland
Sy’s: moon face, central obesity, abdominal striations
Rx: surgical if caused by tumor (tumor in pituitary or adrenal gland)
PAEDS:
Slipped capital femoral epiphysis = growth plate slips off the head of the femur
Developmental milestones O’Sullivan pg 247
Infant reflexes diminished/gone 2-6 mo
PRACTICAL COMPONENT
LIST OF FUNCTIONS EVALUATED BY THE PCE
(This list is not necessarily exhaustive.)
02.01 ASSESSMENT AND EVALUATION (35%±5%)
Data Collection
Obtain the following client information and interpret implications for intervention:
Jason Shane and Amanda Mrsic Apr 2015
02.01.01.01 Past and current history (e.g., medical, surgical, developmental, psychosocial, current status/symptoms, concurrent and past treatments)
02.01.01.02 Results of tests and diagnostic procedures (e.g., imaging, laboratory
tests, functional capacity evaluation, pulmonary function tests)
02.01.01.03 Medications (past and current)
02.01.01.04 Home/work/leisure/play environments, family and community support
systems and resources
02.01.01.05 Client expectations and goals
Tests/Measurements
02.01.02.01 Select and justify evaluation/assessment procedures based on client
needs and expectations, responses, and best available evidence
02.01.02.02 Perform selected physiotherapy evaluations/assessments in a safe and
accurate manner including handling all monitoring devices, equipment, or lines
attached to or around client
02.01.02.03 Examine and evaluate neuromusculoskeletal, neurological,
cardiopulmonary-vascular, integumentary and other systems using appropriate tests
and measures
02.01.02.04 Examine and evaluate mental status (e.g., cognition, memory), hearing,
and visual acuity as they relate to client’s participation in physiotherapy programs
and attainment of goals
02.01.02.05 Screen for contraindications and precautions for treatment planning
(e.g., medical issues; psychosocial issues; safety issues; language comprehension;
educational needs; risk factors and mediators)
02.01.02.06 Observe client’s response to the physiotherapy evaluation/assessment
and respond accordingly
02.01.02.07 Assess client need for assistive, adaptive, and protective devices (e.g.,
positional supports, mobility aids, orthotic or prosthetic devices)
LIST OF FUNCTIONS EVALUATED BY THE PCE (continued)
(This list is not necessarily exhaustive.)
02.02 INTERPRETATION, PLANNING, INTERVENTION, AND RE-EVALUATION
(50%±5%)
Data Interpretation
02.02.01.01 Develop a list of physiotherapy differential diagnoses and determine the
most probably cause of client’s problem
02.02.01.02 Identify indications, barriers, precautions, and contraindications to
treatment, using the best available evidence
02.02.01.03 Determine need for physiotherapy treatment, collaboration, consultation,
or referral
Prognosis
Jason Shane and Amanda Mrsic Apr 2015
02.02.02.01 Determine the potential for recovery or decline with or without
physiotherapy intervention
Goal Setting and Care Planning
In consultation/collaboration with the client and family:
02.02.03.01 Establish short-and long-term goals that are client-centred; and specific,
measurable, attainable, relevant and time-based (SMART)
02.02.03.02 Identify which aspects of intervention involve consultation, collaboration,
delegation, and/or referral
02.02.03.03 Prioritize client’s problems and associated treatments within the context
of available resources
02.02.03.04 Select and justify treatments and procedures, using the best available
evidence and considering environmental factors, safety factors, family/cultural
factors, and client’s impairments, activities and participation levels
02.02.03.05 Identify appropriate outcome measures for use in determining efficacy
of intervention
02.02.03.06 Identify aspects of treatment that can be performed by client
independently or with caregiver/family assistance
02.02.03.07 Schedule treatments to optimize client’s response (e.g., time of day,
medication timing)
02.02.03.08 Facilitate procurement of client equipment and aids
02.02.03.09 Participate in interprofessional continuum of care planning and follow-up
care with client, family and other care givers
Implementation
Use the following interventions in a safe, effective, and ethical manner with
individuals or groups:
02.02.04.01.01 Exercise with or without equipment (e.g., passive, active
assisted, active, resisted, neuromuscular, vestibular, muscle patterning, PNF)
- NORMAL ROM
- Vestibular exercises
PNF patterns: (Yes, they may still ask you about this what year is it again, 1980?)
UPPER EXTREMITY
D1 Flexion UE
flexion, (horiz) adduction, external rotation
Close your hand, turn & lift up and across your face "Grab your seat belt",
verbal cue for D1 Flexion UE
D1 Extension UE
extension, (horiz) abduction, internal rotation
Open your hand, turn & push down and out "Fasten your seat belt"
verbal cue for D1 Extension UE
Jason Shane and Amanda Mrsic Apr 2015
D2 Flexion UE
flexion, (horiz) abduction, external rotation
Open your hand, turn & lift up and out "Pizza man"
verbal cue for D2 Flexion UE
D2 Extension UE
extension, (horiz) adduction, internal rotation
Close your hand, turn & push down and across "sword in the side"
verbal cue for D2 Extension UE
LOWER EXTREMITY
D1 Flexion LE
flexion, adduction, external rotation
Foot up, turn & lift up and across "cross leg on opp knee foot bottom up" “kick soccer
ball”
verbal cue for D1 Flexion LE
D1 Extension LE
extension, abduction, internal rotation
Foot down, turn & push down and out
verbal cue for D1 Extension LE
D2 Flexion LE
flexion, abduction, internal rotation
Foot up, turn & lift up and out "going over a hurdle"
verbal cue for D2 Flexion LE
D2 Extension LE
extension, adduction, external rotation
Foot down, turn & push down and across "cross feet with toes pointed at ankles"
verbal cue for D2 Extension LE
Capsular patterns: ROM loss
O’sullivan pg 4
02.02.04.01.02 Joint mobilization
go through doc made by classmates
open and closed pack positions
● CI’s - cancer, acute arthritis, fracture, dislocation, bone disease, inflammation,
empty/bony end feel, anticoagulant/steroid use, sign of ze BUTT, vertebral
artery insufficiency, CV lig instability
Jason Shane and Amanda Mrsic Apr 2015
02.02.04.01.03 Joint manipulation
● CI’s - fracture, jt instability, inflammation, inflamm jt disease, bone disease,
open wound, poor circulation, sensory deficit in area, spasm or incrd pain with
a test pull (pre manip hold), unsure gen health/diagnosis, anti-coag,
hemophiliacs, can’t relax
02.02.04.01.04 Soft tissue techniques (e.g., massage, friction, stretching)
Friction - CI: ossification, infection, skin breakdown, inflam skin/jt disease
Stretching - CI: acute inflam/infection, unhealed fracture, jt effusion, recent
corticosteroid injection to the involved tissue, in the direction of hypermobility,
specific to certain surgeries ex-hip replacement
PNF Stretching = the use of inhibition techniques to assist mm elongation; when the
stretch reflex is activated in a mm being recruited, the mm on the opp side is
inhibited
massage:
● CI’s - autoimmune diseases during flare ups, fever, haemorrhage, flu, migraine
headache, serious psych diagnosis, recent surgery, acute RA, sickle cell
disease
● relative CI’s (DOC Clearance) - cancer, stroke, bleed disorders, CHF, HTN,
kidney stones
02.02.04.01.05 Fitness/conditioning/endurance exercise programs
02.02.04.01.06 Functional activity training
02.02.04.01.07 Posture training
02.02.04.01.08 Positioning
02.02.04.01.09 Gait/mobility education and training with or without equipment
Jason Shane and Amanda Mrsic Apr 2015
-
Cane - widen base of support, help balance,
Quad cane - not that good for stairs
Crutches - help with lateral stability and improve balance
Forearm crutches - allows for use of hands, but need more arm strength to use
NORMAL GAIT: stance 60%, swing 40%
4 POINT GAIT
- 3 points of support on ground at all times; 1 aid advanced, then opposite LE
advanced, can be done with CRUTCHES OR CANES, slow stable gait
2 POINT GAIT
similar to 4 point only 2 points of contact maintained at all times, less stable,
req better balance CRUTCHES OR CANES
- one leg and contralateral aid advance at same time (ex R cane and L leg
together, then L cane and R leg together
3 POINT GAIT
- 3 points of support on floor, NWB, PWB (<80% can’t use CANE), FeWB on
affected LE
- pt1) affected LE advanced, pt2) wt transferred to floor through aid (both
crutches at the same time or walker), pt3) unaffected leg advanced, and wt
returned to unaffected leg
STEP TO, or STEP THROUGH, can be done with CRUTCHES OR WALKER
02.02.04.01.10 Neurodynamic techniques (e.g., nerve gliding/flossing
exercises)
Jason Shane and Amanda Mrsic Apr 2015
●
●
●
nerve gliding/flossing - do not Ax or treat in presence of CNS signs: myotomes,
dermatomes, reflexes
peripheral N conduction signs: Ax but don’t treat
don’t treat if worsening or undiagnosed symptoms
KEEP READING, THERE’S GOOD STUFF BELOW, COLLEGE GUIDELINES...
LIST OF FUNCTIONS EVALUATED BY THE PCE (continued)
(This list is not necessarily exhaustive.)
02.02.04.01.11 Balance training/proprioceptive training
Balance = ability to maintain COG over base of support; 3 things necessary for
balance are visual, vestibular, proprioception
Proprioception = sensations of jt mvmt (kinesthesia), and joint position
02.02.04.01.12 Sensory training (e.g., desensitization, protective education, sensory
integration)
02.02.04.01.13 Techniques to optimize oxygen transport and facilitate airway
clearance (e.g., positioning, suctioning, secretion clearance, forced expiratory
techniques)
●
Auscultation - know 6 points antrly and 10 points postrly
02.02.04.01.14 Mechanical agents (e.g., traction, continuous passive
movement, compression garment and devices, vasopneumatic devices)
● Traction - incrd IVF diameter, pain inhibition, decreased mm spasm, mm
stretching; Indications-nerve root compression, disc pathology, degeneration, jt
dsfx, hypomobility, pain;
● CI-fracture, infection/inflam, pain with manual traction, signif trauma w/o xrays,
SCI signs and Sy’s
02.02.04.01.15 Conductive thermal agents (e.g., contrast baths, whirlpools, paraffin
wax, hot packs, ice/cold)
02.02.04.01.16 Electrical agents (e.g., EMG biofeedback, iontophoresis,
transcutaneous electrical nerve stimulation [TENS], neuromuscular electrical nerve
stimulation [NMES], interferential current [IFC], high voltage pulsed current [HVPC])
02.02.04.01.17 Electromagnetic energy agents (e.g., shortwave diathermy, LASER,
ultraviolet)
02.02.04.01.18 Acoustic agents (e.g., ultrasound)
02.02.04.01.19 Protective, adaptive, or assistive devices (e.g., tape, splints,
orthotics, prostheses)
02.02.04.02 Recognize and respond to the adverse effects of intervention (e.g., pain,
deterioration in client status) and/or non-adherence
Jason Shane and Amanda Mrsic Apr 2015
Education/Communication/Advocacy
02.02.05.01 Communicate the purpose and results of physiotherapy
evaluation/assessment, proposed treatment procedures, expected outcomes and
progress to client, family, and healthcare and other service providers and verify their
understanding of same
02.02.05.02 Use teaching and communication strategies with clients and family
members that respect culture, learning, communication, language style, and abilities
02.02.05.03 Educate client, family, and healthcare and other service providers in
safe and effective physiotherapy techniques and use and care of equipment as
appropriate
02.02.05.04 Educate the client, family/significant others about the condition, selfmanagement, coping and prevention strategies
02.02.05.05 Educate client regarding credibility of external educational
materials/resources
02.02.05.06 Assist, and where necessary advocate on behalf of, client in obtaining
access to necessary services, funding, equipment, and treatment within the
continuum of care
02.02.05.07 Educate client, family, and healthcare and other service providers about
transitions (e.g., change in level of care, care provider or care funder), other
services, and discharge plans
Intervention Progression
02.02.06.01 Assess client satisfaction and response to treatment with appropriate
outcome measures and benchmarks
02.02.06.02 Perform re-evaluations/re-assessments at appropriate intervals or
based on changes in client status as appropriate
02.02.06.03 Adjust, revise, or discontinue treatment plan when goals are achieved,
client’s status changes, or treatment is no longer effective
LIST OF FUNCTIONS EVALUATED BY THE PCE (continued)
(This list is not necessarily exhaustive.)
02.03 PROFESSIONAL RESPONSIBILITIES (15%±5%)
Professional Accountability
02.03.01.01 Respect the knowledge, rights, confidentiality, and dignity of client and
family
02.03.01.02 Adhere to professional and regulatory codes of ethics/conduct and
standards of practice
02.03.01.03 Participate in processes that evaluate and improve quality and
outcomes of services
Jason Shane and Amanda Mrsic Apr 2015
Communication and Collaboration
02.03.02.01 Secure informed consent for evaluation/assessment and treatment
02.03.02.02 Participate in collaborative health care service delivery (e.g., rounds,
specialty care clinics or meetings)
02.03.02.03 Consult and collaborate with healthcare and other service providers to
ensure services to clients are coordinated and client’s needs are met
Professional Judgment and Reasoning
02.03.03.01 Recognize and practice within the scope and limitations of self and
profession
02.03.03.02 Demonstrate continuing competence (e.g., reflective practice, selfdirected learning)
Practice Management
02.03.04.01 Document all relevant aspects of care including client
evaluation/assessment, treatment plan, progress notes and discharge plan
02.03.04.02 Adhere to federal and provincial laws regarding storage, protection,
disclosure of information, business practices, etc.
02.03.04.03 Assign tasks, guide, and supervise activities of support personnel
as needed
Yah, we went there, we actually went the the College’s website to find this!!!!
CPTBC Practice Standard No 3. Assignment of Task to a Physical Therapist Support
ASSIGNMENT OF TASK TO A PHYSICAL THERAPIST SUPPORT WORKER
Assignment of Task: Transfer of a component of a physical therapy treatment plan to a
physical therapist support worker (PTSW).
Physical Therapist Support Worker: an individual who works under the direction and
supervision of a physical therapist.
Supervision: the means by which the physical therapist monitors the performance of
the PTSW.
An individual who does not work under the direction and supervision of a physical
therapist is not considered a PTSW.
1. The physical therapist must obtain informed consent from each patient for the
involvement of a PTSW in the delivery of their physical therapy treatment plan. PTSW
must be made aware that patient consent can be revoked at any time.
2. The physical therapist must explain to each patient the relationship between the
physical therapist and the PTSW for the purpose of clarifying the difference in roles
and responsibilities as they relate to patient assessment and treatment.
3. The physical therapist must ensure the PTSW is competent (has the knowledge,
skills and abilities) to carry out the assigned tasks.
4. The physical therapist is responsible for the physical therapy task(s) assigned to the
PTSW.
5. The assigned task must be recorded in the clinical record in accordance with the
Practice Standard on Clinical Records.
6. To determine the appropriate level of supervision the physical therapist must
exercise clinical judgment. The following factors should be considered:
Jason Shane and Amanda Mrsic Apr 2015
• Patient preference, practice setting, complexity of the assigned task and
environment, competencies of the PTSW, acuity of the patient’s condition, degree of
judgment and decision making required to carry out the task, level of risk associated
with the task, and patient’s cognitive status.
7. Assigned tasks must be within the physical therapist’s level of competence and be
within the physical therapy scope of practice.
8. The physical therapist must ensure that the PTSW has been instructed in standard
infection control measures CPTBC Practice Standard No 3. Assignment of Task to a
Physical Therapist Support Worker
9. The physical therapist must ensure that the PTSW is aware of patient confidentiality
standards and College Bylaws
10. The physical therapist must be available for consultation. If unavailable, the
physical therapist must arrange for transfer of supervision to another physical
therapist.
11. The physical therapist must instruct the PTSW to recognize any adverse treatment
reactions, cease treatment and immediately report to the supervising physical
therapist.
12. The physical therapist must reassess the patient at timely intervals.
13. The physical therapist must make any changes to the treatment plan and record
the changes in the clinical record.
14. Physical therapists must NOT assign any physical therapy task which has an
evaluation component that immediately influences the treatment program. A physical
therapist must not assign the following tasks to PTSW:
• Interpretation of referrals, diagnosis, or prognosis
• Performance of assessment/evaluative procedures
• Interpretation of assessment findings
• Discussion of physical therapy diagnosis or treatment rationale with anyone other
than the physical therapist
• Planning or initiating physical therapy treatment goals or programs
• Tasks requiring a physical therapist’s clinical judgment
• Modification of treatment beyond established limits
• Completion of documentation that is the physical therapist’s responsibility
• Electro-physical agents (except neuromuscular stimulation or TENS)
• Teaching of the assigned task to another person
• Discharge planning
02.03.04.04 Procure and maintain safe and effective equipment
02.03.04.05 Ensure client safety in all aspects of assessment/evaluation and
intervention
02.03.04.06 Use routine precautions for infection control in all aspects of client
interaction
02.03.04.07 Manage and administer physiotherapy practice using ethical business
Jason Shane and Amanda Mrsic Apr 2015
practices
02.03.04.08 Establish and manage a transparent prioritization process when
demand exceeds ability to deliver services
EXTRAS:
Sign of the Buttock:
- RONFISS; Rheumatic fever, Osteomyelitis, Neoplasm, Fracture, Ischiorectal abscess,
Septic bursitis, Septic arthritis
Synovium = Oct 18th
- lines inner surfaces of joints, prod synovial fluid, lines tendons and form sheaths, forms
bursae
- injury = contusion or compression, friction or stress
Intervertebral disc
- annulus fibrosus = outer layer vascular and nerves ; nucleus pulposus = inside jelly
- degen disc disease P due to facet jt compress, pain on N root, injury to annulus and to
end plates
Cartilage:
- hyaline: between joints ;
- elastic: resp system and ear;
- fibrocartilage: meniscus (even force distribution)
- insertion cartilage: tendons and ligaments
- heal by repair of adj cells from synovium and labrum
Imaging:
X-rays: penetrates soft tissue, doesn’t penetrate bone
X-ray arthrogram: dye injected into jt to see it
Fluoroscopy: live action x-ray
CT: 2D x rays made into 3D by the computer
MRI: magnets used to align and alter the H nuclei in water: detects change in magnetic field
Bone scan: detect BMD, and check for mets, fractures, infections
Ultrasound: soft tissues – LIKE THE BABIES!!!!!!
Floroquinolones: broad spec antibiotics for COPD, pneumonia, GU infections: inc risk of
tendon ruptures (and corticosteroids)
Osteomyleitis: infection of bone: get it with sepsis, open trauma, infected surgical implant;
children at highest risk
Effects of Aging:
Jason Shane and Amanda Mrsic Apr 2015
Sarcopenia: reduction and mm mass and function
Tendons: less metabolic active, more wear and tear, more cross linking, less of strength at
enthesis; Achilles and supraspinatus most prone to injury with age
IMMOBILIZATION:
Effects of bed rest on mm: dec mito, dec red blood supply, fat infiltration, dec strength, atrophy
and contractures
Bones: osteopenia
Ten and lig: disorganization of parallel arrays and less strong
Cartilage: loss of thickness; synovium: adhesions form between synovium and cartilage;
Synovium: inflamed, fatty infiltration; less jt fluid production
Patellar dislocation: due to tight lat retinaculum, weak VMO, direct blow
Ganglion: pocket of synovial fluid
Contracture: shortening of soft tissue: ex dupuytren's
Adhesion: abnormal adherence of collagen fibers
Reflex mm guarding: myofascial trigger points, Pain mm guard around it
Intrinsic mm spasm: prolonged contraction of mm in resp to circulatory and metabolic changes
and it is contracted
Myofacial compartment syndrome: fascia too small to accommodate for mm growth, can
cause mm necrosis
Rhabdomyolosis: mm compressed and starts breaking down, myoglobin accumulates and
backs up in the kidneys, can get kidney failure
Protein balance for mm: contact and stretch release MGF mm growth factor, take steroids; GH,
testosterone, IGF-1; cortisol = breaks down mm,
Mm training: increased cross sectional area, dec fat, inc angle of pennation, resistance training:
dec number of mitochondria (mito used or endurance energyt prod), more caps, more type 2
mm fibres
Satellite cell: mm stem cell; on the periphery, activated by exercise and trauma, and can
completely regenerate mm myofibres
Tenocytes: get more collagen – align into rays, progenitor cells: repair of tendon
Pacinian corpuscles: strength, tension, in jt capsule and free N endings
EIMD: how long, magnitude and vel of strain affect EIMD; age, gender affect it too;
ECCENTRIC
DOMS: peak 48hrs after, not correlated with markers of mm damage
Repeated bout effect: adaptation of mm after eccentric EIMD, after 2nd bout indirect markers of
Jason Shane and Amanda Mrsic Apr 2015
mm damage are reduced
MO: bone formation in the mm; same as HO (neuro)
Deformation curve, toe, linear, elastic, deformation
Types of Collagen:
Collagen type 1 = tendon, end scar strongest
Collagen type 2 = hyaline cartilage
Collagen type 3 = granulation tissue, scar
Achilles rupture; 35, 70, risks: age BMI, sport, male
Jumper’s knee: patellar tendon tendinopathy, lots in kids
Tennis elbow: lat epicondylitis, ECRB
Golfer’s elbow: med epicondylitis
Tib post tendinopathy: compressed under med mal, if hyperpronate can irritate
BONES:
TYPES: flat, tubular, irregular (vertebral bones), sesamoid bones (develop in tendons),
supernumerary (centre of talus – os trigonum)
Osteomalacia – defect in mineralization of collagen matrix – Vit d deficiency (rickets - kids)
Paget’s disease: 2nd most common bone disease., excessive osteoclast, abnormal
regeneration
Ostopetrosis: v rare, inherited, deficiency of carbonic anhydrase, body inability to resorb bone
Osteochondrosis: disorders of epiphyseal growth plates
Kohlers disease: avascular necrosis of navicular
Osgood schlatter's: irritation to tibial tuberosity, or pull bone off
Legg-Calve-Perth: necrosis of femoral head – put in adduction
Osteochondritis dissecans: subchondral necrosis of bone followed by recalcification, bone
and cartilage can pull away
Salter Harris fracture: fracture of the growth plate
Congenital hip dysplasia: malformation of the hip present at birth; hip dislocation, asymm leg
positions
Marfans: lack of fibrillin , long hands, genetic
Larsen syndrome: prominent forehead and wide spaced eyes, genetic disorder, multiple jt
dislocations
Osteogenesis imperfecta: brittle bone disease
Achondroplasia: dwarfism, impaired cartilage formation and effects growth factor for bones
growing.
Multiple epiphyseal dysplasia: cluster of disorders affect epiphyseal growth plates, short
stature and limbs
Acromegaly: overactive pituitary gland
Fibrillation: loss of normal smooth surface, rough edges into tiny fibrils
SCOLIOSIS:
Jason Shane and Amanda Mrsic Apr 2015
3 kinds: 1) Idiopathic, 2) Congenital, 3) Neuromuscular; can be structural or functional
Rx: Education, bracing, stretching, strengthening, postur
Scoliosis Kisner Colby...page 396/7...
Scoliosis usually involves the thoracic and lumbar regions. Typically, in right-handed individuals,
there is a mild right thoracic, left lumbar S-curve, or a mild left thoracolumbar C-curve. There
may be asymmetry in the hips, pelvis, and lower extremities. Structural scoliosis involves an
irreversible lateral curvature with fixed rotation of the vertebrae (Fig. 14.13A).
Rotation of the vertebral bodies is toward the convexity of the curve. In the thoracic spine, the
ribs rotate with the vertebrae so there is prominence of the ribs posteriorly on the side of the
spinal convexity and prominence anteriorly on the side of the concavity.
ECG’s, what is the issue with three PVC’s in a row=>Ventricular tachycardia=>which can b/co
ventricular fibrillation, VERY BAD! Prob that the atria are not contracting because no wave
Cyanosis = bluish discoloration of skin and nailbeds of fingers and toes alont with cold and
moist palms; caused by excess deoxygenated hemoglobin in the blood
Apraxia = disorder of the brain and nervous system that is a person is unable to perform tasks
and movements when asked
● Verbal apraxia-inability to produce motor patterns resulting in speech; in the absence of
●
●
●
impaired understanding , mm paralysis/ weakness or intellect
Ideational apraxia: Cannot carry out learned complex tasks in the proper order, such as
putting on socks before putting on shoes due to mis-identification
motor apraxia= disorder of voluntary movement notwithstanding the in absence of paralysis
or mm weakness
constructional apraxia - unable to draw objects in absence of paralysis
Astereognosis (tactile agnosia) = inability to identify held objects in the absence of language or
sensory loss
Right brain is dominant for body awareness
Anosognosia = a lack of awareness or a denial of a neurologic defect or illness in general, especially
paralysis, on one side of the body (like a limb). It may be attributable to a lesion in the right parietal lobe.
Somatognosia= Inability to correctly identify or orient the parts of one's body or the body of another.
Expressive aphasia=Broca’s
Receptive aphasia=Wernicke’s
CEREBELLAR:
cerebellar ataxia - jerky inaccurate, uncoordinated movement, w/ normal strength and no
hypertonia
Jason Shane and Amanda Mrsic Apr 2015
dysmetria = overshoot the intended goal
dysarthria - trouble with speaking, slurred due to lack of motor coordination
intention tremor - tremor when initiate movement
dysdiadochokinesia - inability to perform rapid alternating movements
NON CEREBELLAR:
athetosis - slow continuous involuntary movements
chorrea - rapid repeated jerky coarse movements
dystonia - frequent maintained contraction of hypertonic mm
hemiballismus - sudden stabbing movements of one side of the body
fasciculation - twitching of mm fibers in single motor neuron unit (often visible on surface, occur
with LMNL)
fibrillation - abnormal contraction of a single mm, only visible with EMG, and seen with dying
neurons
Huntington’s chorea = genetic disorder with writhing (choreoform) movements including limbs,
speech (sound drunk) due to loss of neurotransmitters and GABA
Korsokoff’s syndrome = genetic metabolic injury due to malnutrition or alcoholism, can’t make
new memories, characterized by confabulation
spastic hypertonia (spasticity) - velocity dependent increase in resistance to passive movement
rigid hypertonia - velocity INDEPENDENT increase resistance to passive movement
Metabolic syndrome = pre cursor to Type 2 diabetes, abdominal obesity, high triglycerides,
low HDL’s, HTN, high fasting plasma glucose
Glaucoma =loss of peripheral vision first, followed by central blindness
Cataracts =a clouding of the lens, gradual loss of vision, central vision is lost first, then
peripheral
Resistance exercise is CONTRAINDICATED in Pts with signif: Bony mets, osteoporosis, low
platelet count (<20,000)
***********************
CARDIORESP
Types of breathing:
● breath stacking: stacking little breaths on top of one another when a deep breath is too
painful
● active cycle of breathing: diaphragmatic breaths with a hold at the top, then to normal
Jason Shane and Amanda Mrsic Apr 2015
●
●
●
●
●
breathing, repeat cycle then 3 huffs
autogenic drainage: use breathing to clear secretions
flutter: breath out thru device, vibrations from device will loosen secretions
diaphragmatic breathing: post op, obstructive or restrictive
segmental breathing: improved vent to hypo-ventilated lung areas
pursed lip breathing: help blow off CO2, inc tidal vol, red resp rate, red dyspnea; for
COPD
BREATH SOUNDS: p20 reid and cheung
● bronchial breath sounds: hollow, high pitched, harsh: consolidated pneumonia or lobar
collapse
● normal: soft and low pitched
● decreased or absent: pleural effusion, hemothorax, pneumothorax, emphysema, obese
or elderly
● crackles: fine: atelectasis, interstitial pulmonary fibrosis;
coarse: retained secretions
● wheezes: asthma, COPD
will have inc FRC: vol of air remaining in lungs at end of ordinary expir with age
p38 R&C
ABG’s p178 O’ Sullivan
normal range
pH7.35-7.45
- lower: resp or metabolic acidosis; high: metabolic or resp alkalosis
PaCO2 35-45mmHG
high = resp acidosis (from hypoventilation - COPD, flail chest, neuromuscular disorders,
sleep apnea): help with secretion clearance
- low = resp alkalosis (hyperventilation, pain or anxiety or breathlessness); mechanical
vent
PaO2 80-100mmHG
HCO3 22-28
- decreased: metabolic acidosis;
- increased: metabolic alkalosis
●
●
●
●
resp compensation mins to hours
renal compensation is 1-5 days
metabolic acidosis: renal failure, lactic acidosis, ketoacidosis
metabolic alkalosis: sodium base overload, potassium depletion, vomiting
HAEMODYNAMICS:
WBC low: lethargic, bruise easy
Hb 85-110: put on iron; below 85 = transfusion
- low: fatigue, dizzy, headache, lack of concentration
Jason Shane and Amanda Mrsic Apr 2015
platelets: low = thrombocytopenia, get lots of bruising, and get small bleeds; Normal platelet
count is 150-450,000/uL of blood
IRN: looks at coagulation and clotting time of blood low levels: will have restricted activity or
bed rest
potassium: reg mm tissue, digestion and metabolism low: hypokalemia- weak, fatigue, vomit,
nausea; high: hyperkalemia - min symptoms
sodium: reg blood vol, blood pressure, osmotic equlib, pH
- low; hyponatremia: headaches, confusion, mm spasm, seizures
- high; hypernatremia: S&S of dehydration
magnesium:
- high: hypermagnesemia- nausea, vom, mm weakness
- low: mag deficiency - mm cramps, hyperactive reflexes, tremors and overall weakness
calcium:
- low: hypocalcemia, prolonged QTwave
- high - kidney stones, groans, bones (risk of #) thrones: diarrhea, psyc overtones
*****************
LINES:
PICC - peripherally inserted central catheter: treatments such as chemo or antibiotics, samples
of blood, no freq needles; have to wait to mobilize until PICC insertion cleared by x-ray, close off
before shower or hydrotherapy
Central venous line: sits at vena cava: monitors R atrial pressure, venous tone and circ blood
vol., central venous pressure normal = 5-12
gtube = facial trauma - tube for feeding, turn feed off before PT treatment
arterial line: measure BP, blood sampling for ABG’s, admin meds
pulmonary arterial line: vena cava into R atrium, pulm art or pulm cap: measure pulm art
pressure, pulmonary capillary wedge pressure (L art pressure), right atrial pressure, CO
MORE DEFINITIONS:
TPN: total parenteral nutrition, amino acids and lipids
lumbar drain: drains CSF
continuous bladder irrigation: continuous flow of fluid, prevents obstruction and cleaning, bag
higher than bladder
hemodialysis: removes wastes and extra fluid in blood and returns clean blood to patient: renal
insufficiency and get rid of antibodies in plasma
intracranial pressure ICP: 10-15mmHg
infarction: necrosis develops distal to occlusion of an artery
embolism: passage of any material capable of getting lodged in a blood blood vessel
pulmonary infarctions: death of lung tissue S&S: SOB, chest pain,
edema: presence of excess fluid in interstitial space; anasarca: total body edema
effusion: excess fluid in body cavities
transudate: low in proteins
exudate: high in protein
Jason Shane and Amanda Mrsic Apr 2015
***********
OUTCOME MEASURES:
- Kurtzke Expanded Disability Scale: for MS
- Expanded Disability Status Scale (EDSS): MS
- Oswestry Disability Index: lower back pain
- Hoehn and Yahr Classification of Disability: Parkinson’s
- Unified Parkinson’s Disease Rating Scale (UPDRS): Parkinson’s
- Disability Rating Scale (DRS): Traumatic Brain Injury
-
-
-
Fugl-Meyer Motor strength test: stroke
Stroke Impact Scale (SIS): evaluates how stroke has impacted health and life from Pt’s
perspective; a questionnaire
Rivermead mobility index: functional mobility following stroke
The Community Balance and Mobility Scale: detect “high” level balance and mobility
deficits
The Dynamic Gait Index: Assesses individual’s ability to modify balance while walking in
the presence of external demands
The Functional Independence Measure: measures the level of a patient's disability and
indicates how much assistance is required for the individual to carry out activities of daily
living.
Barthel scale or Barthel ADL index is an ordinal scale used to measure performance
in activities of daily living (ADL)
Knee injury and OA Outcome Scale (KOOS): evaluates s/t and l/t Pt relevant outcomes
of knee injury that can result from post-traumatic OA (ACL injury, meniscus injury)
McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR):
assesses disability in Pts with RA
*********************************
PCE Electro Review
Interferential Current:
- Low voltage, medium intensity
- 2 sinusoidal waves – alternating current
- Each wave = slightly different frequencies and interfere with one another in tissues
creating new wave (linear super-position)
- Series of wave packets (beats)
- Balanced, symmetrical, biphasic, amplitude modulated
- Can output 50-90mA (other machines = much lower) – NO THORACIC APPLICATION
OVER 50mA
- Used for pain, edema, increases blood flow, muscle stimulation
- Motor = 1-10Hz; Sensory (pain) = 80-150Hz
Jason Shane and Amanda Mrsic Apr 2015
-
20-40mins
TENS
- Low voltage, low intensity
- Gate control theory or extrasegmental
Conventional:
o
High frequency (80-150Hz), low pulse duration (60microsec.)
o
Comfortable tingle
o
Acute – analgesic effect only while machine on
o
Electrodes bracket pain
Acupuncture-like:
o
Low frequency (5-10Hz), high pulse duration (200microsec)
o
Motor twitch
o
Chronic pain – 4-6 hours analgesia
o
Electrodes on motor point (want twitch)
LASER
3 features of a laser:
1) Monochromaticity (all photons have a single wavelength),
2) coherence (all photons travel in same phase and direction),
3) collimation (minimal divergence over distance)
- Used to increase tissue healing, decrease pain, decrease inflammation (wound
management)
- Choose laser head based on depth of lesion (red-near infrared = 1-5mm; near-mid
infrared = 5-10mm)
Dose: acute = 2J/per point; chronic = 4 J/per point (look at WALT)
- Frequency: acute = <1000kHz; chronic = >1000kHz
- Continuous or pulsed (laser lasts longer)
- Contact or noncontact (scanning/grid)
- Wear eyewear
Heat:
- 2 fibers for perception of thermal sensation (warmth and heat (>45deg. C)
- Major source of heat gain = metabolism (also absorption of radiation from environment,
etc.)
- Heat loss major source = radiation (also exhalation, evap. of sweat, urine)
- Thermoregulation is controlled by the hypothalamus
- As you get hotter, metabolism increases – Van Hoft (in body temperature >45C = protein
damage)
- Therapeutic effects of superficial tissue heating: tissue healing, pain relief, reduction
of muscle spasm, sedative effect, increased joint ROM, facilitates fine movements
- Paraffin wax baths – 6-8layers, 15minutes (contraindications – skin infections or acute
inflammation of underlying joints should not receive wax; dermatitis can get worse
Contrast bath (hot then cold then hot) – produces blood flow to tissues – good sensory
Jason Shane and Amanda Mrsic Apr 2015
-
stimulation (no evidence of reduction of local edema) – treatment starts and ends with
immersion in hot water – hot = 3-4mins, cold = 1min (repeat 3-4X)
Whirlpool – gating effect – stimulation of moving water – may gently debride wounds
(may sometimes increase edema – dependent position?)
Superficial heat precautions – local burns, altered thermal sensation, ischemic
disease restricting local circulation, DM, PVD, altered heat loss mechanism (ex: obesity),
fungus, exacerbation of dermatitis or eczema, malignancies, open wounds)
COLD
- Cooling reduces metabolic rate – enhances survival of vulnerable cells that have
survived the initial injury – reduces edema (allows vulnerable cells to remain closer to
O2 supply), reduces sharp pain (blocks nerve conduction) – little value for chronic pain
(doesn’t affect those fibers)
- Mild cooling can increase isometric strength, but greater cooling can reduce this
strength, cooling reduces tremor, can reverse conduction block associated with
demyelination of peripheral nerves (heating exacerbates it) – ex: MS
- Therapeutic uses: recent injuries, pain, muscle spasm, spasticity, muscle
strengthening, chronic inflammatory conditions, chronic edema
- Check for allergic reaction to cold after 1 minute and after 5 minutes
- Dangers/contraindications: ice burn, peripheral nerve damage, frostbite, reduced
peripheral blood supply (can further damage tissue), cold sensitivity (Raynaud's, cold
urticaria)
UV
-
Contraindications = photosensitivity, skin cancer, and CT disorder (be aware of drugs
causing photosensitivity)
Used to treat: psoriasis, eczema, vitiligo, pruritus (secondary to liver/kidney disease),
acne, photodermatoses, wound healing, atopic dermatitis
On eyes can cause conjunctivitis or photokeratitis (inflammation of cornea) – cataracts
are caused by chronic exposure to UV
HVPC
- High voltage, high peak intensity, low average intensity
- Monophasic (can build up a bigger net charge)
- Frequency = 1-200Hz, pulse width fixed (5-65microsec.), peak current is high (higher
risk of burning), but long interpulse interval so charge has a chance to dissipate allowing
safer application (total current is very low)
- Mainly used for: decreased pain, decreased edema, increased wound healing,
muscle stim. (enhances oxygenation, blood flow and tissue formation)
- High voltage = more comfortable and large punch = better at punching away or bringing
in molecules
- Wound healing = 50-100Hz (submotor), edema reduction = 5-20Hz (want twitch), muscle
stim = 35-65Hz, pain = same parameters as TENS
- Galvanotaxis – can repel molecules or attract desired cells based on polarity
Jason Shane and Amanda Mrsic Apr 2015
-
Don’t use for inflammation (don’t want to add energy to injury)
For acute edema – active red on edema and set it as negative to push away positive
proteins OR put it on muscle twitch on motor point and nerve trunk (chronic)
Wound healing – one electrode in wound and one 10-20cm away
Phonophoresis and Iontophoresis
Phonophoresis (don’t need to know) - using US to enhance delivery of topically applied drugs
– avoid risks of IV, reduce risk of OD, local Rx, easy method to terminate and bypass liver
● Primary uses: decrease tissue inflammation, reduce pain
● 3 common meds – local anesthetics, anti-inflammatories, counter-irritants
Iontophoresis – method of Rx using current flow between two electrodes to push ions through
the skin barrier
● Current is direct current
● Positively charged drug can be made to cross the skin away from positive electrode
● Under the anode may get an acidic reaction (hardening of skin over time (sclerotic) and
under cathode may get alkaline reaction (softening and burning of skin) – but most
electrodes have buffering agents to prevent this
● Keep the cathode larger (current density is therefore lower and skin is less likely to burn)
● Used for: hyperhidrosis, MSK inflammatory disorders, plantar fasciitis, TMJ
disorders, ischemic skin ulcer, fungal infections, bursitis and tendonitis
● Contraindications include over damaged skin or open lesions, allergy to therapeutic ions,
impaired sensation, over electric implants
Short Wave Diathermy
● Therapeutically heat body tissues at any depth
● 2 types of electromagnetic fields producing the heat (electrostatic and electromagnetic) –
thermal and non-thermal effects
● Physiological effects of pulsed SWD: increased tissue healing, enhance nerve
regeneration, pressure ulcers, chronic low back pain, soft tissue injuries (some
evidence it can be used for pain, muscle spasm, chronic inflammation, delayed wound
healing, chronic infection)
● 2 main indications for application = OA and ankle sprain
● Main contraindications = metallic implants and pacemakers (implanted devices)
● Can get burns (unequal spacing, perspiration, etc.) – patient should just feel mild,
comfortable warmth
EMG Biofeedback:
● Nerve conduction testing – estimates velocity of depolarization along an alpha motor
neuron
● In skeletal muscle, normally silent at rest (short burst of electrical activity during needle
insertion)
● reduced insertional activity seen in fibrotic or severely atrophied muscle (when put
needle in), -increased activity when a muscle is irritable
Jason Shane and Amanda Mrsic Apr 2015
●
●
●
●
Abnormal electrical activity at rest suggests neuropathy or myopathy and is indicated by
fibrillation potentials (rapid, irregular contractions of muscles), positive sharp waves, or
fasciculation potentials
Surface EMG – provides information about muscle activity (in order to uptrain or
downtrain activity)
Used to: improve control over defective muscles or improve control over stressed
muscles (ex: hemiplegia, SCI, spasticity, dystonia, recovering peripheral nerve injuries)
Used as a tool not a treatment
NMES:
● The use of electrical stimulation to generate an action potential in a nerve leading to
contraction of skeletal muscle - Pulsed and biphasic
● Used for: pain modulation, edema management, decrease spasticity, muscle
strengthening
● Parameters: pain = same as TENS – intensity can be turned up to sensory or motor
threshold, edema = same as HVPC – intensity to muscle twitch, muscle stim and
spasticity = 35-65Hz – intensity to tetany
● On:off time set based on muscle grade of strength – grade 5 muscle strength = 1:1 and
grade 1 = 1:5
● Electrode placement – anode = nerve trunk (or muscle belly), cathode = motor point (or
muscle belly) – can surf cathode to get the right spot (1/3 proximal, 2/3 distal for motor
point)
● Side effects: rhabdomyelosis, ischemic colitis, inappropriate ICD discharge
● 12-15 contractions per session
Ultrasound:
● Sound waves
● Maintain contact and keep head moving and perpendicular to tissue
● Parameters: frequency 1MHz (deep) and 3MHz (superficial); intensity (0.5 acute and 2 =
high for chronic while 1-1.2 = moderate for chronic), pulsed (acute) and continuous
(chronic); acute = 5-10mins, chronic = 20 minutes
● Apply to area not larger than 2-2.5xERA (ERA = area producing 5% or more of max.
power output – higher = better) ● Used for – thermal effects: decreased pain, decreased joint stiffness, improved
blood flow, promote healing (decreases inflammation) and non-thermal effects:
wound healing, inflammation and soft tissue healing
● Contraindications: implantable devices, malignancy, bleeding disorder, infection, DVT,
don’t use on Medtronic stimulation system
Functional Electrical Stimulation
● Used for: treatment of disuse atrophy, increasing ROM, re-educating muscle,
managing spasticity, gait orthoses, improving motor recruitment, increasing
muscle endurance, re-educating gait
● Individuals with CNS condition benefit from this – stroke, MS, SCI, CP, PD, TBI and
Jason Shane and Amanda Mrsic Apr 2015
●
●
orthopedic conditions or conditions resulting from deconditioning
Individuals who cannot benefit – LMNL, peripheral nerve lesions, motor neuron disease,
GBS, polio and post-polio syndrome, fixed contractures
Especially used for drop-foot stimulation (reduce fall risk) and improving subluxation of
GH joint
ESTIM CONTRAINDICATIONS
- Areas where it could affect electrical devices (ex: pacemaker)
- Low back/abdomen/acupuncture points of pregnant women
- Areas of malignancy
- Acute hemorrhage
- DVT or thrombophlebitis
- CVA or TIA
- TB
- Osteomyelitis
- Chest if cardiac issues
- Neck/head region in people with seizures
- Damaged/at risk skin areas
- Infection
- Recently radiated areas
- Impaired sensory awareness
- Acute inflammation
- Trans-thoracically or trans-cerebrally
- Cognition impairments
- NMES contraindicated to chest, intercostals, and lower abdomen
****
NERVES
Common Peroneal branches:
Common peroneal in popliteal fossa:
- Sensory: Superficial peroneal
- Motor: Peroneus brevis, Peroneus longus,
Cutaneous sensory:
- Lower leg: Anterolateral
- Foot: Dorsum of foot and big toe
- Medial & Intermediate dorsal cutaneous nerves of foot
Deep peroneal
- Motor branches in leg: Tibialis anterior, Extensor hallucis & Extensor digitorum longus,
Peroneus tertius
Lateral terminal branch in foot: Extensor digitorum brevis
Jason Shane and Amanda Mrsic Apr 2015
Tibial nerve:
● branch of the sciatic nerve, passes through the popliteal fossa to pass below the arch of
soleus.
● In the popliteal fossa the nerve gives off branches to:
○ motor = gastrocnemius, popliteus, soleus and plantaris muscles
○ cutaneous = becomes the sural nerve (distal branch of the tibial nerve and
supplies the back of the leg and lateral side of the foot and little toe)
- Below the soleus muscle the nerve lies close to the tibia and supplies the:
● motor = tibialis posterior, the flexor digitorum longus and the flexor hallucis
longus.
- In the foot it divides into the:
1) Medial plantar (calcaneal) nerve
● cutaneous: supplies the heel and medial sole of the foot
● motor: abductor hallucis, the flexor digitorum brevis, the flexor
hallucis brevis
2) Lateral plantar nerve
● cutaneous: to the lateral sole and lateral one and one half toes
(like the ulnar nerve).
● motor: quadratus plantae, flexor digiti minimi, adductor hallucis,
the interossei, three lumbricals. and abductor digiti minimi.
LUMBAR PLEXUS - draw out
If I Get Laid F*** Off Sex (Hey, kids may be reading this ;)
Jason Shane and Amanda Mrsic Apr 2015
Nerve
Segment
Innervated muscles
Cutaneous
branches
Iliohypogastric
T12-L1
• Transversus abdominis
• Abdominal internal
oblique
• Anterior
cutaneous ramus
• Lateral cutaneous
ramus
Ilioinguinal
L1
Genitofemoral
L1, L2
Lateral femoral cutaneous
L2, L3
Obturator
L2-L4
• Obturator externus
(ADduct thigh, LAT rotate)
• Adductor longus
• Adductor brevis
• Gracilis
• Pectineus
• Adductor magnus
• Cutaneous ramus
Femoral
L2-L4
• Iliopsoas
• Pectineus
• Sartorius
• Anterior
cutaneous
branches
• Anterior scrotal
nerves in males
• Anterior labial
nerves in females
• Cremaster in males
• Femoral ramus
• Genital ramus
• Lateral femoral
cutaneous
Jason Shane and Amanda Mrsic Apr 2015
• Quadriceps femoris
Short, direct muscular
branches
• Saphenous
• Psoas major
• Quadratus lumborum
• Iliacus
• Lumbar intertransverse
T12-L4
PES ANSERINE: (medial side of knee)
Sartorius....................Femoral
Gracilis........................Obturator
Bursae = pes anserine burase
semiTendinosus............Tibial
SGT FOT
LUMBO-SACRAL PLEXUS
Nerve
Segment
Innervated muscles
Superior gluteal
L4-S1
Gluteus medius
Gluteus minimus
Tensor fasciae latae
Jason Shane and Amanda Mrsic Apr 2015
Cutaneous branches
Inferior gluteal
L5-S2
Posterior cutaneous
femoral
S1-S3
Gluteus maximus
Posterior cutaneous femoral
• Inferior cluneal nerves
• Perineal branches
Direct branches from
plexus
• Piriformis
S1-2
Piriformis
• Obturator internus
L5-S1
Obturator internus
• Quadratus femoris
L5-S1
Quadratus femoris
L4-S3
Semitendinosus (Tib)
Semimembranosus (Tib)
Biceps femoris
• Long head (Tib)
• Short head (Fib common peroneal)
Adductor magnus (medial part,
Tib)
Sciatic
Sciatic
Tibial L4S3
Common fibular
(peroneal)
Fibular
L4-S2
Lateral sural cutaneous
Communicating fibular
• Superficial fibular
L5-S2
lateral compartment
Peroneus longus (runs post to
lat malleolus)
Peroneus brevis
Medial dorsal cutaneous
Intermediate dorsal cutaneous
• Deep fibular
(peroneal)
L4-S2
anterior compartment and
dorsum of foot
Tibialis anterior
Extensor digitorum longus
Extensor digitorum brevis
Extensor hallucis longus
Extensor hallucis brevis
Peroneus tertius
Lateral cutaneous nerve of big
toe
Intermediate dorsal cutaneous
Tibial nerve
L4-S3
DEEP Posterior compartment
Triceps surae
Plantaris
Popliteus
Tibialis posterior
Flexor digitorum longus
Flexor hallucis longus
Medial sural cutaneous
Lateral calcaneal
Medial calcaneal
Lateral dorsal cutaneous
SUPERFICIAL post
compartment
Gastrocnemius and soleus
Jason Shane and Amanda Mrsic Apr 2015
(S1-2)
• Medial plantar
(from tibial nerve)
Abductor hallucis
Flexor digitorum brevis
Flexor hallucis brevis (medial
head)
Lumbrical (first and second)
Cutaneous to medial plantar
aspect of foot
• Lateral plantar
(from tibial nerve)
Flexor hallucis brevis (lateral
head)
Quadratus plantae
Abductor digiti minimi
Flexor digiti minimi
Lumbrical (third and fourth)
Plantar interossei (first to third)
Dorsal interossei (first to fifth)
Adductor hallucis
Cutaneous to lateral plantar
aspect of foot
Pudendal and
coccygeal
Pudendal
(Pudendal plexus)
S2-S4
Muscles of the pelvic floor:
Levator ani
Superficial transverse perineal
Deep transverse perineal
Bulbospongiosus
Ischiocavernosus
Sphincter anus externus
Urethral sphincter
Coccygeal
(Coccygeal plexus)
S5-Co1
Coccygeus
Jason Shane and Amanda Mrsic Apr 2015
Inferior rectal
Perineal
• Posterior scrotal/labial
• Dorsal penis/clitoris
Anococcygeal
Dorsal branches
sural nerve: formed by the junction of the medial sural cutaneous (from tibial nerve) with the
peroneal anastomotic branch of the lateral sural cutaneous nerve (from common fibular
nerve)
Jason Shane and Amanda Mrsic Apr 2015
BRACHIAL PLEXUS
From
Nerve
Roots[2]
Muscles
Cutaneous
roots
dorsal
scapular
nerve
C5
rhomboid muscles and
levator scapulae
-
Jason Shane and Amanda Mrsic Apr 2015
roots
long thoracic
nerve
C5, C6,C7
serratus anterior
-
upper trunk
nerve to the
subclavius
"C5",C6
subclavius muscle
-
upper trunk
suprascapular
nerve
C5, C6
supraspinatus and
infraspinatus
-
lateral cord
lateral
pectoral nerve
C5, C6,
C7
pectoralis major (by
communicating with the
medial pectoral nerve)
-
lateral cord
(terminal N)
musculocutan
eous nerve
C5, C6,
C7
coracobrachialis,
brachialis and biceps
brachii
becomes the
lateral cutaneous
nerve of the
forearm
lateral cord
lateral root of
the median
nerve
C6, C7
fibres to the median
nerve
-
posterior cord
superior/uppe
r
subscapular
nerve
C5, C6
subscapularis (upper
part)
-
posterior cord
thoracodorsal
nerve(middle
subscapular
nerve)
C6, C7,
C8
latissimus dorsi
-
posterior cord
lower / inferior
subscapular
nerve
C5, C6
subscapularis (lower
part ) and teres major
-
posterior cord
axillary nerve
C5, C6
anterior branch: deltoid
and a small area of
overlying skin
posterior branch: teres
minor and deltoid
muscles
posterior branch
becomes upper
lateral cutaneous
nerve of the arm
posterior cord
(terminal N)
radial nerve
C5, C6,
C7, C8,
T1
triceps brachii,
supinator, anconeus,
the extensor muscles of
the forearm, and
brachioradialis
skin of the
posterior arm as
the posterior
cutaneous nerve
of the arm
medial cord
medial
pectoral nerve
C8, T1
pectoralis major and
pectoralis minor
-
medial cord
medial root of
the median
nerve
C8, T1
fibres to the median
nerve
all flexors of forearm
except FCU, part of
portions of hand
not served by
ulnar or radial
Jason Shane and Amanda Mrsic Apr 2015
FDP,
medial cord
medial
cutaneous
nerve of the
arm
C8, T1
-
front and medial
skin of the arm
medial cord
medial
cutaneous
nerve of the
forearm
C8, T1
-
medial skin of the
forearm
medial cord
(terminal N)
ulnar nerve
C8, T1
flexor carpi ulnaris, the
medial two bellies of
flexor digitorum
profundus, the intrinsic
hand muscles except
the thenar muscles and
the two most lateral
lumbricals
the skin of the
medial side of the
hand and medial
one and a half
fingers on the
palmar side and
medial two and a
half fingers on
the dorsal side
The main portion of the MEDIAN NERVE supplies the following muscles:
Superficial group:
● Pronator teres
● Flexor carpi radialis
● Palmaris longus
Intermediate group:
● Flexor digitorum superficialis muscle
The anterior interosseous branch of the median nerve supplies the following muscles:
Deep group:
● Flexor digitorum profundus (only the lateral half)
● Flexor pollicis longus
● Pronator quadratus
Hand
-
median nerve supplies:1st and 2nd lumbrical muscles, muscles of the thenar eminence by a
recurrent thenar branch.
The rest of the intrinsic muscles of the hand are supplied by the ulnar nerve.
The median nerve innervates the skin of the palmar side of the thumb, the index and middle
finger, half the ring finger, and the nail bed of these fingers.
The lateral part of the palm is supplied by the palmar cutaneous branch of the median nerve,
which leaves the nerve proximal to the wrist creases. This palmar cutaneous branch travels in a
separate fascial groove adjacent to the flexor carpi radialis and then superficial to the flexor
retinaculum. It is therefore spared in carpal tunnel syndrome.
Jason Shane and Amanda Mrsic Apr 2015
-
The muscles of the hand supplied by the median nerve can be remembered using the mnemonic,
"LOAF" for Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis
brevis. (NB: OAF are the thenar eminence)
Jason Shane and Amanda Mrsic Apr 2015
Layers of the Anterior Forearm
All median nerve except FCU and medial half of FDP
1. Superficial
- pronator teres
- flexor carpi radialis
- palmaris longus
- flexor carpi ulnaris (ulnar nerve)
2. Intermediate
- flexor digitorum superficialis (ulnar nerve is medial half)
3. Deep -innervated by ant. interosseous nerve which is branch of median nerve
- pronator quadratus
- flexor digitorum profundus
- flexor pollicis longus
All innervated by RADIAL nerve:
● triceps,
● brachoradialis
All mm listed below are innervated by post interosseous nerve which is a branch of the
radial nerve
- supinator
1. Extend hand (carpi)
- extensor carpi radialis brevis
- extensor carpi radialis longus
- extensor carpi ulnaris
2. Extend medial 4 digits (fingers)
- extensor digitorum
Jason Shane and Amanda Mrsic Apr 2015
- extensor indicis
- extensor digiti minimi
3. Extends thumb (pollex) (snuff box)
- abductor pollicis longus
- extensor pollicis brevis
- extensor pollicis longus
Muscles of Anterior Compartment:
INNERVATED by MEDIAN Nerve except FCU
1. Superficial
- pronator teres
- flexor carpi radialis
- palmaris longus
- flexor carpi ulnaris (INNERVATED BY ULNAR NERVE)
2. Intermediate
- flexor digitorum superficialis
3. Deep
- pronator quadratus
- flexor digitorum profundus 1 and 2
- flexor pollicis longus
thenar eminence (OAF): opponens pollicis, ABD pollicis, flex pollicis brevis
1st 2 lumbrical; LOAF
ULNAR NERVE innervates:
- Hypothenar eminence (OAF)- opponens DM, ABductor DM, Flexor DM brevis
- Interossei- Pad, and Dab
- ADDuctor pollicis
- 3rd and 4th lumbricals
- FCU
- medial ½ of FDP
- FCU
**************
NEURO:
RANCHOS LOS AMIGOS: - does not predict improvement over long term, helps understand
behaviour and progression of brain injury over time, useful for therapist, PT, and family;
Jason Shane and Amanda Mrsic Apr 2015
1=no response, 5=confused, 10=normal
OUTCOME
I
NO RESPONSE:
Does not respond to voices, sounds, light, or touch; appears in a deep sleep.
II
GENERALIZED RESPONSE:
Limited, inconsistent, non-purposeful responses; first reaction may be to deep
pain; may open eyes but will not seem to focus on anything in particular
III
LOCALIZED RESPONSE:
Inconsistent responses but purposeful in that reacts in a more specific manner
to stimulus; may focus on a presented object; may follow simple commands.
IV
CONFUSED, AGITATED:
Heightened state of activity; confusion; unable to do self-care; unaware of
present events. Reacts to own inner confusion, fear, disorientation; excitable
behavior may be abusive or aggressive.
V
CONFUSED, INAPPROPRIATE, NON-AGITATED:
Appears alert; responds to commands; follows tasks for 2-3 minutes but easily
distracted by environment; frustrated; verbally inappropriate; does not learn new
information.
VI
CONFUSED APPROPRIATE:
Follows simple directions consistently; needs cueing; can relearn old skills;
serious memory problems but improving; attention improving; self-care tasks
performed without help; some awareness of self and others.
VII
AUTOMATIC APPROPRIATE:
If physically able, can carry out routine activities but may have robot-like
behavior, minimal confusion, shallow recall; poor insight into condition; initiates
tasks but needs structure; poor judgement, problem-solving and planning skills;
overall appears normal.
VIII
PURPOSEFUL APPROPRIATE:
Jason Shane and Amanda Mrsic Apr 2015
Alert, oriented; recalls and integrates past events; learns new activities and can
continue without supervision; independent in home and living skills; capable of
driving; defects in stress tolerance, judgment; abstract reasoning persist; many
function at reduced levels in society.
Glasgow coma scale: eye opening, verbal response, motor response;
from 0-15, less than 8 is severe head injury
LANDMARKS:
Jason Shane and Amanda Mrsic Apr 2015
second rib = superior angle of scapula
Well, that’s it. If you actually made it to the end of this document, congrats! We feel pretty
confident you’ll not only pass, but kill the written exam. By the way, not sure if you counted, but
this doc is 88 pages long. Whoa, can you say OCD!
Happy studying :)
Jason + Amanda
Jason Shane and Amanda Mrsic Apr 2015