NPTE Mega Review

Motions in frontal plane
Click the card to flip 👆
1 / 1874
Terms in this set (1874)
Free Nerve EndingsNociception. Sensitive to noxious biochemical and mechanical stimuliGolgi Tendon OrgansSense change in muscular tensionPacinian Corpusclesrespond to deep pressure and vibrationRuffini EndingStretching of skin, joint capsule, velocity of joint positionType I Muscle Fibers"Slow Twitch" Aerobic, red, tonic, slow-oxidative Low fatigability, high capillary density and myoglobin content, extensive blood supply and mitochondria Marathon, swimmingType II Muscle Fibers"Fast Twitch" Anaerobic, white, phasic, fast-glycolytic High fatigability, low capillary density, myoglobin, mitochondria, blood supply. Larger fibers. High Jump, sprintingTMJ Depression (opening)-Lateral Pterygoid -Suprahyoid -InfrahyoidTMJ Elevation (closing)Temporalis Masseter Medial PterygoidTMJ ProtrusionMasseter Lateral Pterygoid Medial PterygoidTMJ RetrusionTemporalis Masseter DigastricTMJ Side to sideMedial/Lateral pterygoid Masseter TemporalisCervical FlexionSCM Longus Colli ScalenesCervical ExtensionCervical erector spinae (Iliocostalis, Longissimus, Semispinalis cervicis) Splenius Cervicis Multifidus TrapeziusCervical Rotation and SidebendingSCM Scalenes Splenius, Longissimus, Iliocostalis Cervicis Levator Scap MultifidusThoracic/Lumbar FlexionRectus Abdominus Internal/External obliqueThoracic/Lumbar ExtensionErector spinae QL MultifidusThoracic/Lumbar Rotation/Lateral BendingPsoas major Quadratus lumborum External oblique Internal oblique Multifidus Longissimus thoracis Iliocostalis thoracis RotatoresScapula ElevationUpper Trap Levator ScapScapula ProtractionSerratus anterior Pec minorScapular Upward RotationUpper/Lower Trap Serratus AnteriorScapular Downward RotationRhomboids Levator Scap Pec MinorScapular DepressionLatissimus Dorsi Pectoralis Major/Minor Lower TrapScapular RetractionMiddle Trap RhomboidsGH FlexionAnterior deltoid Coracobrachialis Pec Major (clavicular head) Biceps brachiiGH ExtensionLatissimus dorsi Teres major Posterior deltoid Triceps brachii (long head)GH AbductionMiddle delt SupraspinatusGH AdductionPec major Lat Teres MajorGH Horizontal AbductionPosterior delt Infraspinatus Teres MinorGH Horizontal AdductionAnterior Delt Pec majorGH External (Lateral) RotationTeres Minor Infraspinatus Posterior DeltGH Internal (Medial) rotationSubscap Teres Major Pec Major Lat Anterior DeltElbow FlexionBiceps Brachii Brachialis BrachioradialisElbow ExtensionTriceps Brachii AnconeusRadioulnar SupinationBiceps Brachii SupinatorRadioulnar PronationPronator Teres Pronator QuadratusWrist FlexionFlexor Carpi Radialis Flexor Carpi Ulnaris Palmaris LongusWrist ExtensionExtensor Carpi Radialis Longus Extensor Carpi Radialis Brevis Extensor Carpi UlnarisRadial DeviationExtensor Carpi Radialis Longus/Brevis Extensor Pollicis Longus/Brevis Flexor Carpi RadialisUlnar DeviationExtensor Carpi Ulnaris Flexor Carpi UlnarisFinger FlexionFlexor Digitorum Superficialis/Profundus Flexor Digiti Minimi Interossei LumbricalsFinger ExtensionExtensor digitorum Extensor Indicis Extensor Digiti MinimiFinger AbductionDorsal Interossei (DAB) Abductor Digiti MinimiFinger AdductionPalmar Interossei (PAD)Thumb FlexionFlexor pollicis Longus and Brevis Opponens PollicisThumb ExtensionExtensor Pollicis Longus/Brevis Abductor Pollicis LongusThumb AbductionAbductor Pollicis Longus/BrevisThumb AdductionAdductor PollicisThumb OppositionOpponens Pollicis Opponens Digiti Minimi Flexor Pollicis Brevis Abductor Pollicis BrevisHip FlexionIliopsoas Sartorius Rectus Femoris PectineusHip AbductionGlute med/min Piriformis TFL Obturator internusHip ExtensionGlute Max and med Semitendinosus/Semimembranosus (medially) Biceps Femoris (laterally)Hip AdductionAdductor magnus, longus, brevis GracilisHip Internal (Medial) RotationTFL Glute Med/Min Pectineus Adductor LongusHip External (Lateral) RotationGlute Max Obturator Externus/Internus Piriformus Gemelli SartoriusKnee ExtensionRectus Femoris Vastus Lateralis, Medialis, IntermediusKnee FlexionBiceps Femoris Semitendinosus, Semimembranosus SartoriusPlantarflexionGastroc Soleus Tibialis Posterior Peroneus Longus/Brevis Plantaris Flexor HallucisDorsiflexionTibialis Anterior Extensor Hallucis Longus Extensor Digitorum Longus Peroneus TertiusInversionTibialis Posterior/Anterior Flexor Digitorum LongusEversionPeroneus Longus, Brevis, TertiusToe FlexionFlexor Digitorum Longus/Brevis Flexor Hallucis Longus, Brevis Flexor Digiti Minimi Longus Quadratus Plantae LumbricalsToe ExtensionExtensor Digitorum Longus and Brevis Extensor Hallucis Longus and Brevis LumbricalsToe AbductionAbductor Hallucis Abductor Digiti Minimi Dorsal interossei (DAB)Toe AdductionAdductor Hallucis Plantar Interossei (PAD)Shoulder JointsGH SC AC SGlenohumeral Joint: -Motions -Loose-packed position -Close-Packed Position -Capsular Pattern-Motions: Flex, Ext, AB/ADD, Ext/Internal Rotation -Loose-packed position: 55 degrees abduction, 30 degrees horizontal adduction (scaption) -Close-Packed Position: ABD and Ext Rotation -Capsular Pattern: External Rotation, Abduction, Internal RotationSC Joint: -Motions -Loose-packed position -Close-Packed Position -Capsular Pattern-Motions: Elevation, Depression, Proctraction/Retraction, Ext/Internal Rotation -Loose-packed position: Arm at side -Close-Packed Position: Max shoulder elevation -Capsular Pattern: Pain at end range of motionAC Joint -Motions -Loose-packed position -Close-Packed Position -Capsular Pattern-Motions: Anterior/Posterior Tilting, Upward/Downward Rotation, Protraction/Retraction -Loose-packed position: Arm at side -Close-Packed Position: Arm abducted to 90 degrees -Capsular Pattern: Pain at extremes of range of movementLigaments of ShoulderAcromioclavicular Coracoacromial forms a roof over humeral head to limit superior translation of humeral head and prevent AC separation Coracoclavicular limits superior clavicle translation(conoid, trapezoid) Coracohumeral limits inferior humeral translation Costoclavicular is the primary supporting ligament for SC joint Glenohumeral (Superior, Middle, Inferior) Transverse Humeral attaches between greater and lesser tubercles of humerus, spanning bicpital groove to maintain tendon of LHBGlenohumeral LigamentsSuperior: Limits adduction and ER in 0-45 deg ABD Middle: Limits ER in 45 deg ABD Inferior: Limits inferior translation. Above 90 deg ABD--> -Anterior band limits ER -Inferior band limits IRElbow JointsHumeroradial Humeroulnar Proximal RadioulnarHumeroradial Joint -Motions -Loose-packed position -Close-Packed Position -Capsular Pattern-Motions: Flexion, extension, supination, pronation -Loose-packed position: Full ext, supination -Close-Packed Position: 90 deg flex, 5 deg supination -Capsular Pattern: Flex, Ext, Supination, PronationHumeroulnar Joint -Motions -Loose-packed position -Close-Packed Position -Capsular Pattern-Motions: Flexion/extension -Loose-packed position: 70 deg elbow ext, 10 deg supination -Close-Packed Position: Ext -Capsular Pattern: Flex, extProximal Radioulnar Joint Motions: -Loose-packed position -Close-Packed Position -Capsular PatternMotions: Pronation, Supination -Loose-packed position: 70 deg elbow flex, 35 deg supination -Close-Packed Position: 5 deg supination -Capsular Pattern: Supination, PronationCubital FossaTriangular space at anterior elbow bordered by brachioradialis, pronator teres, brachialis, and humeral epicondyles. Contains: Biceps brachii tendon, median nerve, radial nerve, brachial artery, median cubital veinCubital TunnelSpace formed by UCL, FCU, medial head of triceps, and medial epicondyle. Space becomes smallest with elbow in full flexion Contains: Ulnar nerveAnnular ligamentSurrounds the head of radius and allows head of radius to rotate and maintain contact with the radial notch of the ulnaOlecranon bursaMain bursa of the elbow, located posterior to olecranon process. Most easily injured, and becomes inflamed with direct trauma to elbow due to superficial positionRadiocarpal joint Motions: -Loose-packed position -Close-Packed Position -Capsular Pattern-Motions: Flexion, extension, radial/ulnar deviation -Loose-packed position: Neutral with slight ulnar deviation -Close-Packed Position: Extension with radial deviation -Capsular Pattern: Flex/ext equalAnatomic snuffbox-Bordered by Abductor Pollicis Longus, Extensor Pollicis Brevis, and Extensor Pollicis Longus (Brevis sandwich) -Scaphoid may be palpated through this structure when there is concern for a fracture.Carpal Tunnel-Space between carpal bones and flexor retinaculum, and the median nerve runs through this structure. -Tenosynovitis, inflammation of retinaculum, or anything that decreases the space may result in compression of the median nerve.Dorsal Radiocarpal ligament-Only major ligament on dorsal surface of wrist. -Limits wrist flexion. -Runs from posterior distal radius to lunate/triquetrum.Extensor RetinaculumCrosses dorsal aspect of wrist and covers extensor tendons. Prevents "bowstringing" with wrist extensionFlexor RetinaculumCrosses palmar aspect of wrist, covering flexor tendons. Prevents flexor tendons from "bowstringing" with wrist flexion. Attachment site for thenar/hypothenar musclesInterosseus MembraneFibrous connective tissue that runs obliquely from radius to ulna. -Spans from proximal to distal radioulnar joint and serves as a stabilizer against axial forces to wristTriangular Fibrocartilage Complex-Cartilaginous disc that sits between ulna, lunate and triquetrum -Provides stability to wrist joint and connects radius and ulna together -Distributes force across wristTunnel of Guyon-Anatomic region formed by the hook of the hamate bone and the pisiform bone -the ulnar nerve and artery pass into the hand through this regionIliofemoral Joint Motions: -Loose-packed position -Close-Packed Position -Capsular PatternMotions: Flex/Ext. Abd/Add, Internal/External rotation -Loose-packed position: 30 deg flex, 30 deg abd, slight external rot -Close-Packed Position: Full ext, internal rotation -Capsular Pattern: flexion, abduction, internal rotationHip BursaeIliopsoas: between anterior joint capsule and iliopsoas tendon Trochanteric: between greater trochanter and different glute muscles Ischiogluteal: between ischium and glute maxFemoral TriangleBordered by inguinal ligament, sartorius, and adductor longus Structures (from medial to lateral): Femoral vein, artery, and nerve (VAN)Iliofemoral ligament-Resists anterior displacement of hip and prevents hyperextension -Strongest ligament in the bodyIschiofemoral ligamentResists posterior displacement of femoral headPubofemoral ligamentLocated anteromedially & inferiorly, limits excessive hip extension & abductionLigamentum TeresProvides physical attachment between head of femur and inferior rim of the acetabulum -Provides limited stability but blood vessels and nerves that supply femoral head run through this sheathKnee Joint Overview Bones, articulations, type of jointMade up of femur, tibia, and patella, with tibiofemoral and patellofemoral articulations. Hinge joint formed by articulation of tibia and femurTibiofemoral Joint Motions: -Loose-packed position -Close-Packed Position -Capsular PatternMotions: Flexion, extension, internal/external rotation -Loose-packed position: 25 deg flex -Close-Packed Position: Full ext, ext rotation of tibia, flexion/extension -Capsular Pattern: Flex, extAnterior Cruciate Ligament-runs from anterior intercondylar area of tibia to medial aspect of lateral femoral condyle in intercondylar notch ( -Prevents anterior displacement of tibia on femur Injured through: -noncontact twisting injury associated with hyperext and varus/valgus stress to knee. -severe knee hyperextension -Tibia being driven anteriorly on femur, or femur driven posteriorly on tibia Special tests: Anterior drawer, Lachman, lateral pivot shift, SlocumPosterior Cruciate Ligament-Runs from the posterior intercondylar tibia to the anterolateral surface of the femoral medial condyle. -Prevents posterior displacement of tibia on femur Injured through: -"Dashboard Injury" where tibia is driven posteriorly on femur as well as femur driven anteriorly on tibia -Severe knee hyperflexion (falling on bent knees) Special tests: Posterior Drawer, Posterior sagMedial Collateral Ligament-Runs from medial femoral epicondyle to medial aspect of shaft of the tibia. Deep capsular fibers are attached to the medial meniscus -Prevents excessive valgus displacement of tibia relative to femur Injured through: -Pure valgus load at knee without rotation (lateral blow to knee in football) -Often involves injury to ACL or medial meniscus Special test: Valgus stress testLateral Collateral Ligament-Runs from lateral femoral epicondyle to fibular head -Prevents excessive varus displacement of tibia relative to femur Injured through: -Pure varus load at knee without rotation, often sustained via medial blow to the knee. -Rarely torn without concurrent injury to ACL or PCL Special Tests: Varus stress testArcuate ligament complexArcuate ligament Oblique Popliteal Ligament Lateral Collateral Ligament Popliteus Tendon Lateral Head of gastroc Assists cruciate ligaments in controlling posterolatearl rotatory instability of knee and provides support to posterolateral joint capsuleBursae of KneePrepatellar: lies over patella and allows for greater movt of skin covering anterior patella Superficial Infrapatellar: Lies between patellar tendon and skin Deep Infrapatellar: lies between patellar tendon and tibiaMenisciAttached to proximal surface of tibia and serve to deepen the articular surfaces of the tibia where they articulate with femoral condyles, and function as shock absorbers. Thicker w/ better blood supply on the outside, thinner with less blood supply on inside./Pes anserineCommon insertion point of gracilis, semitendinosus, and sartorius on medial tibia.Fat pads of kneeQuadriceps, prefemoral, and intrapatellar. Infrapatellar is most commonly affected, can be source of anterior knee pain when impinged (Hoffa's syndrome)PlicaeExtensions of synovial membrane sometimes found in anterior knee, usually medial to patella. Can be source of anterior knee pain.Knee retinaculum (Lateral and medial)Ligamentous structures that attach to femur, tibia, and menisci. Lateral is stronger than medial, and plays a large role in patellar positioning.Talocrural Joint Motions: -Loose-packed position -Close-Packed Position -Capsular PatternFormed by articulations of distal tibia, talus, and fibula. Stable in DF, more mobile in PF. Motions: Dorsiflexion, plantarflexion -Loose-packed position: 10 deg PF, midway between max INV and EV -Close-Packed Position: Max DF -Capsular Pattern: PF, DF Mobilization: Anterior for PF Posterior for DFSubtalar Joint Motions: -Loose-packed position -Close-Packed Position -Capsular PatternFormed by three articulations between talus and calcaneus (anterior, middle, posterior). Anterior and middle articulations are formed by two convex facets on the talus and two concave facets on the calcaneus. Posterior articulation is a concave facet on inferior talus and a convex facet on the calcaneus Motions: Inversion, eversion -Loose-packed position: Midway between extremes of ROM -Close-Packed Position: Supination -Capsular Pattern: Limited varus ROm Medial glide increases eversion Lateral glide increases inversionMidtarsal joint Motions: -Loose-packed position -Close-Packed Position -Capsular PatternFormed by the talocacanealnavicular joint and the calcaneocuboid joint. Motions: Inversion, eversion -Loose-packed position: Midway between extremes of ROM -Close-Packed Position: Supination -Capsular Pattern: DF, PF, add, medial rotationAnterior talofibular ligamentLigament in ankle that is taut in PF and resists inversion of calcaneus and talus. Also resists anterior translation of talus on tibia.Calcaneneofibular ligamentLigament in ankle that resists inversion of talus within midrange of talocrural motionPosterior talofibular ligamentLigament in ankle that resists posterior displacement of talus on tibia.Deltoid ligamentLigament in ankle formed by: -Anterior tibiotalar ligament, posterior tibiotalar ligament -Tibiocalcaneal ligament -Tibionavicular ligament This ligament resists eversion of the talusPlantar fasciaThick layer of tissue on plantar aspect of foot that originates on calcaneal tuberosity and inserts onto the plantar forefoot. Helps support weight of body and support arches of foot for improved propulsion during gaitAnkle retinaculaExtensor retinacula is anterior to ankle, contains tendons on extensor musculature and prevents them from "bowstringing" as ankle dorsiflexes. Flexor retinaculum and peroneal retinaculum are also present.Retrocalcaneal BursaBursa between Achilles tendon and calcaneus, acting as a cushion between the tendon and bone.Sinus tarsiThe superior portion of the calcaneus contains a groove called the calcaneal sulcus. The inferior portion of the talus contains a matching groove called the sulcus tali. Collectively, these two sulci form the:Cervical Spine Motions: -Loose-packed position -Close-Packed Position -Capsular PatternSeven vertebrae, including atlantooccipital joint and the atlantoaxial joint Motions: Flexion, extension, lateral flexion (sidebending), rotation -Loose-packed position: Midway between flexion and extension -Close-Packed Position: Extension -Capsular Pattern: Lateral flexion and rotation equally limited, extensionAtlantooccipital Jointfirst joint formed by occipital condyles of skull sitting on articular fossa of the 1st vertebra allows capital flexion & extension ("Yes")Atlantoaxial jointJoint between C1 and C2 that permits majorty of cervical rotationzygapophyseal jointsJoints between the superior and inferior articular processes of vertebraeAlar ligamentsattach dens of axis (C2) to occipital condyles. Resist flexion, contralateral side bending, contralateral rotation. Also limit sagittal plane translation between axis and occiputAnterior longitudinal ligamentLimits spinal extension and reinforces anterior portion of intervertebral disksBrachial plexusNetwork of nerves formed by C5-T1 nerve roots that combine to form trunks, divide to form divisions, cords, and then peripheral nerves. These nerves innnervate muscles of upper quarterCruciform ligamenttransverse ligament of atlas and vertical ligament from skull; holds body of C2 and dens to the inside of the skull. Limits upper cervical flexion and atlantoaxial translationIntervertebral disksFormed by Annulus Fibrosis (dense layer of collagen fibers and fibrocartilage that firmly attaches to adjacent vertebrae to provide tensile strength during movement) and the Nucleus Pulposus (Gelatinous mass in center of disc that provides shock absorption)Intervertebral foraminaLateral openings between adjacent vertebrae for spinal nerves and blood vessels. Increased size with flexion and contralateral side bending, decreased size with extension and ipsilateral sidebending.Nerve root entrapmentsResult from closure or narrowing of intervertebral foramen due to arthritic changes, spurring, or narrowing of intervertebral disks.Ligamentum FlavumConnects lamina of adjacent vertebrae and limits flexion and rotation of spineLigamentum NuchaeLimits flexion in cervical spinePosterior Longitudinal LigamentLimits flexion in spine and reinforces posterior aspect of intervertebral disksUncovertebral jointsFormed betweenn lateral projections on adjacent vertebrae between C3 and T1. Guide motio in sagittal plane and limit motion in other two planesThoracolumbar spine Motions: -Loose-packed position -Close-Packed Position -Capsular Pattern12 thoracic vertebrae, 5 Lumbar vertebrae. First 10 T spine vertebrae have articular facets on each transverse process where ribs articulate. Motions: Flexion, extension, lateral flexion, rotation -Loose-packed position: Midway between flexion and extension -Close-Packed Position: Extension -Capsular Pattern: Lateral Flexion and rotation equally limited, extensionAnterior sacroiliac ligamentConnects anterior ilium to anterior sacrum. Considered the weakest sacroiliac ligament.Posterior Sacroiliac ligamentConnects PSIS to 3rd and 4th sacral segments. Strong, with fibers running in multiple directions and combining with sacrotuberous ligament fibers. Limits all sacral motions, especially posterior sacral rotationCoccyxArticulates with sacrum and consists of four small fused vertebral bodiesIliolumbar ligamentConnects posterior portion of ilium to the transverse process of L5, and limits all motions between L5 and S1Interosseus Sacroiliac LigamentConnects sacrum and ilium and is deep to posterior sacroiliac ligament. Resists anterior and inferior sacral movementsLumbar PlexusFormed by nerve roots of T12-L4, innvervates anterior and medial muscles of the theigh and dermatomes of the medial leg and foot. Largest and most important branches of the plexus are the obturator and femoral nervesPubic symphysisJoiint formed between each end of the pubis bone. Covered in hyaline cartialge with a fibrocartilage disk in between.Ribs12 pairs that form the wall of the thorax and attach to vertebrae 1-7: attached to sternum through costal cartilage 8-10: Join with costal cartilage of 1-7 11-12: articulate only with bodies of T11-12, classified as "floating"Sacrospinous ligamentConnects ischial spine to lateral sacrum and coccyx. Limits anterior sacral rotation.Sacrotuberous ligamentSacrum to ischial tuberosity. Resists sacral anterior rotationa dn prevents superior translation of sacrum.SacrumProvides an attachment for iliac bones and protects pelvic organs. Attached to pelvis by sacroiliac ligamentsThoraculumbar fasciaConnected to spinous processes of lumbar vertebrae, PSIS, and iliac crest. Three layers separate lumbar muscles into compartments and provide spinal stability, transmit forces, resist lumbar flexion, and provide muscular attachment site.C1 Resistive TestCervical RotationC2-4 Resistive TestShoulder ElevationC5 Resistive TestShoulder AbductionC5-6 Resistive TestElbow FlexionC6 Resistive TestWrist ExtensionC7 Resistive TestElbow Extension, Wrist FlexionC8 Resistive TestThumb ExtensionT1 Resistive TestFinger AdductionL1-2 Resistive TestHip FlexionL3-4 Resistive TestKnee ExtensionL4-5 Resistive TestAnkle DorsiflexionL5 Resistive TestGreat Toe ExtensionS1 Resistive TestAnkle Plantar FlexionUpper Quarter Reflex TestingC5: Biceps C6: Brachioradialis C7: TricepsLower Quarter Reflex TestingL4: Patellar Tendon S1: Achilles TendonUpper Quarter Dermatomal TestingC2: Posterior Head C3: Posterolateral Neck C4: AC Joint C5: Lateral Arm C6: Lateral Forearm and Thumb C7: Middle Finger C8: Little finger and ulnar border of hand T1: Medial ForearmLower Quarter Dermatomal TestingL2: Anterior Thigh L3: Middle third of anterior thigh L4: Patella and medial malleolus L5: Fibular head and dorsum of foot S1: Lateral and plantar aspect of foot S2: Medial Aspect of posterior thigh S3-S5: Perianal areaLower Quarter Functional TestingL4-L5: Heel walking S1: Toe walking L4-S1: Straight leg raiseViscerogenic pain:pain that originates from the kidneys, sacroiliac, pelvic lesions, and retroperitoneal tumors pain is neither aggravated by activity nor relieved by rest Examples: Kehr's Sign: Positive when pressure to upper abdomen or supine position reproduces L shoulder pain. Blood accumulates in abdominal cavity, often due to spleen rupture, causing irritation of diaphragm and phrenic nerve (C3-5) that refers pain to L shoulder. Gallstones: Gallbladder's innervation from mid-thoracic spinal segments leads to right upper abdonem or interscapular pain. May refer to R shoulder if diaphragm is irritated. Myocardial Infarction: Heart is innervated with C3-T4 spinal segments, and patients may experience pain on L side of body in chest, midback, shoulder, arm, neck, or jaw.Types of Normal End FeelsFirm (Stretch): ankle DF, finger EXT, Hip IR, Forearm supination Hard (bone to bone): Elbow EXT Soft (tissue approximation): Elbow/Knee flexionTypes of Abnormal End FeelsEmpty Firm Hard SoftEmpty End FeelStoppage of range of motion due to trauma to an effected muscle or joint.. -Joint inflammation, fracture, bursitisFirm End feel (abnormal)Increased tone, tightening of capsule, ligament shortening Frozen shoulder, TMJ capsular fibrosisHard End Feel (abnormal)Fracture, osteoarthritis, osteophyte formationSoft End Feel (abnormal)edema, synovitis, ligament instability/tearMMT GradesZero (0/5): No palpable muscle contraction Trace (1/5): Palpable muscle contraction but no joint movement Poor Minus (2-/5): No complete ROM in gravity eliminated position Poor (2/5): Complete ROM only in gravity eliminated position Poor Plus (2+/5): Able to initiate movement against gravity Fair Minus (3-/5): Can't complete ROM against gravity but can complete more than half range Fair (3/5): Completes ROM against gravity without resistance Fair Plus (3+/5): Completes ROM against gravity with only minimal resistance Good Minus (4-/5): Completes ROM against gravity with min/mod resistance Good (4/5): Completes ROM against gravity with mod resistance Good Plus (4+/5): Completes ROM against gravity with mod/max resistance Normal (5/5): Completes ROM with max resistanceactive insufficiencyWhen a 2 joint muscle contracts (shortens) across both joints simultaneouslyPassive insufficiencyTwo joint muscle is lengthened over both joints simultaneouslyTypes of Power GripsUsed when strong grip is needed, involves stabilization of the object against the palm of the hand. Fingers in flexion, wrist is in ulnar deviation and slight extension -Cylindrical: Entire hand wraps around object. Soda can -Fist: Thumb and fingers overlap. Hammer -Spherical: Fingers are separated from one another. Baseball -Hook: Second and third IP joints create a "hook". Pail handleTypes of Precision GripsUsed when accurate and precies hand movements are needed. -Digital Prehension (Three finger pinch): Pad to Pad contact between thumb, index finger, and middle finger. Pencil -Lateral Prehension: Contact between thumb and lateral side of index finger. Key -Tip Prehension: Thumb opposition (tip to tip). NeedleShoulder dislocation special tests-Apprehension test for anterior shoulder dislocation (90 90 with supine ER) -Apprehension test for posterior shoulder dislocation (90 flex and IR, posterior directed force) -Sulcus sign (Greater than 2 cm = 3+, 1-2 cm = 2+, less than 1 cm = 1+Biceps Tendon Pathology special tests-Speed's Test: Resisted active shoulder flexion with palpation of bicipital groove, positive for pain -Yergason's Test: Resisted forearm supination and ER -Ludington's Test: Hands behind head, alternately contract/relax biceps muscles. Absence of movement is positive for long head of biceps ruptureRotator Cuff Pathology Special Tests-Drop Arm: Patient slowly lowers arm from 90 deg abd. Positive = failure to slowly lower arm or presence of severe pain, may indicate rotator cuff tear -Hawkins-Kennedy Impingement Test: 90 deg flexion, Passive IR, positive for reproduction of pain. May indicate supraspinatus impingement -Infraspinatus Test: 90 deg elbow flexion, shoulder in 45 deg ER. Patient resists ER force to forearm. Positive = infraspinatus strain/tear -ER Lag Sign: Bent elbow, 20 deg scap, end range ER, ask patient to hold position. If patient cannot hold position, positive for infra/supraspinatus pathology -Lift off sign: Full IR patient is asked to raise hand off small of back. If unable to complete, subscap lesion may be present -Neer Impingment: Elevate patient's arm through flexion, positive test = pain, indicates supraspinatus impingement -Supine Impingment Test: Passive full flexion, then ER and adducts shoulder so arm is near patient's head. From this position, IR shoulder. Positive for pain -Supraspinatus Test (Empty Can): 90 deg abduction, 30 deg horiz ADD, thumb pointing down, resisted ABD. Positive for weakness.Thoracic Outlet Syndrome Tests-Adson Maneuver: Palpating radial pulse, therapist asks patient to rotate head to face test shoulder and extend head while therapist passively ER and EXT patient's shoulder. Positive for Absent/Diminished radial pulse. -Allen Test: 90 deg ABD, ER, and Elbow Flex. Radial pulse palpated, patient's head turns away from test shoulder. Positive for Absent/Diminished radial pulse -Costoclavicular Syndrome Test: Palpating radial pulse, patient lifts chest in "military posture". Positive for absent/diminished radial pulse may indicate subclavian artery compression between first rib and clavicle. -Roos Test: 90 deg ABD, ER, Elbow flexion (field goal). Patient opens and closes hands for three minutes. positive for inability to maintain position, weakness of arms, sensory loss, or ischemic pain. -Wright Test (Hyperabduction Test): Passive ABD while monitoring radial pulse. Positive for absent/diminished raidal pulse, may be indicative of costoclavicular compressionAC Joint testAC Crossover Test: 90 deg shoulder flexion, then passive full Horiz ADD. Positive for pain on AC.Labral TestsO'Brien's (Active Compression Test): 90 deg shoulder flexion, 10-15 deg horiz ADD, empty can position (IR). Therapist applies downward force, then ER (thumb up) and retests. Positive for superior labral tear if patient experiences pain in IR but not ER. -Glenoid Labrum Tear (Clunk) Test: Therapist places one hadn on posterior humeral head, and other hand stabilizes humerus proximal to elbow. Passive aDD and ER over patient's head, then applies anterior force to humerus. Positive = Clunk or grinding sound, may be indicative of Glenoid Labral tear -Jerk Test: 90 deg shoulder flexion, IR with elbow bend. Therapist provides axial compression force through elbow w/ horiz add. Clunk or jerk as humeral head subluxes posteriorly may indicate posterior instability, and pain could indicate posterior labral lesionULTT1Shoulder = Depression and Abduction to 110° Elbow = extension Forearm = supination Wrist = extension Finger & Thumb = extension Cervical spine = Contralateral side flexion Nerve bias: Median nerve, Anterior Interosseus NerveULTT2Shoulder = Depression and Abduction to 10° Elbow = extension Forearm = supination Wrist = extension Finger & Thumb = extension Shoulder = lateral rotation Cervical spine = Contralateral side flexion Nerve bias: Median nerve, Musculocutaneous nerve, Axillary NerveULTT3Shoulder = Depression and Abduction to 10° Elbow = extension Forearm = pronation Wrist = flexion and ulnar deviation Finger & Thumb = flexion Shoulder = medial rotation Cervical spine = Contralateral side flexion Nerve Bias: Radial nerveULTT4Shoulder = Depression and Abduction to 10° - 90° Elbow = flexion Forearm = supination Wrist = extension and radial deviation Finger & Thumb = extension Shoulder = lateral rotation Cervical Spine = Contralateral side flexion Nerve Bias: Ulnar NerveElbow Ligamentous Instability TestsVarus Stress Test: Tests LCL. Positive for increased laxity compared to opposite side, apprehension, or pain. Positive test may indicate LCL sprain Valgus Stress Test: Tests MCL. Positive for increased laxity compared to contralateral limb, apprension, or pain. Positive tests may be indicative of MCL sprainEpicondylitis Tests-Cozen's Test: Resisted wrist pronation, radial deviation, and extension with palpation at latereal epicondyle. Positive for weakness or pain on lat epicondyle. Indicative of lateral epicondylitis. -Lateral Epicondylitis Test: Patient extends third digit against resistance. Positive for pain or muscle weakness -Medial Epicondylitis Test: Therapist passively supinates the forearm, extends the wrist and elbow. Positive for pain in medial epicondyle. -Mill's Test: Therapist pronates forearm, flexes wrist, extends elbow. Positive for pain in lateral epicondyle.Elbow Neurological Dysfunction TestsElbow Flexion Test: Patient fully flexes both elbows while extending wrists, holding the position for 3-5 minutes. Positive for cubital tunnel syndrome if tingling or paresthesia is noted in ulnar nerve distribution Pinch Grip Test: Patient pinches tips of index fingers and thumbs together. If unable to pinch tip to tip and goes pad to pad, positive for anterior interosseus nerve dysfunction. -Tinel's Sign: Therapist taps between olecranon process and medial epicondyle. Positive for tingling in ulnar nerve distribution, may indicate ulnar nerve compressionWrist Ligamentous Instability TestsUlnar Collateral Ligament Instability Test: Therapist holds patient's thumb in extension and applies valgus force to MCP joint of thumb. Positive for excessive valgus movement and may be indicative of tear in UCL. May indicate presence of "gamekeeper's thumb"Wrist Vascular Insufficiency TestAllen Test: Patient opens and closes hand several times and maintains hand in closed position. Therapist compresses radial and ulnar arteries and patient relaxes hand. Therapist releases pressure on one artery and observes color of hand and fingers. Positive for delayed or absent flushing of radial or ulnar half of hand. May indicate occlusion of radial/ulnar arteryWrist Contracture/Tightness TestsBunnell-Littler Test: Patient holds MCP in slight EXT. Therapist moves PIP into flexion. If PIP does not flex with MCP joint extended, may be tight intrinsic muscles or capsular tightness. If PIP fully flexes with MCP in slight flexion, there may be intrinsic muscle tightness without capsular tightness. -Tight Retinacular Ligament Test: PIP is held in neutral position, therapist attempts to flex DIP. if unable to flex DIP, retinacular ligaments or capsule may be tight. If therapist flexes DIP with PIP in flexion, retinacular ligaments may be tight with normal capsuleWrist Neurological Dysfunction Tests-Carpal Compression Test (Median Nerve Compression Test): Therapist applies pressure to median nerve in carpal tunnel for 30 seconds. Positive for CTS for pain or paresthesia in median nerve distribution -Froment's sign: Therapist attempts to pull piece of paper away from patient's thumb and index finger. Positive for patient flexing distal phalanx of thumb due to adductor pollicis paralysis. If patient hyperextends MCP joint, termed Jeanne's Sign. May be indicative of ulnar nerve compromise or paralysis -Phalen's Test: Patient holds flexed wrist position (reverse prayer) for 60 seconds, positive for ingling in median -Tinel's sign: Therapist taps over patient's anterior wrist, positive for tingling in thumb, index/middle finger, and lateral half of ring finger. May indiccate CTS due to median nerve compressionDe Quervain's Tenosynovitis TestFinkelstein Test: Patient makes fist with thumb tucked inside fingers, therapist ulnarly deviates wrist. Positive for pain over AbPL and EPB at wrist, indicative of tenosynovitis in thumbGrind test (thumb)Therapist applies compression and rotation through first metacarpal. Positive for pain and may be indicative of DJD in CMC jointMurphy SignPatient makes fist. If third and fourth CMP are level with first and second, may be indicative of dislocated lunateHip Contracture/Tightness TestsEly's Test: Patient passively flexes patient's knee in prone. Positive for spontaneous hip flexion, indicative of rectus femoris tightness Ober's Test: Patient sidelying with lower leg flexed. Therapist moves test leg into EXT and ABD, then slowly lowers test leg. Positive for inabilty of test leg to adduct and touch the table. May indicate IT band or TFL contracture Piriformis Test: Patient in sidelying, test leg up, hip flexed and knee bent. Therapist presses down on knee, positive for pain or tightness, may be indicative of piriformis tightness or compression on sciatic caused by piroformis Thomas Test: Patient lies supine, bends one knee to chest. If patient's straight leg rises from table, may be indicative of hip flexion contracture Tripod Sign: Patient sits with knees flexed to 90 over edge of table. Therapist passively exgends one knee. Positive for hamstring tightness of trunk extends. 90/90 SLR: Patient extends knees from 90/90 in supine. Positive if knee remains in 20 deg or more of flexion.Pediatric Hip TestsBarlow's Test: Patient in supine with hips flexed to 90 deg and knees flexed. Therapist moves test leg into ADD while applying forward pressure to greater trochanter. Positive for click or clunk, and may dislocate hip. "Going out to the BAR" Ortolani's Test: Patient is supine with hips flexed to 90 deg and knees flexed. Therapist abducts hips and applies Anterior pressure to greater trochanters until resistance is felt at approx 30 deg. Positive for click or clunk and may be indicative of dislocation being reduced "If you are out, you need to go homeAnterior Labral Tear Test (FADDIR)Tests anterior-superior impingement syndrome, anterior labial tear, & iliopsoas tendinitis. Patient supine. Examiner takes the hip to full flexion, lateral rotation and full Abduction as a starting position. Examiner then extends hip combined with medial rotation and adduction. (+) pain or the production of the patient's symptoms with or without a click. Note: (FADDIR) = flexion adduction internal rotation.FABER testPatient supine, cross one ankle above other knee. Stabilize opposite hip, while pressing crossed knee down + pain at the hip: inflammation or trauma of the hip joint May be indicative of SI or hip joint abnormalitiesQuadrant/Scour TestTherapist flexes and adduts patient's hip with knee in ful flexion, applying compressive force through shaft of femur while passively moving hip. Positive for grinding, catching, crepitation in hip, may be indicative of arthritis, avascular necrosis, or an osteochondral defectCraig's TestPatient in prone with knee flexed to 90, therapist palpates greater trochantera nd internally and externally rotates hip until GT is parallel with table. Degree of femoral anteversion corresponds to angle formed by lower leg with perpendicular axis of table. Normal anteversion for adults: 8-15 degreesKnee Ligamentous TestsAnterior Drawer, Lachman, Lateral Pivot Shift -Posterior Drawer, Posterior Sag -Slocum Test: Patient with knee at 90 and hip at 45, foot rotated to provide 30 deg of internal rotation. Therapist sits on patient's foot and provides anterior force to tibia on femur. Positive for movement primarily on lateral side. Indications: Anterolateral laxity. Can also assess anteromedial instability with 15 deg external rotation of tibia -Valgus/Varus stress testMeniscal Pathology TestsApley's Compression Test: Prone with knee at 90, compressive force through tibia with IR and ER. Positive for pain or clicking. Bounce Home Test: Maximal knee flexion in supine, passive knee extension. Positive for rubbery end feel or incomplete extension McMurray Test: Patient in supine, knee fully flexed. Therapist provides IR and EXT, then ER and EXT to knee. Positive for click or crepitus over joint line, may be indicative of posterior meniscal lesion Thessaly Test: One leg stance, 5 deg flexion of knee. Patient rotates femur on tibia 3 times, then repeats with 20 deg knee bend. Positive for joint line discomfort, catching or locking in knee.Knee Patellar Tests-Brush/Sweep Test: Therapist places on hand below joint line of medial surface of patella, sweeps upward towards suprapatellar bursa. The other hand then strokes down lateral surface of patela. Positive for wave of fluid below medial distal border of patella, indicates knee effusion -Patellar Tap Test: Therapist taps patella. Positive if patella seems to be floating -Clarke's Sign: Therapist applies pressure with hand to superior pole of patella, patient contracts quadriceps muscle. Positive for pain, indicative of PFP -Hughston's Plica Test: Therapist flexes knee and medially rotates tibia with one hand while other hand moves patella medially. Positive for popping over medial plica with knee passively flexed or extended -Noble Compression Test: Therapist maintains pressure over lateral epicondyle of knee while patient extends. Positive for pain over lateral femoral condyle at 30 deg of knee flexion, indicative of IT band friction syndrome -Patellar Apprehension Test:Therapist places thumbs on medial border of patella and pushes it laterally. Positive for apprehension or attempt to contract quads to avoid subluxation.Ankle Special TestsAnterior Drawer Test: Positive for excess anterior translation of the talus from the mortise, indicates ATF sprain Lateral Rotation Stress Test (Kleiger Test): With patient seated at end of table w/knees bent, therapist ERs foot. If patient reports pain over ATF or PTF and interosseus membrane, positive for high ankle sprain. If patient reports pain medially and therapist can feel talus shift from medial malleolus, positive for deltoid ligament tear Talar Tilt Test: Patient in sidelying, knee flexed to 90 deg. Therpist stabilizes distal tibia, tilts talus into ABD and ADD. Positive for excess ADD, may be indicative of CCF sprain -Thompson Test: Squeeze gastroc. If no passive PF, achilles tendon may be ruptured -Tibial Torsion Test: Patient in sitting with knees over edge of table. Therapist places thumb and index finger of one hand over medial/lateral malleoli, then measures angle formed by axes of knee and ankle. Normal ER of tibia is 12-18 deg in an adult -True leg length Discrepancy Test: Patient in supine, hips and knees extended. Measure from distal point of ASIS to distal point of medial malleolus. Positive for bilateral variation of greater than 1 cm.Cervical Spine Tests-Cervical Flexion/Rotation Test: Patient in supine, therapist fully flexes C spine and rotates in each direction while maintaining flexion. Should have 45 deg each. If limited, dysfunction is occurring at AA joint. Can be provocative for cervicogenic headache. -Distraction Test: Used for patients with radicular symptoms. Therapist places one hand under patient's chin and other under occiput, providing a upward distraction force. Positive for cervical nerve root compression if pain is decreased with distraction force -Foraminal Compression Test: Therapist places both hands on top of patient's head while sidebending and presses down. Positive for pain radiating into arm toward flexed sign, indicates nerve root compression -Vertebral Artery Test: Therapist places patient's head into extension, sidebending, and rotation to ipsilateral side. Positive for dizziness, nystagmus, slurred speech, or LOC, may indicate vertebral artery compression.Lumbar/SI Special TestsGapping Test: Patient lies supine, therapist applies downward and lateral pressure to ASISs. If pain experienced in SI, glute, or posterior leg, positive for sprain of anterior SI ligaments SI Joint Stress Test: Patient positioned in supine, Therapist applies downward and lateral force to ASIS. Positive for pain in SI or glutes, may indicate SI joint dysfunction -Sitting Flexion Test: Patient sitting with knees flexed to 90 and feet on floor. Hips adducted to allow patient to bend forward, Therapist palpates PSIS and monitors while flexing. Positive if one PSIS moves farther cranially. May indicate articular restriction. -Slump Test: Patient sits at edge of table, moves into lumbar and thoracic flexion. Then extends knee and DFs ankle. If patient can't extend knee without pain, patient can raise head and try again. If symptoms decrease of if patient can bend knee farther, positive for neural tension. -Standing flexion test: Positive for one PSIS moving farther in cranial direction. -Straight leg raise Test: With patient in supine, therapist flexes patient's hip while maintaining knee extension until patient complains of pain or tightness in low back or posterior leg. Therapist lower leg until patient feels no pain. Then therapist dorsiflexes ankle. If symptoms return, postive for neural tensionCongenital Hip Dysplasia Condition: Etiology: S/Sx: Testing: Tx:Condition: Malalignment of femoral head within acetabulum, develops during last trimester in utero Etiology: Malposition in utero S/Sx: Asymmetric hip ABD with tightness and femoral shortening of involved side. Testing: Ortolani's, Barlow's, diagnostic ultrasound Tx: Harness, bracing, splinting, traction. Open reduction with application of cast required if conservative treatment fails.Congenital Limb Deficiencies Condition: Etiology: S/Sx: Tx:Condition: Longitudinal (reduction/absence of elements within long axis of bone) or transverse (developed to a level beyond which no skeletal elements exist) Etiology: Poor blood supply, infection, drug exposure in utero, genetic. S/Sx: Limb abnormality Tx: Symmetrical movements, strengthening, weight bearing activities, prosthetic training when appropriateGlenohumeral Instability Condition: Etiology: S/Sx: Testing: Tx:Condition: Excessive translation of humeral head during active rotation. Can include Subluxation (joint laxity where more than 50% of humeral head translates over glenoid rim w/out dislocation) or Dislocation (complete separation of articular surfaces of glenoid and humeral head). 85% of dislocations detach glenoid labrum (Bankart lesion) Etiology: Most common is anterior dislocation associated with excessive ER and ABD S/Sx: Subluxation--popping in and out of place), pain, paresthesias, dead arm feeling, positive apprehension test. Dislocation: Severe pain, paresthesias, limited ROM, Shoulder fullness, shoulder supported by contralateral limb Tx: Immobilization, ROM, isometric strengthening, PRE.Juvenile Rheumatoid Arthritis (JRA) Condition: Etiology: S/Sx: Testing: Tx:Condition: Most common chronic rheumatic disease in children. Can be Systemic, Polyarticular, or Oligoarticular. Etiology: Virus, infection, or trauma triggers an autoimmune response producing JRA in a child with a genetic predisposition S/Sx: --Systemic: 10-20% of cases. Acute onset, fevers, rashes, enlargement of spleen/liver, inflammation of lungs and heart. --Polyarticular: 30-40% of cases. High female incidence, significant rheumatic factor, arthritis in more than 4 joints with symmetrical joint involvement --Oligoarticular: 40-60% of cases. Affects less than 5 joints with asymmetrical joint involvement. Testing: Tx: Pharmacological management (NSAIDs, corticosteroids, antirheumatics, immunosuppressives). PROM, AROM, positioning, splinting, pain management. Surgery may be indicated secondary to contractures or irreversible joint destruction NOTE: In gait-- -Decreased cadence -Decreased PF at toe off -Decreased Hip EXT at terminal stance -Increased anterior pelvic tiltLateral Epidondylitis Condition: Etiology: S/Sx: Testing: Tx:Condition: Inflammation of common extensor muscles at origin on lateral epicondyle of humerus. Etiology: Eccentric loading of the wrist extensor muscles (usually ECRB). Poor mechanics, tennis racquet with handle that is too small or strings with too much tension. Common in racquet sports and throwing sports. S/Sx: Pain anterior or distal at lateral epicondyle. Pain worsens with repetition and resisted EXT. Tx: Strength, flexibility and endurance of wrist extensors. Epicondylitis strap can reduce tension on epicondyle.Legg-Calve-Perthes Disease Condition: Etiology: S/Sx: Testing: Tx:Condition: Avascular necrosis of femoral head leading to degeneration. Stages: Condensation, Fragmentation, Re-ossification, and Remodeling Etiology: Trauma, genetic predisposition, vascular abnormalities, infection S/Sx: Pain, decreased ROM, antalgic gait, positive Trendelenburg Tx: Scottish Rite brace to hold hips in ABD.Osgood-Schlatter Disease Condition: Etiology: S/Sx: Testing: Tx:Condition: Also known as traction apophysitis. Etiology: Repetitive tension to patellar tendon over tibial tuberosity in young athletes, causing a small avulsion of tibial tuberosity and mild swelling S/Sx: Point tenderness over tibial tuberosity, antalgic gait, pain with increasing activityOsteoarthritis Condition: Etiology: S/Sx: Testing: Tx:Condition: Chronic disease that causes degeneration of articular cartilage, primarily in weight bearing joints, resultin in deformity and thickening of subchondral bone that impairs functional status. Most common sites are hands, hips, and knees. Etiology: Occurs during middle age. More common in men before 55, more common in women after 55. Risk factors include weight, fractures/joint injuries, occupational/athletic overuse S/Sx: Gradual onset of pain present at affected joint, increased pain post exercise, pain with weather changes, enlarged joints, crepitus, stiffness, limited ROM, Heberden's (DIP) and Bouchard's (PIP) nodes. Testing: Tx: PROM, AROM, strengthening, weight loss, bracing, arthroscopic surgery, joint arthroplasty. Some knee OA patients benefit from hyaluronic acid injections.Osteogenesis imperfecta (brittle bone disease) Condition: Etiology: S/Sx: Testing: Tx:Condition: Connective tissue disorder that affects formation of collagen during bone development, resulting in poor bone strength. Etiology: Genetic inheritance. Types I and IV are autosomal dominant, Types II and III are autosomal recessive. S/Sx: Pathological fractures, osteoporosis, hypermobile joints, bowing of long bones, weakness, scoliosis, impaired respiratory function Tx: Education on proper handling and facilitation of movement and fracture management. Wheelchair prescription in severe cases where ambulation is not realistic.Patellofemoral Syndrome Condition: Etiology: S/Sx: Testing: Tx:Condition: Pain or discomfort at anterior knee, also called chondromalacia patella (softening of articular cartilage of patella) Etiology: Repetitive overuse disorder from increased force at PF joint (deceased quad strength, decreased LE flexibility, increased tibial torsion, femoral anteversion. Females, individuals in a growth spurt, runners who increase mileage recently, and overweight individuals more at risk S/Sx: Anterior knee pain, pain with prolonged sitting, pain with ascending/descending stairs, swelling, crepitus. Testing: Tx: Depends on contributing factors. LE flexibility, patellar taping, quad strengthening.Plantar Fasciitis Condition: Etiology: S/Sx: Testing: Tx:Condition: Inflammation of plantar fascia at the proximal insertion on medial tubercle of calcaneus. Excessive tension over time creates chronic inflammation and microtears at proximal insertion of plantar fascia Etiology: Acute injury from excessive loading of foot or chronic irritation from excessive pronation or prolonged duration of pronation. Most common in patients 40-60 years old. S/Sx: Tenderness at insertion of plantar fascia on medial calcaneal tubercle, heel spur, pain in morning or after periods of prolonged inactivity, difficulty with prolonged standing, pain when walking barefoot. Tx: Heel cup, tennis ball/rolling pin massage, medial longitudinal arch taping, achilles stretching, soft soled footwear, orthotics to minimize hyperpronationRheumatoid Arthritis Condition: Etiology: S/Sx: Testing: Tx:Condition: Systemic autoimmune disorder that presents as a chronic inflammatory reaction in synovial tissues of a joint with periods of exacerbation and remission. Etiology: Unknown. Women affected more than men, most common age of onset is 40-60 years old. S/Sx: Symmetrical joint involvement. Tenderness, warmth, morning stiffness, decreased appetite, fatigue, Swan neck (DIP flexion, PIP ext) or Boutonniere (DIP ext, PIP flexion), low grade fever Testing: Diagnosed based on presentation of involved joints, presence of blood rheumatoid factor, and radiography. Tx: DMARDs can slow progression of joint destruction/deformity. PROM, AROM, Joint protection, body mechanics, education.Rotator Cuff Tear Condition: Etiology: S/Sx: Testing: Tx:Condition: Tear in Supraspinatus, Infraspinatus, Teres Minor, or Subscapularis muscle due to acute trauma or chronic degenerative pathology. Can be partial-thickness (portion of tendon) to full-thickness, and can range from small (1cm or less) to large (5 cm or greater) Etiology: Impaired blood supply to tendon resulting in degeneration (particularly in patients over 50), repetitive microtrauma, macrotrauma, postural abnormalities. S/Sx: Arm in IR and ADD, tenderness at GT and acromion, limitation in flexion, ABD with upper trap recruitment, increased tone Tx: Prevent Adhesive Capulitis. Surgery can be arthroscopic, mini open or traditional open approach. Immobilization with sling, with 4-6 wks required for large tears. PROM-->AAROM-->AROM+RROM. Return to dynamic overhead motionin 9-12 monthsScoliosis Condition: Etiology: S/Sx: Testing: Tx:Condition: Lateral curvature of the spine, classified as functional (LL discrep, muscle imbalance, posture), neuromuscular (developmental pathology such as CP or Marfan) or degenerative (normal aging process, facilitated by disk herniation, bone demineralization, osteophyte formation). Neuromuscular and Degenerative scoliosis are structural rather than functional Etiology: Typically idiopathic S/Sx: Shoulder level asymmetry w/ or w/out rib hump. Pain not typically associated with spinal curvature, usually a result of abnormal forces on other tissues from curvature. Tx: Orthosis warranted at 25-40 degrees, surgery required over 40 deg. Mild curve = 10 deg or less. Less than 20 deg is usually asymptomatic.Talipes Equinovarus (Clubfoot) Condition: Etiology: S/Sx: Testing: Tx:Condition: Deformity where heel points downward and forefoot turns in. Etiology: Often accompanies other neuromuscular abnormalities (spina bifida, arthrogryposis). S/Sx: Adduction of forefoot, varus positioning of hindfoot, equinus of ankle. Tx: Splinting and serial casting. Restore proper positioning of ankle and foot.Total Hip Arthroplasty (THA)Condition: Removal of hip joint surfaces (femoral head and acetabulum) and replacement by implants. Can utilize anterolateral, direct lateral, or posterolateral approach. Indications: OA, RA, Osteomyelitis, Avascular Necrosis Fixation can be cemented (allows WBAT immediately) or cementless (relies on bone growth, may be PWB or NWB initially, more for young active individuals). Average lifespan of implant is 15-20 years. Complications: DVT, infection, PE, femoral fractures, dislocation.THA Anterolateral Approach and PrecautionsAccess to hip joint between TFL and glute med. Some hip abductors are released from GT and hip is dislocated anteriorly. Precautions: Hip flexion beyond 90, hip EXT, ER and ADDTHA Direct Lateral Approach and PrecautionsDivides TFL and vastus lateralis longitudinally to access hip joint, leaves posterior glute med attached to GT. Posterior tissues and capsule are left intact, minimizing dislocation probability, ideal for noncompliant patients. Precautions: Hip flexion beyond 90, EXT, ER, ADDTHA Posterolateral Approach and PrecautionsHip joint accessed by splitting glute max in line with muscle fibers. Short ERs are released and hip ABDs retracted anteriorly, and femur is dislocated posteriorly.. This maintains glute med and vastus lateralis. Most common approach but highest dislocation rate. Precautions: Hip flexion beyond 90, ADD, IRTotal Knee Arthroplasty (TKA) -Compartments -Degree of Constraint -Fixation methodsRemoval of proximal and distal knee surfaces and replacing them with an implant. Lifespan of 15-20 years. Compartments: -Unicompartmental (only medial or lateral joint surface replaced) -Bicompartmental (entire surface of femur and tibia were replaced) -Tricompartmental (replacement of femur and tibia along with patella) Can also be classified by degree of constraint: -Unconstrained: No inherent stability, relies on soft tissue for stability (unicompartmental) -Semiconstrained: Some degree of stability without compromising mobility, most common TKA. -Fully Constrained: Most stability, restricts one or more planes of motion, causing greater implant stress and higher likelihood of implant failure. Fixation methods: Cemented, uncemented, and hybridLaminectomySurgical Considerations: Performed for disc protrusion or spinal stenosis. Complete: removal of entire lamina, spinous process, and Rehab Considerations: Weight restrictions, restrictions on active motion (often extension)Spinal FusionSurgical Considerations: Indicated with unstable spinal segments, advanced arthritis, or uncontrolled peripheral pain. Pedicle screws immobilize segments while bony callus forms between segments. Lumbar fusion uses posterior approach, cervical uses anterior approach typically. Rehab Considerations: Lifting restrictions, restrictions on active motion (bending/twisting). Bracing (cervical collar, TLSO) may be used to help compliance. Rehab usually begins 6 weeks post op, with instrumentation it can be less.Total Shoulder Arthroplasty (TSA)Surgical considerations: Performed when joint components are arthritic, or secondary to fracture or rotator cuff arthropathy. Glenoid and humeral head areboth replaced in TSA, while a shoulder hemiarthoplasty replaces only one. Reverse Total Shoulder reverses concave/convex relationship, used for dysfunctional RTC. All use an anterior approach where subscap is detached for easy access. Rehab Considerations: Immobilization for several weeks, longer if repair performed on tendon. Movement precautions for 6-8 weeks.Subacromial DecompressionSurgical Considerations: Performed when impingement does not respond to conservative treatment. Can be open (deltoid detached), mini open (split deltoid) or arthroscopic. Could also involve acromioplasty, bursectomy, or removal of degenerative distal clavicle. Rehab Considerations: Rapid recovery--sling used for 1-2 wks and early rehab for pain and ROM. Passive EXT limited in deltoid repairs to limit stress.Rotator Cuff RepairSurgical Considerations: Graded according to depth (partial vs full) and according to width (small = 1 cm or less, medium 1-3, large 3-5, massive greater than 5 cm). Small requires only debridement, all others require repair (sutures, anchors, staples). Generally arthroscopic, possibly open or mini open if large. Rehab Considerations: Sling at discretion of surgeon. Precautions are no AROM, lifting, or WB through arm for some weeks.Capsular Shift Procedure (Shoulder Stabilization)Surgical considerations: Performed for chronic shoulder instability. Joint capsule tightened by cutting capsule and overlapping ends to reduce capsular redundancy. Portion of capsule tightened depends on direction of instability (anterior is most common so anterior capsule is most often tightened). Labral repairs may be performed since labral injuries often accompany dislocations. Bankart (anterior labrum) or SLAP (superior labrum). Usually arthroscopic Rehab Considerations: Anterior capsule repair gets normal sling, should avoid ER, EXT and HOR ABD, and IR if subscap is detached. Posterior capsule repair gets neutral rotation sling (handshake), avoiding IR, FLEX, and HOR ADD. AROM asap after surgery, don't wait for full motion for strength. Avoid contracting biceps with SLAP.Hip ORIF (Open Reduction - Internal Fixation)Surgical Considerations: Surgical repair to proximal hip fractures in femoral neck and intertrochanteric region. Nonunion and osteonecrosis are common with fem neck fractures (intracapsular, can lead to loss of blood supply). Intertrochanteric are extracapsular. Fixation occurs with plates and screws, or an intramedullary nail. If patient has poor healing capacity, THA is considered. Always open procedure. Capsulotomy is performed if fem neck is involved. Rehab Considerations: Early weight bearing, ambulation, ROM. Fixation failure--persistent thigh or groin pain, LL discrep not present initially, non-improving Trendelenburg, or ER positioning.Surgeries to fix Articular Cartilage DefectsMicrofracture Procedure: Awl penetrates subchonral bown, causing an ingrowth of fibrocartilage. Osteochondral Autograft Transplantation: Cartilage is harvested from NWB surfaces to form a plug to fill chondral defect Autologous Chondrocyte Implantation: Healthy cartilage is harvested and cultured so it will grow, then implanted. Rehab Considerations: Weight bearing restrictions, depending on size and location of lesion. Adherence to weight bearing restrictions is critical.Anterior Cruciate Ligament ReconstructionSurgical Considerations: Arthroscopic surgery, preferred autograft over allograft. Bone-patellar tendon-bone graft is gold standard, due to bone-to-bone healing. Gracilis or semitendinosus grafts are common but fixation is not as strong. Rehab Considerations: Period of immobilization in hinged brace. ROM emphasis on full EXT early. Exercise focus on iso quads/hamstrings and closed chain early. Patellar Tendon graft patients should be cautions with quad strengthening early, opposite for gracilis/semi grafts. Graft tissue most vulnerable 6-8 wks pos surgery, failure happening secondary to poor compliance. 100% graft maturation 12-16 months post.Surgery for meniscus injuries1: Partial meniscectomy, torn piece of meniscus is removed. Chosen when tear is in avascular inner third of meniscus or for older individuals. No weight bearing restriction. 2: Meniscal Repair. Tear is sutured together. Chosen for younger patients or when tear is on the outer third. Weight bearing restriction.Lateral Ankle ReconstructionSurgical Considerations: Performed secondary to complete tear of ATF or CCF, or secondary to chronic ankle instability. Two methods both using an open approach that may include arthroscopy or subchondral drilling: 1. Repair of torn ligaments, suturing them back together 2. Harvesting an autograft (usually peroneus brevis) to replace torn ligaments. This option is chosen when original ligaments have deteriorated and cannot be repaired.Achilles Tendon RepairPerformed arthroscopically if done within days, and tendon is sutured together. If done after a delay, surgery may need to be open and may require augmentation with a graft (flexor hallucis longus, peroneus brevis, plantaris) instead of suturing. Research shows that ankle casted in neutral and PWB leads to less restricted ROM over long term, which is more aggressive than traditional NWB for several weeks.Greenstick FractureBending and incomplete break of a bone; most often seen in childrenNonunion FractureFracture that fails to heal after 9-12 monthsComminuted Fracturefracture in which the bone is splintered or crushedCompound Fracturebone breaks through the skinDisease Modifying Antirheumatic Drugs (DMARDs)Slow/stop rheumatic disease progression, used mostly in early stages. High incidence of drug toxicity. Sides: nausea, headache, toxicity, sepsis, retinal damage Examples: Methotrexate, leflunomide, chloroquine, TNF inhibitors, Enabrel, HumiraGlutocorticoids (Corticosteroids)Hormonal, anti-inflammatory, metabolic effects (suppression of articular/systemic diseases) to treat endocrine dysfunction, rheumatic or respiratory disorders. Results in weakened immune system (PT must wear mask). Toxicity: moon face, buffalo hump, personality changes. At risk for osteoporosis and muscle wasting. Examples: Hydrocortisone/Cortisol, Prednisone, Prednisolone, Methylprednisone, Dexamethasone, NasonexNonopioid AgentsProvide analgesic and anti-inflammatory effects and anti-pyretic effects. Reduce prostaglandins, decreasing inflammation. Used for mild/moderate pain, fever, muscle ache, inflammation Sides: nausea, ulcers, GI distress Implication for PT: patients are at risk for masked pain allowing for movement beyond limitation. Examples: Acetaminophen, NSAIDS (Aspirin, Naproxen, ibuprofen, Celebrex/Celexocib)Opioid Agents (Narcotics)Analgesia for severe pain management by stimulatig opioid receptors in CNS to prevent pain signals from reaching destination. Used for severe pain, sedation, managing opioid dependence, relief of severe and persistent cough (codeine) Sides: Mood swings, sedation, confusion, vertigo, dulled cognitive function, orthostatic hypotension Treatment should be scheduled two hours post administration to maximize analgesic benefit. Examples: Morphine, Meperidine, Oxycodone, Fentanyl, CodeineSpondylolisthesis (Degenerative Spondylolisthesis)Forward slippage of one vertebra on the vertebra below it. Can be congenital, degenerative, post traumatic, or pathologic. Most common site is L4-5. Over 50 is most common, more common w/ AA and women. Degenerative is caused by arthritis and bone spurs that develop to resist motion when disc cannot. Symptoms: Back pain that is worse with exercise, lifting overhead, standing, getting out of bed or a car, walking up stairs/incline, and positioning in EXT. Will have "step off sign" If L4 is anteriorly displaced relative to L5, it's L5-S1 spondolysthesis. "The level of the slip is one level below the step off deformity) Meyerding scale: Grade 1-5, with Grade 1 at less than 25% and Grade 5 at 100% slippageTemporomandibular Joint DysfunctionDiagnosis: Injury or derangement of TMJ, intra-articular disks, or supporting structures. Over time meniscus of TMJ becomes compressed and torn, allowing ball and socket of joint to deteriorate w/ bone on bone grinding. Risk factors: Chewing on one side of mouth, eating tough food, clenching/grinding teeth, nail biting. Symptoms: Unilateral or bilateral pain, muscle spasm, abnormal/limited jaw motion, headache, tinnitus. May complain of clicking or popping.Transfemoral Amputation due to OsteosarcomaHighly malignant cancer begins in the medullary cavity of a bone (long bones most affected) and leads to formation of a mass. Amputation may be necessary to remove tumor. Clinical Presentation: Pain and swelling, weakness of extremity leading to fracture (may be first sign of osteosarcoma). Early metastases of lungs in 90% of cases. Fatigue, loss of balance, phantom pain, residual limb hypersensitivity, psychological issues Lying in prone position is beneficial to decrease the incidence of a hip flexion contractureTranstibial Amputation due to Arteriosclerosis Obliterans (PAD)Diagnosis: Peripheral vascular disease that produces thickening, hardening, and narrowing/occlusion of arteries. Results in ischemia and ulceration of affected tissues, leading to necrosis, gangrene, and amputation. Clinical Presentation: Intermittent claudication producing cramps and pain in gastroc/soleus, decreased pulse, ischemia, pallor, and decreased temperature. Ankle Brachial Index, Segmental Limb Pressure, Pulse volume recordingsGait: Standard Terminology1. Heel strike 2. Foot Flat 3. Midstance 4. Heel off 5. Toe Off 6. Acceleration 7. Midswing 8. DecelerationGait: Rancho Los Amigos Terminology1. Initial Contact 2. Loading Response 3 Midstance 4. Terminal Stance 5. Pre-swing 6. Initial Swing 7. Mid-swing 8. Terminal SwingUlnar Gutter Splint-aka ulnar FA based static wrist orthosis -provides rigid support for fxs, inflammatory conditions of soft tissue/nerve injuries; reduces pain and inflammation; protects against joint damage; immobilization to promote healing -Population: Boxer's fx of 5th metacarpal, skin graft, wrist sprain/fracture, sports, work related injuries, arthritis, congenital hand deformities -Wear at all times except when bathingDistal Interphalangeal SplintRadial Gutter SplintCovers Radial side of forearm and second/third digits. Immobilizes metacarpals and phalanges, used following fractures.Thumb Spica Splint-stabilizes and supports CMC joint, IP joint free, includes wrist -provides rest to pt who has pain or edema in thumb 2/2: RA, sprains, wrist instabilities and surgical repair, DeQuervain's tenosynovitis, Skier's/Gamekeeper's thumb -splint should be worn: during activs that may require extra support; activs that include repetitive movts; at night to provide a functional resting splintHALO vest orthosisInvasive cervical thoracic orthosis that provides full restriction of all cervical motion. Commonly used with spinal injuries to prevent damage during recovery until spine is stableMilwaukee Orthosisdesigned to promote realignment of spine due to scoliotic curvature.Taylor Bracethoracolumbosacral orthosis that limits trunk flexion and extension through a 3 point control design.Thoracolumbosacral Orthotic Brace (TLSO)Used to prevent all trunk motions, post-surgical stabilization.Foot Orthosisa removable appliance placed within a shoe that applies forces to the foot either to relieve pain or to improve balance and function in standing and walking.Ankle Foot Orthosis (AFO)brace that is worn on the lower leg and foot to support the ankle and correct foot drop. Requires medial/lateral control by patient.Articulated AFOAllows for free, unrestricted sagittal plane motion. -Good when solid AFO is too rigid -for spastic cerebral palsy, knee hyperext, correctable ankle equinus -For medial/lateral stability at anklePosterior StopLimits amount of PF, if displays an increase in PF • Used to limit foot slap at heel strike!!Dorsiflexion StopVelcro strap on posterior aspect of AFO that limits DFPosterior Leaf Spring AFOdorsiflexion assistance and foot clearance during swing phase (foot drop) -Pt has mild spastic CP, or isolated DF weakness -Little to no medial/lateral ankle support -Minimal restriction of sagittal ankle motionGround Reaction AFOAllows for control at ankle and knee, prevents collapse into flexion during stance phase by restricting DF at ankle -Used for knee buckling during stance phase or crouched gait -SCI, CVA, MS, GB, or other Neuro condition for weak quads -Must have at least 3/5 mmt at quads and hip stabilityKnee Ankle Foot Orthosis (KAFO)For patients with more extensive paralysis or limb deformity -knee control provides medial-lateral hyperextension restriction while allowing flexionCraig-Scott KAFOdesigned specifically for persons with paraplegia. allows a person to stand with a posterior lean of trunk.Hip-Knee-Ankle-Foot Orthosis (HKAFO)Orthosis controls rotation and ab/adduction at the hip, and restricts patients to swing-to or swing-through gait pattern.Reciprocating Gait Orthosis (RGO)incorporates a cable system to assist with advancement of lower extremities during gait. when patient shifts weight onto a selected lower extremity, the cable system advances the opposite LE. Used primarily for paraplegia.Parapodiumstanding frame designed to allow a patient to sit when necessary. primarily used in peds.Shoe modificationsHeel wedge: Prevents hindfoot eversion/inversion, or treat pes planus/cavus Heel Lift: Used for LLD or achilles tendonitis/repair Heel Cushion: Calcaneal spur or Plantar Fasciitis Heel Cup: Provides shock absorption for heel, used for calcaneal spur or PF Metatarsal Bar/Pad: Relieves pressure from met heads by transferring to met shafts, used for metatarsalgia Rocker Bar: Similar to met bar, but assists patients with terminal stance, specifically toe off.Upper Extremity AmputationsForequarter (scapulothoracic) Shoulder disarticulation Transhumeral Elbow Disarticulation Transradial Wrist Disarticulation Partial Hand DigitalLower Extremity AmputationsHemicorporectomy (Pelvis and both lower extremities) Hemipelvectomy (1/2 of pelvis and LE) Hip Disarticulation Transfemoral Knee Disarticulation Transtibial Syme's: Removal of foot at ankle joint with removal of malleoli) Transverse Tarsal (Chopart): Amputation through talonavicular and calcaneocuboid joints, preserving plantarflexors and sacrifices dorsiflexors, often resulting in equinus contracture Tarsometatarsal (Lisfranc): Removal of metatarsals, preserving DFs and PFs.K-Level 0Prosthesis does not enhance quality of life or mobility, patient is ineligible for knee or foot/ankle prosthesis.K-Level 1Patient can transfer, ambulate on level surface with fixed cadence, and is a limited/unlimited household ambulator Knee: Single axis, constant friction Ankle/Foot: SACH, single axisK Level 2Patient is able to traverse low-level barriers (curbs, stairs, uneven surfaces) and is a limited community ambulator Knee: Polycentric, constant friction Ankle/Foot: Flexible-keel or multi-axial footK Level 3Variable cadence and unlimited community ambulator, can traverse most environmental barriers, and uses prosthetic beyond simple locomotion. Knee: Hydraulic/pneumatic, microprocessor, variable friction mechanism Ankle/Foot: Energy storing, dynamic response, multiaxialK Level 4Patient exceeds basic ambulation skills, exhibits high impact, stress, or energy levels. Child, athlete, or active adult. Can use any system for knee or foot/ankle.Single Axis Knee ProstheticDifficult to reciprocate during gait, may or may not have knee EXT assist or weight activated stance control. Has a constant friction mechanism.Polycentric Knee ProstheticHeavier than single axis, reciprocal gait is more fluid, but may or may not have knee EXT assist or stance control. Has constant friction mechanism.Hydraulic Knee ProstheticVariable friction for improved swing and stance phase controlMicroprocessor Knee ProstheticMultiple programs available, allows for fluid management of stair descent. Requires charging, variable friction.SACH Foot SystemNon-articulating, rigid keel. Inexpensive, low maintenance, cushioned heel for shock absorption. No energy return or accommodation for uneven surfaces.Single Axis footAllows PF/DF, improved knee stability in weight acceptance, lacks energy return if not paired with dynamic response footdynamic response footCan be articulating or non-articulating. Keel can store and return some energy, may have split keel to allow for improved surface accomodationHydraulic Microprocessor for FootFiner control over stability/mobility, improved shock absorption, non appropriate for all environments.Amputee Mobility Predictor (AMPPRO)Outcome measure designed to measure ambulatory potential of lower limb prosthesis users, correlated to K level.L-TestOutcome measure of amputee mobility, similar to the TUG, except a 90 deg turn is performed after initial 3 m, total length is 20 m, and 4 turns are involved.Foot slapWeak dorsiflexors, dorsiflexor paralysisToe down instead of heel strikePF Spasticity PF contracture Weak DF DF paralysis LLD Hindfoot painClawing of toesToe flexor spasticity Positive support reflex (contraction of extensors and flexors in infant)Heel lift in midstanceInsufficient DF range PF spasticityNo toe offForefoot/toe pain Weak PF Weak toe flexors Insufficient PF ROMExaggerated Knee flexion at contactWeak quads Quad paralysis Hamstrings spasticity Insufficient EXT ROM Too much PF at foot Too soft of heel (tibia travels forward in front of femur, causing ext)Hyperextension in stanceCompensation for weak quads PF contractureExaggerated Knee flexion at terminal stanceKnee flexion contracture Hip flexion contractureInsufficient flexion with swingKnee effusion Quad EXT spasticity PF Spasticity Insufficient flexor ROMInsufficient Hip flexion at initial contactWeak hip flexors Hip flexor paralysis Hip extensor spasticity Insufficient hip flexion range of motionInsufficient Hip Extension in StanceInsufficient hip EXT ROM Hip Flexion contracture Lower extremity flexor synergyCircumduction in swingCompensation for weak hip flexors Compensation for weak DF Compensation for weak hamstringsHip hiking during swingCompensation for weak DF Compensation for weak knee flexors Compensation for extensor synergy patternExaggerated Hip Flexion during swingLower Extremity flexor synergy Compensation for insufficient ankle dorsiflexionAntalgic gaitA protective gait pattern where the involved step length is decreased in order to avoid weight bearing on the involved side usually secondary to pain. Rapid and short swing phase on uninvolved limbAtaxic gaitStaggering, unsteadiness, wide BOS and exaggerated movementsCerebellar gaitWide based, uncoordinated arms, staggering. Associated with cerebellar disease.Circumduction Gait patternCircular movement of limb during swing phase to compensate for insufficient hip/knee flexion or dorsiflexion.Double stepGait pattern where alternate steps are a different length or different rateEquine gait patternHigh steps, excessive gastroc activityFestinating gaitA gait pattern where a patient walks on toes as though pushed. It starts slowly, increases, and may continue until the patient grasps an object in order to stop.Hemiplegic gait patternPatient abducts paralyzed limb, swings it around, then brings it forward so the foot comes to the ground in front.Parkinsonian Gait patternIncreased forward flexion of trunk and knees, shuffling gait. Festinating may occur.Scissor gaitLegs cross midline upon advancementSpastic gaitStiff movement, toes catch and drag, legs held together, hip and knee joints flexed. Common in spastic paraplegia.Steppage GaitFeet and toes are lifted through hip and knee flexion to excessive heights, usually secondary to DF weakness. Foot slaps at initial contact with ground secondary to decreased controlTabetic gait patternHigh stepping ataxic gait pattern where the feet slap groundTrendelenburg Gait PatternExcessive lateral trunk flexion and weight shifting over stance leg that indicates gluteus medius weaknessVaulting Gait PatternSwing leg advances by elevating pelvis and PF of stance legLateral Bending in prosthetic/amputeeProsthetic causes: -Prosthesis too short -Improperly shaped lateral wall -High medial wall -Prosthesis aligned in abduction Amputee causes: -Poor balance -Abduction contracture -Improper training -Weak hip abductors on prosthetic side -Hypersensitive and painful residual limbAbducted Gait with prosthetic/amputeeProsthetic: -Too long prosthesis -High medial wall -Poorly shaped lateral wall -Prosthesis positioned in abduction -Inadequate suspension -Excessive knee friction Amputee: -Abduction Contracture -Improper training -Adductor roll -Weak hip flexors and adductors -Pain over residual limbCircumducted gait (prosthetic/amputee causes)Prosthetic: -Prosthesis too long -Excessive knee friction -Socket too small -Excessive PF Amputee: -Abduction contracture -Improper training -Weak hip flexors -Lacks confidence to flex the knee -Painful anterior distal residual limb -Inability to initiate prosthetic knee flexionExcessive Knee Flexion during stance (amputee/prosthetic causes)Prosthetic: -Socket set forward in relation to foot -Excessive dorsiflexion -Stiff heel -Prosthesis too long Amputee Causes: -Knee flexion contracture -Hip flexion contracture -Pain anteriorly in residual limb -Decrease in quad strength -Poor balanceVaulting (Prosthetic/Amputee causes)Prosthetic Causes: -Too long prosthesis -Inadequate socket suspension -Excessive alignment stability -Excessive plantarflexion Amputee Causes: -Residual limb discomfort -Improper training -Fear of stubbing toe -Short residual limb -Painful hip/residual limbRotation of forefoot at heel strike (prosthetic/amputee causes)Prosthetic: -Excessive toe-out built in -Loose fitting socket -Inadequate suspension -Rigid SACH heel cushion Amputee causes: -Poor muscle control -Improper training -Weak medial rotators -Short residual limbForward Trunk Flexion (Prosthetic/Amputee Causes)Prosthetic Causes: -Socket too big -Poor suspension -Knee instability Amputee Causes: -Hip Flexion contracture -Weak hip extensors -Pain with ischial weight bearing -Inability to initiate prosthetic knee flexionMedial or lateral whip (prosthetic/amputee causes)Prosthetic: -Excessive rotation of knee -Tight socket fit -Valgus in prosthetic knee -Improper alignment of toe break Amputee Causes -Improper Trainig -Weak hip rotators -Knee instabilityApe HandPeripheral nerve injury to median nerve, resulting in weakness with thumb flexion/opposition, and thumb may fall in line with other digits since thumb extensors overpower. Thenar atrophy.Cervical Radiculopathy Clinical Prediction RuleHighly likely if all four are present 1. Positive ULTTA 2. Involved-side Cervical rotation ROM less than 60 deg 3. Positive Distraction 4. Positive Spurling's ACarpal Tunnel Syndrome Clinical Prediction RuleHighly likely if at least 4/5 is present 1. Shaking hands 2. Wrist ratio over 0.67 3. Symptom Severity Scale over 1.9 4. Diminished sensation in thumb 5. Age over 45Anterior Interosseous Nerve Syndrome (AINCompression to the anterior interosseous nerve ONLY Motor deficits, no sensory loss Results in a motor loss involving the flexor digitorum longus, flexor profundus to the index finger, and pronator quadratus Tested using "OK sign" testPronator Teres Syndromemedian nerve compression, like CTS Unlike CTS: -aching in forearm -No night symptoms -positive tinel's sign OT: elbow splint at 90, avoid repetition post op OT: AROM, gliding, strengthen (2 wks), sensory re-ed, work modLumbar Manipulation CPRShould be considered if 4/5 are present 1. Pain less than 16 days 2. No symptoms below nkee 3. FABQ less than 19 4. IR of more than 35 deg for one hip 5. Hypomobility of at least one level of L-SpineOttawa Ankle RulesX-ray is only required if pain in malleolar Zone AND ANY ONE of following 1. Bone tenderness along distal 6 cm of posterior edge of tibia or tip of medial malleolus 2. Bone tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus 3. Inability to WB immediately and in ER for four stepsOttawa Foot RulesX ray only required if pain in midfoot AND ANY ONE of following are present 1. Bone tenderness at base of 5th MT 2. Bone tenderness at navicular 3. Inability to WB immediately and in ER for four stepsCuneiformsmedial, intermediate, lateralBones of the footCuboid is lateral Navicular is medial 1st cuneiform is medialCarpal bonesscaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate Some Lovers TRI Positions (lateral) That They Can't HandleFemale Athlete TriadEating disorder Osteoporosis (depleted estrogen) Amenorrhea (changes in hypothalamus)Femoral TorsionRotation between femur's shaft and neck 8-15 deg anterior anteversion is normal Less than 8 deg is femoral retroversionFemoral AnteversionTOE IN during ambulation W-sitting Excessive hip IR, restricted hip ER Increased Q angle Genu Vaglum Femoral torsion OVER 15 degFemoral RetroversionTOE OUT during ambulation Excess Hip ER, restricted IR Genu Varum, medial compartmental pain Tibial IR compensation Femoral torsion less than 8 deg Relatively uncommonForefoot VarusBig toe up. Supination of forefoot Compensated by forcing medial forefoot to ground Can be "Rigid varus", so bring the ground up to the food! Add medial wedge Can be "Flexible varus", so assist the foot the ground! Add lateral wedgeForefoot ValgusBig toe down. Pronation of forefoot. Often associated with Pes Planus Can be "Rigid", so bring the ground up to the foot! Add a lateral wedge Can be "Flexible", so assist the foot to the ground! Add a medial wedgeGoutMonoarticular inflammatry process in first MTP that develops in those with high uric acid in the blood, causing needlelike crystals to form and cause pain, redness, warmth, and swelling Etiology: Mainly males over 30 with a purine rich diet (fish, seafood, bacon) and/or alcoholism. Sxs: -Elevated Uric acid (over 7 mg/DL -Pain starts at night GOUT TOE Great toe pain One joint in most cases-1st MTP Uric acid elevated over 7 Tachycardia Tophi (uric acid crystal chunks) Overly sensitive Erythema and feever Colchicine, Alopurinol. and NSAIDSAnterior Innominate Rotation- With Supine to sit test, goes Long to Short (ALS) Treatment: MET on hamstrings (opposite anterior)Posterior Innominate Rotation-With supine to sit, test leg goes short to long (SLP) Treatment: MET on hip flexors (opposite posterior)Medial Meniscal Injury-Firmly attached to joint capsule, MCL, ACL, PCL, and semimembranosus -Tears in outer 1/3 have better chance of healing, while inner 2/3 (avascular) often require surgery MOI: Pivot on planted foot, during sports or stepping in a hole Sxs: Mild to severe pain with clicking and popping. Catching at certain parts of range. Clear OA as option. Tests: Apley's, Mcmurray'sUpper rib MobilizationInferior glides Improve Inhalation III Superior glides Improve Exhalation SIE When I do upper rib mobilizations, III SIEJoints falling anterior to Line of GravityAtlanto-Occipital Joint (cervical extensors and suboccipitals) CT Joint (Thoracic erector spinae) SI joint (TA) Knee joint (Hamstrings, gastroc) Ankle joint (PFs)Joints falling posterior to Line of GravityCervical Joint (Anterior Scalene, Deep neck flexors) Lumbar Joint (Abdominals) Hip Joint (Iliopsoas)Excessive Knee extension during IC-Loading response (Transtibial prosthesis)What should happen: knee flexes between 8-10 deg to allow for weight acceptance Deviation: Pt keeps knee extended on prosthetic side, making the limb longer and reducing shock absorption C/O: Walking uphill and distal anterior stump pain CAUSES: 1. Too soft cushioned heel, allowing for too much PF too quickly. PF = Knee EXT, DF = Knee flex 2. Posteriorly Displaced Socket or Anteriorly set Prosthetic Foot, setting knee posterior to foot in IC, causing LOG to be in front of knee, and causing extensor momentBuckling during IC-Loading with Transtibial ProsthesisNormal: Knee flexes between 8-10 deg Deviation: Buckles into knee flexion, or avoids by shortening stance time. C/O: Knee buckling, instability, fear of falling Causes: 1. Too hard cushioned heel. Does not allow for PF, stuck in DF, so pt loses shock absorption and compensates with knee flexion to get foot on ground. (DF = Knee Flexion, PF = Knee extension 2. Anteriorly Displaced Socket or Posteriorly Set Prosthetic Foot -Sets knee anterior to foot during IC, causing LOG to be behind knee, causing flexor momentWide BOS in midstance (Transtibial Prosthesis)Normal: Prosthesis in EXT, body weight is supported in single limb stance with level pelvis and neutral trunk Deviation: BOS moves laterally, prosthetic limb moves more laterally, prosthetic hip abducts C/O: Pain at proximal lateral brim of socket, pain at medial distal end of residual limb Causes: 1. Outset foot. Loss of medial support causes wide base to compensate 2. Medially leaning pylon (part that connects foot to socket). Top of pylon is more medial than bottom, causing pt to lose medial support in midstance.Reverse Muscle Actionwhen distal bone is stabilized and proximal bone moves. (Closed Chain Exercise OKC: Middle delt abducts shoulder. CKC (iso on wall): Middle delt brings origin (scap spine) to insertion (distal tuberosity), causing scapular downward rotationRA vs OARA is usually bilateral, systemic complaints, exacerbations and remissions, painful warm joints (esp fingers and wrist - "sausage joints"). Swan's neck deformity (flexion of the DIP with hyperextension of the PIP joint). OA: Morning stiffness, asymmetrical, degenerative wear and tear, increased pain w/WB, crepitus/clickingShin Pain Differential DiagnosisShin Splints: Repetitive overuse causing dull pain that is non-focal, extending over 5 cm. Present at start of workout, improves during ex, then returns Stress Fracture: Repetitive overuse causing deep pain that is focal with point tenderness less than 5 cm in length, and present at rest (and with activity). Use vibration and percussion (tuning fork) to provoke symptoms. Compartment Syndrome: Severe trauma to anterior compartment, causing severe pain with fullness, numbness, burning, or tingling. Worse with stretching, present during rest and activity. May not have dorsal pedal pulseKim TestPosterior inferior labrum tear testO'Brien TestSLAP tear Full internal rotation of shoulder and elbow pronation while therapist applies downard forceEmpty Can TestSupraspinatus Tear (1 or 2) Passive abduction to 90, then resistance (full can) Internal rotaiton and abduction to 90 (empty can)Drop Arm TestGrade 3 Supraspinatus tear Pts arm passively abducted to 90, patient is asked to slowly lower arm down to side. Positive if arm drops and pt cannot control it.SLAP tear-Lesion of superior labrum that extends anterior to posterior -Type 2 is most common (detachment of superior labrum from glenoid along with LHB tendon) Proceed with caution if biceps tendon is detached -Direction of instability most likely to be anterior Post-op rehab: -elevation PROM limited 30 deg per week (90 deg by week 3-4) -ONLY passive IR and ER -AVOID active elbow flex/supination for 6 wks -AVOID shoulder EXT with elbow EXT for 6 wks -Avoid resisted biceps contraction for 8 wks -Avoid ABD/ER combo for 12+wksSlipped Capital Femoral EpiphysisWeak femoral epiphyseal growth plates cause excessive mechanical stress -Traumatic onset (LCP is insidious) -May have trendelenburg gait -Capsular pattern present (NOT present in LCP) -Usually surgery is requiredLegg-Calve-Perthes DiseaseAvascular necrosis of femoral head -Atraumatic onset, ages 3-12 (SCFE is 12-15) -May have trendelenburg gait -No capsular pattern -Disease lasts 2-5 yrs and pts recover w/consiervative treatmentThumb MechanicsFlexion/Extension: Concave on convex, Roll/Glide same direction. (medial/ulnar roll and medial glide to improve flexion) Abduction/Adduction: Convex on concave, Roll glide in opposite directions (Volar/Palmar Roll and Dorsal glide for ABduction)TMJ Dysfunction: Bite Down/Cotton Roll TestTongue depressor or cotton roll is placed on one side of the patient's mouth in between the teeth. Patient is asked to bite down onto the object. Pain reproduced on SAME side of cotton roll: MUSCLE on same side is causing pain Pain reproduced on OPPOSITE side of cotton roll: JOINT on the opposite side is causing pain. "Biting down on one side stresses the TMJ on the opposite side"Vaulting gaitActive PF of stance limb to clear contralateral limb in swing phase Causes: -LLD -Contralateral prosthesis too long -Contralateral foot stuck in PFKnee Thrust GaitRapid knee hyperextension in midstance. Most often occurs to move COM anterior to knee, producing knee extensor movement Causes: -Weak/Spastic Quads -PF ContractureTrendelenburg GaitMarked lateral lean towards weak LE in midstance to decrease load on ipsilateral hip abductors Causes: -Glute med/min weakness -Same-side hip adductor tightness -Superior gluteal nerve palsyDelayed Heel Off GaitLack of PF resulting in inability to transfer weight onto forefoot Causes: -Weak PF -Excessive DF -Tibial Nerve palsy -Anterior foot painEarly Heel OffInability to achieve DF in midstance Causes: -Limited posterior talocrural capsular mobility -Tight/Spastic PF -Heel painBackward Trunk leanGlute avoidance! Flores walk! -Causes: Weak glute, inferior gluteal nerve palsyVertebrobasilar Artery InsufficiencySupplies cerebellum, brainstem, occipital lobes 5 D's: Drop attacks Dysphagia Dysarthria Diplopia Dizziness 3 N's: Nystagmus, Nausea, Numbness Testing: Quadrant Vertebral Artery test -Pt extends, side bends and rotates to same side for 30 sec. If pt's sxs reproduced, contralateral artery is impaired. Cervical Extension+Rotation tests CONTRALATERAL ARTERY Cervical Flexion/Rotation Tests BOTHOswestry Disability IndexSelf report questionnaire that measures the degree to which back or leg pain impacts functional activities. -assess the level of pain and interference with physical activities such as sleeping, self-care, sex life,social life and traveling. -6 items rated 0-5 100 = 100% disabled 0% = 0% disabledScoliosisabnormal lateral curvature of the spine Named by the Convexity. LEFT curve will have a C open on the right RIGHT curve will have C open on the left Cobb angles: 10 degrees or higher with axial rotation to confirm diagnosisVolkmann Ischemic ContractureContraction of the fingers and sometimes, the wrist, with loss of muscular power with death and resultant contracture of the forearm musculature, that sets in rapidly after severe injury around the elbow joint.CreepPermanent deformation of tissue through application of low magnitude load over a long period of time. Example: Dynamic splintingAnterior glide of talusImproves PFPosterior glide of talusImproves DFRadial glide of proximal carpal rowIncrease Ulnar DeviationUlnar glide of proximal carpal rowIncrease Radial deviationPosterolateral Approach ContraindicationsFlexion, Adduction, IR (FADIR)Anterior glide of tibia on femurIncrease knee EXT (heel off, terminal stance)Central Nervous SystemBrain, Brainstem, Spinal CordBrain DivisionsForebrain (prosencephalon) Midbrain (mesencephalon) Hindbrain (Rhombencephalon)Brainstem SectionsMidbrain Pons Medulla OblongataForebrain (Prosencephalon)Contains: Telencephalon -Cerebrum -Hippocampus -Basal Ganglia -Amygdala Diencephalon: -Thalamus -Hypothalamus -Subthalamus -EpithalamusMidbrain (Mesencephalon)Tectum: -Superior and inferior Colliculi Tegmentum: -Cerebral Aquedut -Periaqueductal Gray -Reticular Formation -Substantia Nigra -Red NucleusHindbrain (Rhombencephalon)Metencephalon -Cerebellum, Pons Myelencephalon -Medulla OblongataGray MatterBrain and spinal cord tissue that appears gray with the naked eye; consists mainly of neuronal cell bodies (nuclei) and lacks myelinated axons.White matterMyelinated axons, nerve fibers without dendritesLobes of the brainFrontal, Parietal, Occipital, TemporalPeripheral Nervous Systemthe sensory and motor neurons that connect the central nervous system to the rest of the body. Made up of Autonomic Nervous System and the Somatic Nervous System -12 Cranial Nerves and Ganglia -31 pairs of spinal nerves exit vertebral column through intervertebral foramina: 8 Cervical 12 Thoracic 5 lumbar 5 Sacral 1 CoccygealEfferent FibersCarry motor signals from CNS to effectorsAfferent FibersCarry sensory signals from receptors to CNSGangliaclusters of cell bodies in the PNS. They give rise to peripheral and central nerve fibers.Autonomic Nervous SystemDivision of PNS that controls glands and muscles of internal organs. Largely automatic responses that don't reach consciousness and emphasize homeostasis and stress response. Contains two divisions: Sympathetic: Emergency response, Norepinephrine transmission, stimulating response. "Fight or flight" Parasympathetic: Conserving/restoring energy, ACh transmittion, inhibitory response. "Feed and breed"Somatic Nervous SystemDivision of PNS that controls muscles. Voluntary movements, ability to touch, smell, see, taste, and hear.Limbic SystemA doughnut-shaped system of neural structures at the border of the brainstem and cerebral hemispheres; involved in control/expression of moddoand emotion, processing recent memory, olfaction, appetite, and emotional responses to food. Lesions here can result in aggression, fearfulness, altered sexual behavior, or motivationANS DysfunctionANS influences all internal organs, blood vessels, and glands, controlling BP, HR, RR, Temp, metabolism, etc. Constipation, erectile dysfunction, Horner's syndrome, vasovagal syncope, orthostatic hypotension, and postural tachycardia are all ANS dysfunctions that can be caused by outside pathology or primary damage. Treated with pharmacological interventions.TelencephalonCerebrum Hippocampus Basal Ganglia AmygdalaCerebrumArea of the brain responsible for all voluntary activities of the body. Two hemispheres joined by corpus callosum.Left Cerebral HemisphereDominates in speech sounds & in understanding sequential, rational & analytical conceptsRight Cerebral HemisphereControls left body, Creative, Visual, facial recognition, visual, and musical traits, nonverbal communication, negative emotions, and concept comprehensionFrontal Lobe Functions*Voluntary movement (primary cortex/precentral gyrus) *Intellect *Orientation *Broca's area: Speech and concentration *Personality, temper, judgment, reasoning, behavior, self-awareness, executive functionsFrontal Lobe ImpairmentContralateral weakness Perseveration/inattention Personality changes/antisocial behavior Broca's Aphasia (expressive deficits) Delayed/Poor intiation Emotional LabilityParietal FunctionSensory Touch, kinesthesia, vibration, temp Receives info from other areas of brain regarding senses and memory Provides meaning or objects, interprets language and words, spatial/visual perceptionParietal ImpairmentDominant hemisphere (usually left): Agraphia, alexia, agnosia Non-dominant hemisphere: Dressing apraxia, contstructional apraxia, anosognosia (unaware of deficit) Contralateral sensory deficits Impaired language comprehension and impaired tasteTemporal Function-Hearing and smell -Wernicke's area (ability to understand/produce meaningful speech, verbal and general memory)Temporal DysfunctionLearning deficits Wernicke's Aphasia (receptive deficits) Antisocial/aggressive behavior Difficulty with facial recognition, memory loss, inability to categorizeOccipital FunctionVisual processing--colors, light, shapes, 3D, judging distanceOccipital Impairment-homonymous hemianopsia -impaired extra ocular mvmt -reading and writing impairment -cortical blindness with bilat lobe involvementHippocampusResponsible for forming/storing new memories and important to learning language. Embedded in lower temporal lobe.Basal GangliaGray matter masses in the white matter of cerebrum: -Caudate -Putamen -Globus Pallidus -Substantia Nigra -Subthalamic Nuclei Responsible for voluntary movement, regulation of autonomic movement, posture, tone, and motor responses.Basal Ganglia Dysfunction-Difficulty starting, stopping or sustaining movement -Uncontrollable, repeated movements (shaking) -Muscle spasms and muscle rigidity -Parkinson's/Huntington's, Tourette's, ADD, OCD, addictionAmygdalaEmotional and social processing. Processing of memory and formation of emotional memeory.Thalamusthe brain's sensory switchboard, located on top of the brainstem; it directs messages to the sensory receiving areas in the cortex and transmits replies to the cerebellum and medulla and appropriate association cortex. Coordinates sensory perception and movement.Thalamic Pain Syndromea condition caused by damage to the thalamus resulting in burning or tingling sensations and possibly hypersensitivity to things that would not normally be painful such as light touch or temperature change. Contralateral to thalamic lesionHypothalamusRegulates homeostasis using hormones, controlling hunger, thirst, sexual behavior, sleeping, body temp. Lesions produce impairments based on area of damage (obesity, sexual disinterest, poor temp control, diabetes insipidus)SubthalamusRegulates movements by skeletal muscles, associated with basal ganglia and substantia nigra.EpithalamusContains pineal gland, which secretes melatonin and regulates internal clock.CerebellumControl of finely coordinated movements. Coordination center, voluntary movement and balance. "Small brain." Rapid alternating movements. Damage to one side of cerebellum will produce ipsilateral impairment. Lesions produce ataxia, nystagmus, tremors, hypermetria, poor coordination, and deficits in postural reflexes.PonsRegulates RR and associated with orientation of head in relation to auditory/visual stimuli. Cranial nerves V-VIII originate from pons.Medulla OblongataConnects to pons superiorly and spinal cord inferiorly. Influences autonomic nervous activity and regulation of RR and HR. Reflex centers for vomiting, coughing, and sneezing. Damage produces contralateral impairment. Cranial nerves IX-XII originate from this structure.Anterior Cerebral ArterySupplies frontal lobe, and medial surface of frontal and parietal lobes. Occlusion results in: -Paraplegia -Incontinence -Personality changes -Aphasia, Apraxia, Agraphia -Perseveration -Akinetic Mutism (mimicks catatonia)Middle Cerebral ArterySupplies most of outer cerebrum, basal ganglia Most common site of CVA Occlusion results in: -Contralateral hemiplegia -Global, Wernicke's, or Broca's Aphasia -Homonymous Hemianopsia -Apraxia -Contralateral weakness and sensory loss of face/lower extremityPosterior Cerebral Artery (PCA)Supplies Occipital and inferior temporal lobes, subthalamic and basal nucleus, thalamus, and portion of midbrain. Occlusion results in: -Thalamic Pain syndrome -Hemiballismus, ataxia, athetosis, choreiform movement -Homonymous Hemianopsia -Visual agnosia -Cortical blindness -Memory impairmentVertebral-Basilar ArterySupplies Cerebellum, medulla, pons, occipital cortex, and midbrain. Occlusion results in: -Locked-in syndrome, coma, vegetative state -Wallenberg syndrome (secondary to lat medullary infarct) results in ataxia, verigo, ipsilateral facial pain/temp impairment and contralateral pain/temp impairment -vertigo, nystagmus -Dysphagia, Dysarthria, SyncopeMeningitisInflammation of the meninges. Bacterial meningitis is fatal in hours. Sxs: -Fever, headache, vomiting -Complaints of stiff/painful neck -Pain in lumbar area and posterior thigh -Brudzinski's sign: flexion of neck facilitates flexion of hips and knees -Kernig's sign: Pain with hip flexion combined with knee extension -Sensitivity to light Treatment with antibiotics and steroids, lumbar puncture for diagnosisHydrocephalusIncrease of CSF in ventricles of brain due to poor resorption, obstructed flow, or excessive CSF production. Can be congen, acquired, or idiopathic. Can be caused by spina bifida, choroid plexus neoplasm, cerebral palsy, tumor, meningitis, or encephalocele. Sxs: -Enlarged head or bulging fontanelles in infants -Headache -Vision and behavioral changes -Seizures, altered appetite or vomiting -Downward deviation of eyes ("sun-setting") -IncontinenceFasciculus cuneatusTrunk, neck, and UE: Proprioception, 2 pt disc, graphesthesiaFasciculus GracilisTrunk, LE: Proprioception, 2 pt disc, vibration, graphesthesia Gracilis like the leg muscleSpinocerebellar tractIpsilateral subconcious proprioceptionSpinoreticular tractAfferent pathway for reticular formation, influences level of consciousness.Spinotectal tractAfferent info for spinovisual reflexes, movement of eyes and head towards stimulusSpinothalamic tractpain and temperatureCorticospinal tractVoluntary refined movements of distal extremities. Pyramidal. Damage to this tract results in positive Babinski sign, absent cremasteric reflex, and loss of fine motor skillsReticulospinal tractextrapyramidal motor tract responsible for facilitation or inhibition of voluntary and reflex activity through the influence on alpha and gamma motor neuronsRubrospinal tractExtrapyramidal motor tract responsible for motor input of gross postural tone, facilitating activity of flexor muscles, and inhibiting the activity of extensor musclesTectospinal tractextrapyramidal motor tract responsible for contralateral postural muscle tone associated with auditory/visual stimuliVestibulospinal tractExtrapyramidal tract for ipsilateral postural adjustments after head movements, extensor activation and flexor inhibition. Damage to extrapyramidal tracts results in paralysis, hypertonicity, exaggerated DTRs, and clasp-knife reactionBrown-Sequard SyndromeHemi-section of the cord - ipsilateral (same side) spastic paralysis and loss of position sense - contralateral (opposite side) loss of pain and thermal senseA fibersPeripheral nerve fibers. Large size, myelinated with high conduction rates. Sensory components: -Primary muscle spindle endings (low threshold stretch) -Secondary muscle spindle endings (change in length facilitates muscle contraction) -GTOs: (interrupt muscle contractions on stretch of tendon) Alpha: alpha motor neurons, muscle spindle primary endings, GTOs, touch Beta: Touch, kinesthesia, muscle spindle secondary endings Gamma: Touch, pressure, gamma motor neurons Delta: Pain, Touch, pressure, tempB FibersPeripheral nerve fiber Medium diameter, myelinated, reasonably fast Preganglionic fibers of autonomic nervous systemC fibersPeripheral Nerve Fibers Small diameter, unmyelinated, slow conduction rate. Postganglionic fibers.C1 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Vertex of skull Muscles innervated: None Reflexes (if any): None Paresthesias: NoneC2 dermatome Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Temple/forehead/occiput Muscles innervated: Longus colli, SCM, rectus capitis Reflexes (if any): None Paresthesias: NoneC3 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Neck, posterior cheek, temporal area, mandible Muscles innervated: Trap, Splenius capitis Reflexes (if any): None Paresthesias: Cheek, side of neckC4 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Shoulder, clavicle, upper scap Muscles innervated: Trap, Levator Scap Reflexes (if any): None Paresthesias: Clavicle and upper scapC5 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Delt, Anterior arm to base of thumb Muscles innervated: Supraspinatus, infraspinatus, delt, biceps Reflexes (if any): Biceps, brachioradialis Paresthesias: NoneC6 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Anterior arm, radial side of hand to thumb and index finger Muscles innervated: Biceps, supinator, wrist extensors Reflexes (if any): Biceps, brachioradialis Paresthesias: Thumb and index fingerC7 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Lateral arm/forearm to index, long and ring fingers Muscles innervated: Triceps, wrist flexors Reflexes (if any): Triceps Paresthesias: Index, long, and ring fingersC8 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Medial arm and forearm to long, ring, and middle fingers Muscles innervated: Ulnar deviators, thumb EXT, thumb adductors Reflexes (if any): None Paresthesias: Little fingerT1 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Medial side of forearm to base of little finger Muscles innervated: Finger abductors Reflexes (if any): None Paresthesias: NoneT2 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Medial upper arm to medial elbow, pec and midscap areasT3-T-12 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: -T3-6: upper thorax -T5-7: Costal margin -T8-T12: Abdomen and lumbar region Muscles innervated: None Reflexes (if any): None Paresthesias: NoneL1 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Back, over trochanter and groin Muscles innervated: None Reflexes (if any): None Paresthesias: GroinL2 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Front of thigh and knee Muscles innervated: Psoas, hip adductors Reflexes (if any): None Paresthesias: Anterior thighL3 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Back, upper buttock, anterior thigh/knee, medial lower leg Muscles innervated: Psoas, quads, thighs Reflexes (if any): Knee jerk, prone knebend positive, pain on full SLR Paresthesias: Medial knee, anterior lower legL4 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Medial buttock, lateral thigh, medial leg, dorsum of foot, big toe Muscles innervated: Tibialis anterior, extensor hallucis Reflexes (if any): Weak or absent knee jerk, SLR limited, side flexion limited Paresthesias: Medial aspect of calf and ankleL5 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Buttock, posterior/lateral thigh, lateral aspect of leg, dorsum of foot, medial half of sole, first, second, and third toes Muscles innervated: Extensor hallucis, peroneals, glute med, DFs Reflexes (if any): SLR limited one side, neck flexion painful Paresthesias:S1 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Lateral and plantar aspect of foot Muscles innervated: Calf and hamstrings, glute wasting, PFs Reflexes (if any): Achilles reflex wek or absent Paresthesias:S2 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Buttock, thigh, posterior leg Muscles innervated: Same as S1 +peroneals Reflexes (if any): Achilles Paresthesias: Lateral leg, knee, and heelS3 dermatomeDermatome: Groin, medial thigh to kneeS4 Dermatome: Muscles innervated: Reflexes (if any): Paresthesias:Dermatome: Perineum, genitals, lower sacrum Muscles innervated: Bladder, rectum Reflexes (if any): None Paresthesias: Saddle area, genitals, anus, impotence, posterior herniationCranial NervesCN I: Olfactory (Sensory) CN II: Optic (Sensory) CN III: Oculomotor (Motor) CN IV: Trochlear (Motor) CN V: Trigeminal (Both) CN VI: Abducens (Motor) CN VII: Facial (Both) CN VIII: Vestibulocochlear (Sensory) CN IX: Glossopharyngeal (Both) CN X: Vagus (Both) CN XI: Accessory (Motor) CN XII: Hypoglossal (Motor) OOOTTAFVGVAH "Oh oh oh, to touch and feel" SSMMBMBSBBMM "Some say marry money..."CN IOlfactory Sensory: Smel Test: Familiar odors (chocolate, coffee)CN IIOptic Sensory: Vision (central and peripheral vision) Test: Visual fields Common pathologies: Multiple sclerosis, Posterior CVACN IIIOculomotor Motor: Levator of eyelid, superior/inferior/medial recti, inferior oblique Test: Visual tracking (up, down, and medial gaze), and reaction to light Common Pathologies: MS and Horner'sCN IVTrochlear Motor: Superior oblique Test: Visual tracking (down and in)CN VTrigeminal Sensory: Touch/pain on face, membranes of nose, sinuses, mouth and tongue Motor: Mastication Test: Corneal reflex, facial sensation, push down on chin Common Pathologies: ALS, Trigeminal NeuralgiaCN VIAbducens Motor: Lateral rectus of eyeball Test: Lateral gazeCN VIIFacial Sensory: Taste on anterior tongue Motor: Facial muscles, lacrimal and sublingual glands Test: Facial expressions, taste Common Pathologies: ALS, Bell's Palsy, GBCN VIIIVestibulocochlear Sensory: Hearing and balance Test: Hear watch ticking, hearing tests, balance and coordination testCN IXGlossopharyngeal Sensory: Posterior tongue sensation and taste, pharynx Motor: Pharynx Test: Gag reflex, swallowing Common Pathologies: ALS, GB , Medullary StrokeCN XVagus Sensory: Pharynx, larynx, bronchi, taste in tongue/epiglottus Motor: Muscles of palate, pharynx, larynx. Thoracic and ab viscera Test: Gag reflex, ability to swallow, "Say ahhhhh"CN XIAccessory Motor: SCM and Trap Test: Resisted Shoulder shrugCN XIIHypoglossal Motor: Muscles of tongue Test: Tongue protrusion (if injured, tongue deviates towards injured side)Muscle innervated by Lumbar PlexusPsoas major, minor Quadratus LumborumMuscles innervated by Sacral PlexusPiriformis Superior and inferior gemelli Obturator Internus Quadratus FemorisMuscles innervated by tibial division of Sciatic NerveSemitendinosus Semimembranosus Biceps Femoris (long head)Muscles innervated by Common Peroneal division of Sciatic NerveBiceps Femoris (short head)Muscle innervated by Inferior Gluteal NerveGlute MaxMuscles innervated by Superior Gluteal NerveGlute med, min TFLMuscles innervated by Femoral NerveQuads (RF, VL, VM, VI) Iliacus Sartorius PectineusMuscles innervated by Obturator NerveAdductor longus, brevis, magnus Obturator Externus GracilisMuscles innervated by Tibial NerveGastroc Soleus Popliteus Tibialis Posterior Plantaris FHL FDLMuscles innervated by Deep Peroneal NerveTibialis Anterior EHL EDL, EDB Peroneus TertiusMuscles innervated by Superficial Peroneal NervePeroneus Longus Peroneus BrevisMuscles innervated by Medial Plantar NerveAbductor Hallucis 1st Lumbrical FDB FHBMuscles innervated by Lateral Plantar NerveAbductor, flexor, opponens digiti minimi 2nd-4th lumbricals Dorsal/Plantar Interossei Quadratus Plantae Adductor HallucisSuperficial ReflexesElicited by gentle cutaneous stimulationAbdominal Superficial ReflexT8-L1 Stroke each quadrant of abdomen diagonally towards umbilicus. Umbilicus deviates towards stimulusCorneal "blink" ReflexCN V (Trigeminal) feels the pain CN VII (Facial) closes the eyelid Ask the patient to look away, stroke the cornea using piece of cotton. Both eyes should blink with contact to one eye.Cremasteric ReflexL1-2 Stroke skin of upper medial thigh. Testicle should elevate ipsilaterallyGag reflexCN IX (Glossopharyngeal) and CN X (Vagus) Stimulate back of throat. Gag will occur, may be absent in % of normal populationPlantar reflexL5-S1 Stroke lateral aspect of the sole from heel to ball of foot and medial to base of great toe. Normal response is flexion. If extension, positive Babinksi sign.Reflex Grading0 = no reflex, always abnormal 1+ = diminished response 2+ = normal 3+ brisk/exaggerated response 4+ - hyperactive, always abnormal responsePeripheral NeuropathyCan cause absent reflexes. Can be caused by diabetes, alcoholism, vitamin deficiencies, cancers, and toxins.Hyperactive DTRsCaused by upper motor neuron injury.BarognosisPerceive the weight of different objects in the handGraphesthesiaability to "read" a number by having it traced on the skinStereognosisability to recognize objects by feeling their form, size, and weight while the eyes are closedPallanesthesialoss of vibration sensationHypesthesiadecreased sensitivity to touchCausalgiapersistent, severe burning pain that usually follows an injury to a sensory nervePeripheral Nerve InjuriesEtiology: -Mechanical (compression) -Crush/Percussion (fracture/compartment syndrome) -Laceration -Penetrating trauma (stab wound) -Stretch (traction) -High velocity trauma (MCA) -Cold (Frostbite) Sxs: Total loss of muscle over time, replacement by fibrous tissueDouble crush syndromeexistence of two separate lesions along the same nerve that create more severe symptoms than if only one lesion existedMononeuropathyIsolated nerve lesion to a single peripheral nerve(trauma, entrapment) Example: CTSNeuromatumor composed of nerve (benign) Associated with vasculitis, AIDS, and amyloidosisPolyneuropathyDiffuse Nerve dysfunction, symmetrical and secondary to pathology, not trauma. Sensory impairments in stocking glove distribution, motor weakness/atrophy, weaker distally than proximally. Associated with Guillain-Barre, peripheral neuropathy, neurotoxic drugs, and HIVWallerian DegenerationDegeneration of a nerve distal to injuryNeurapraxiaMildest form of acute nerve injury Conduction blocked due to myelin dysfunction, with axonal continuity preserved. Nerve conduction preserved proximal and distal to lesion. Nerve fibers not damaged, with no evidence of nerve degeneration. Pt complains of pain in distribution Pressure injuries Sxs: Pain, minimal muscle atrophy, numbness or loss of motor/sensory function. Rapid recovery, will occur within 4-6 weeks.AxonotmesisMore severe form of acute nerve injury. Reversible injury to damaged nerve fibers. Damage occurs to axons, but endoneurium is preserved. Distal Wallerian degeneration can occur. Pt complains of pain in distribution Nerve can regen distal to site of lesion at 1 mm per day, with spontaneous and spotty to no recovery. Traction, compression, crush injuries most commonNeurotmesisMost severe form of acute nerve injury Axon, myelin, connective tissue are all damaged irreversibly with no possibility of regeneration. Flaccid paralysis and waisting of muscles occur, total loss of sensation to nerve area. No pain. Complete neural loss. Muscle wasting. All motor/sensory loss distal to lesion is permanently.Axillary nerve injury can be caused byfracture of humeral neck, anterior dislocation of shoulderMusculocutaneous nerve injury can be caused byclavicular fractureRadial nerve injury can be caused bycompression of nerve in radial tunnel or humeral fracture,Quadrangular SpacePosterior circumflex humeral artery and Axillary nerve PAs play in the quadArcade of FrohseFibrous ridge at the proximal aspect of the supinator muscle that may compress the radial nerve. Near the radiocapitellar joint, the radial nerve branches into the deep, motor, posterior interosseous nerve and the superficial sensory branch. It is the deep branch that passes beneath the arcade of Frohse which is the most common site of compression of the radial nerveMedian nerve injury can be caused byCompression in the carpal tunnel, pronator teres entrapmentUlnar nerve injury can be caused byCubital tunnel compression, tunnel of Guyon entrapmentFemoral nerve injury can be caused byTHA, displaced acetabular fracture, anterior femoral dislocation, hysterectomy, appendectomySciatic nerve injury can be caused byBlunt force trauma to buttocks, THA, injection to nerveObturator nerve injury can be caused byFixation of femur fracture, THAPeroneal nerve injury can be caused byFemur, tibia, or fibular fracture, positioning during surgical proceduresTibial nerve injury can be caused bytarsal tunnel entrapment, popliteal fossa compressionSural nerve injury can be caused bycalcaneal fracture, lateral malleolus fractureUpper Motor Neuron DiseaseLesion to cerebral motor cortex, internal capsule, brainstem or spinal cord. Sxs: weakness of involved muscles, hypertonicity, hyperreflexia, mild disuse atrophy, and abnormal reflexes. Damaged tracts are in lateral white column of spinal cord. Examples: -CP -Hydrocephalus -ALS (upper/lower) -CVA -Birth injuries -MS -Huntington's -TBI -Psuedobulbar Palsy -Brain tumorsLower Motor Neuron DiseaseLesion to nerves or their axons at or below level of brainstem. Ventral gray column of spinal cord may also be affected. Sxs: flaccidity or weakness of muscles, decreased tone, fasciculations, muscle atrophy, and decreased or absent reflexes. Examples: -Poliomyelitis -ALS -Guillain-Barre -Spinal Cord tumors -Trauma -Progressive muscular atrophy -Infection -Bell's Palsy -CTS -Muscular Dystrophy -Spinal Muscular AtrophyAthetosisbizarre, slow, twisting, writhing movement, resembling a snake or worm. When brief, they merge with chorea (Choreoathetosis) and when sustained, they merge with dystonia. Common in several forms of CP secondary to BG pathologyChoreasudden, rapid, jerky, purposeless movement involving limbs, trunk, or face. Often equated to fidgeting. Ballism is a form of this that involves large amplitude, flailing movements. Those that suffer from Huntington's disease often present with this.Ataxialack of muscle coordinationDystoniaLarger axial muscle involvement rather than appendicular muscles. Sustained muscle contraction that causes twisting, abnormal postures. Can have sustained agonist/antagonist, repeated contractions of one group, voluntary movements creating involuntary movts, torsion spasms. Common diagnoses: Parkinson's, CP, encephalitis.Ticssudden, rapid, recurrent, nonrhythmic motor movements or vocalizationsTremorsInvoluntary, rhythmic, oscillatory movements that are classified into: Resting--Observable at rest, don't disappear w/ rest and increase with stress (pill rolling w/PKsons) Postural--Observable during voluntary contraction to maintain posture. Ex: rapid tremor w/ hypothyroidism, fatigue, or anxiety Intention (kinetic)--Absent at rest, observable with activity and increase as target approaches, indicating lesion of cerebellum. Seen in MS.AkinesiaInability to initiate movementAstheniaGeneralized weakness secondary to cerebellar pathologyClasp-knife responseA form of resistance seen during range of motion of a hypertonic joint where there is greatest resistance at the initiation of range that lessens with movement through the range of motion Results from damage to cortex or brainstemCogwheel rigidityResistance to movement has phasic quality. Seen in Parkinson's, and basal ganglia lesionsDysdiadochokinesiainability to perform rapid alternating movementsDysmetriainability to control the ROM and force of muscular activityHemiballisminvoluntary and violent movement of a large body part. Form of chorea.Lead pipe rigidityUniform and constant resistance as limb is movedModified Ashworth ScaleTo test for spasticity; apply quick stretch to muscle so it is lengthened quickly 0= no inc. in tone 1= slight inc. in tone, catch and release or minimal resistance at end of ROM when affected part moved in flex or ext 1+= slight inc. in tone, catch, followed by min. resistance t/o remainder (< half) of ROM 2= more marked inc. in tone through most of ROM, but affected parts easily moved 3= considerable inc. in tone, passive mvmt diff. 4= affected parts rigid in flex or extBenign Paroxysmal Positional Vertigoa common cause of vertigo that occurs when there is a shift in the location of small crystals in the semicircular canals 2 types: Canalithiasis and cupolithiasis. Canalithiasis is more common. Assessed using Dix-Hallpike test and treated with canalith repositioning techniques. Will not have positive RombergCanalithiasisVariant of BPPV where otoconia are free floating within the semicircular canal. More common. Brief duration of symptoms while in position that disappear while patient is in the position.CupolithiasisNot as common. As long as patient is in provoking position, they will experience symptomsEpley's Maneuverused to TX Benign paroxysmal positional vertigo Head rotates to affected ear first, then rotated 45 deg to each side.Posterior canal BPPVUp-beat, torsional nystagmus towards affected side. Most common.Superior canal BPPVDown beat, torsional nystagmus toward affected side. Straight downbeat with no torsion or bidirectional means CNSPeripheral Vestibular Disorders-BPPV -Vestibular -Hypofunction (vestibular neuritis, labyrinthitis) -Bilateral Vestibular Hypofunction (BVL, usually ototoxicity) -Meniere's Disease -Mal de Debarquement -Perilymphatic Fistula -Motion SensitivityCentral Vestibular Disorders-TIA/Stroke -Acoustic Neuroma -Cerebellar Tumor -Vertebrobasilar insuficciency -Concussion/Head Injury -Vestibular migraine -Multiple SclerosisCentral vs Peripheral vertigo1. Nystagmus - bidirectional in central - only vertical in peripheral. Fast segment of movement indicates opposite direction of lesion. 2. Peripheral is episodic/Short duration 3. Tinnitus, hearing loss only in peripheral, vertigo is more significant 4. Refractoriness only present in peripheral (tilt test, ex) 5. Brainstem sx / focal neur. deficits only in central (diplopia, weakness, numbness, LOC)Unilateral vestibular hypofunctionNausea, vomiting, nystagmus, vertigo, postural instability. Habituation exercises are indicated (neural adaptation) Romberg will be POSITIVE As well as Gaze stability trainingBilateral Vestibular HypofunctionPathology affecting both sides of vestibular symptom. Disequilibrium, gait ataxia. Vertigo and Nystagmus NOT expected, so habituation NOT indicated Gaze stability training indicated Postural stability training indicatedAphasiaImpairment of processing for understanding (receptive) or speaking (expressive) language. Caused by TBI, CVA, tumor, infection. 95% of R handed persons and 66% of L handed persons are L hemisphere dominant for language. More sudden onset = higher extent of aphasia. Can be Fluent (Wernicke's, Conduction) or Non-Fluent (Broca's, Global)Fluent AphasiaLesion often in temporal or parietal lobe or Wernicke's area. Speech output is functional, prosody is fine, but speech makes no sense and lacks substance. Use of paraphasias and neologisms (substitutions in a word making it unrecognizable) Wernicke's and Conduction are examplesNon-fluent AphasiaLesion is typically in frontal lobe of dominant (often left) hemisphere Poor word output, dysprodosic speech (bad rhythm and inflection) Poor articulation, and words are hard to come by. Broca's and Global are examplesWernicke's AphasiaAlso known as "receptive aphasia", unable to "receive" comprehension. Also fluent aphasia, sensory aphasia. Typically caused by MCA stroke with lesion in auditory association cortex of L Lateral Temporal Lobe Reading and auditory comprehension impaired, writing impaired, but muscular ability to speak is not. Will talk in complete sentences that have no meaning with made up words.Conduction AphasiaLack of ability to conduct between listening and speech, can't repeat words or phrases. Reading intact, writing impaired.Broca's Aphasia"Expressive aphasia", a type of non-fluent aphasia, and most common form. Can understand, but unable to express speech. MCA causing lesion in premotor area of L Frontal Lobe Slow, hesitant speech with limited vocab and difficulty with sentences. Auditory and reading comprehension are intact, but speak in short phrases with great effort due to motor impairment. BEN has Broca's Broca's Expressive Deficits NonfluentGlobal AphasiaWhen both production and understanding of language is damaged. Combination of Broca's and Wernicke's. typically MCA with lesion in frontal and temporal lobesPromoting Aphasics' Communicative Effectiveness (PACE)Like Charades! Goal is to improve pt convo skills. Pt gets pic prompt and must use diff communication modalities to convey messageVisual Action Therapy (VAT)Most often used with global aphasia. Pt traces objects, then matches objects to tracing. Progress to pantomiming tasks, using gestures to identify visible objects and to symbolize absent objects. Non-verbal treatmentVerbal ApraxiaNon-dysarthric and non-aphasic impairment of speech articulation. Verbal expression impaired secondary to deficits in motor planning. Patient can understand, but unable to initiate speech.DysarthriaUpper motor neuron lesion affects muscles used in articulation, resulting in slurred speech.Cerebral AngiographyX-ray imaging of the arterial blood vessels in the brain after injection of contrast material to determine narrowing or blockage of brain arteries. Used to diagnose CVA, brain tumor, aneurysm, or vascular malformation.CT scana series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body to view bones, tissues, and organs. Rules out vascular malformations, tumors, cysts, herniated disks, hemorrhage, epilepsy.Discographyradiological examination of the intervertebral disk structures with injection of a contrast medium Evaluates integrity and pathology of spinal diskElectroencephalography (EEG)process of recording the electrical activity of the brain. Rules out seizure disorders, brain death, brain tumors, degenerative disorders.Electromyography (EMG)recording the strength of muscle contraction as a result of electrical stimulation. Measures activity from brain or spinal cord to peripheral nerve root. Used to rule out muscle pathology, nerve pathology, denervated muscle, lower motor neuron injuryEvoked PotentialsExternal stimuli (auditory, visual, proprioceptive) are used to evoke electric potentials in brain, and electrodes record the amount of time it takes for the impulse to reach the brain. Rules out MS, brain tumor, acoustic neuroma, SCIMRIa technique that uses magnetic fields and radio waves to produce computer-generated images that distinguish among different types of soft tissue; allows us to see structures within the brain Rules out tumors, MS, and had trauma.Myelographya radiographic study of the spinal cord after the injection of a contrast medium through a lumbar puncture High risk for headache following spinal tap. Rules out subarachnoid space abnormalities, spinal nerve injury, herniated disks, fracturesNerve Conduction VelocityTest that measures how fast an impulse travels along a nerve. Can pinpoint an area of nerve damage. Rules out peripheral neuropathies, CTS, demyelination, and peripheral nerve compression Compromise: Latency increases, velocity decreases. NOTE: will only test distal component of peripheral nerve. Cannot detect abnormalities in lesions proximal to dorsal root ganglionPositron Emission Tomography (PET)a method of brain imaging that assesses metabolic activity by using a radioactive substance injected into the bloodstream. Rules out cerebral circulatory pathology, metabolism dysfunction, tumors, brain changes following injury or drug abuseLumbar Spinal Puncturewithdrawal of cerebrospinal fluid from between two lumbar vertebrae. Most commonly at L-3-4. Used to rule out meningitis, tumor, infection, and hemorrhageAntiepileptic agentsalso known as anticonvulsants, they are used to reduce the frequency of seizures by inhibition of cerebral neurons. -Seconal/Secobarbital -Clonazepam/Klonopin -Valproic Acid -Phenytoin/Dilantin -Carbamazepine -Gabapentin -MethsuximideAntispasticity agentsPromote relaxation in spastic muscles by selectively binding in CNS or skeletal muscle to reduce spasticity. -Baclofen -Valium/Diazepam -Dantrolene -Zanaflex/TizanidineDirect Cholinergic AgentsMimic the action of the parasympathetic nervous system, induce the rest-and-digest response by binding directly to cholinergic receptors and mimicking ACh. Used for dementia, decrease in GI motility, glaucoma, Myasthenia Gravis May increase HR and dizziness, cause GI distress, or other parasympathetic effects. -Duvoid/Bethanechol -Pilocar/PilocarpineIndirect Cholinergic AgonistsInhibit Acetylcholinesterase to keep ACh bioavailable, increasing cholinergic synaptic transmission. -Aricept/Donepezil -Tensilon/Edrophonium -Prostigmin/Neostigmin -Cognex/TacrineDopamine Replacement AgentsRelieve symptoms of PD secondary to decrease of endogenous dopamine. Can cross blood brain barrier to transform into dopamine in the brain. Sides: Arrhythmias, GI distress, dyskinesias, orthostatic hypotension, tolerance Max benefit from scheduling therapy 1 hour after admin of levodopa. -Sinemet/Madopar/Levodopa -Symmetrel/AmantadineMuscle Relaxant AgentsRelieve tonic/continuous spasm occurring secondary to MSK or PN injury rather than CNS injury. Sides: Sedation, drowsiness, nausea, dependence -Valium/Diazepam -Flexeril/Cyclobenzaprine -Paraflex/ChlorzoxazoneAlzheimer's DiseaseNeurodegenerative disorder that results in deterioration and irreversible damage to cortex and subcortical areas. S/Sx: Changes in higher cortical functions (new learning, memory, concentration), progressing to loss of orientation, depression, rigidity, bradykinesia, and impaired self-care. End-stage is severe intellectual/physical disability, incontinence, dependence, and inability to speak. Tx: Cholinergic agents (Cognex, Donepezil and Rivastigmine) can alleviate some sxs and control behavior with substantial sides.Amyotrophic Lateral Sclerosis (ALS)Degenerative disease producing UMN and LMN impairments, no sensory deficits. Loss of anterior horn cells in spinal cord and motor nuclei in lower brainstem causes weakness and atrophy. Corticospinal and corticobulbar tracts demyelinate, causing UMN deficits. LMN Sxs: Asymmetric msk weakness (distal to prox), fasciculations, cramping, and atrophy of hands UMN Sxs: Lack of coordination, spasticity, clonus, Positive Babinski Global Sxs: Fatigue, oral motor impairment, motor paralysis, respiratory paralysis Tx: Riluzole/RilutekBell's PalsyTemporary unilateral facial paralysis secondary to trauma w/demyelination or degen of facial nerve. Common between 15-45. Etiology: Secondary to viral infection, especially herpes simplex/zoster Sxs: Asymmetrical facial drooping of eyelid and mouth, drooling, dryness of eye, inability to close eyelid due to weakness Tx: Anti-viral meds and high dose steroids. PT for stimulation of facial nerve, facial massage/exerciseCarpal Tunnel SyndromePeripheral nerve entrapment due to compression of median nerve passing through carpal tunnel, increasing pressure in carpal tunnel from normal 2-10 mmHg to 30 mmHg, causing sensory and motor disturbances in median nerve distribution Etiology: Repetitive use, RA, Pregnancy, diabetes, trauma, Tumors, hypothyroidism Sxs: Sensory changes and paresthesia in median nerve distribution. Radiation into UE, shoulder, neck. Night pain, hand weakness, muscle atrophy, decreased grip strength, clumsiness, decreased wrist mobility. Tx: splinting, ergonomics, corticosteroid injections, surgical release.Friedrich's AtaxiaMost common autosomal recessive ataxia. Gait unsteadiness early in life, followed by UE ataxia, dysarthria, and paresis. Mental function declines and tremors may be seen. Impaired reflexes vibration, and position senses.Spinocerebellar AtaxiasMain autosomal dominant ataxias. Many manifestations affecting CNS and PNS, often presenting with neuropathy, pyramidal signs (loss of fine motor, Babinski), ataxia, and RLSAcquired AtaxiasNonhereditary, from neurogenerative disorders (alcoholism, hypothyroidism, vitamin E deficiency), or toxin exposure (Carbon Monoxide, heavy metals, lithium).Diabetic NeuropathyProlonged exposure to high blood glucose results in nerve ischemia, impairing nerve function. Sxs: Weakness/sensory deficits dystally in symmetrical pattern, with c/o tingling, numbness and pain typically in feet. Can include wasting of muscles in feet/hands, stocking glove sensory distribution impairments, and orthostatic hypotension.EpilepsyHypersynchronous electrical discharge of cortical neurons, typically unprovoked and unpredictable. Seizures are transient events that are hallmark signs of epilepsy but one seizure does not equal epilepsy. Etiology: Most are idiopathic, but may include genetics, head trauma, dementia, CVA, CP, down's, and autism. Sxs: LO awareness or LOC, disturbances in movt, sensation, modd, or mental function.Guillain-Barre SyndromeAlso called acute polyneuropathy. Autoimmune response to previous respiratory infection, flu, immunization, or surgery causing a temporary inflammation and demyelination of PNS myelin sheaths, sometimes resulting in axonal degeneration. Sxs: Motor weakness in distal to proximal progression, NO LOSS OF SENSATION, and possible respiratory paralysis. Initially presents with symmetrical distal motor weakness that peaks 2-4 weeks post onset. Muscle/respiratory paralysis, DTR absence, and inability to speak/swallow may occur. Can be life threatening. Tx: Immunosuppressive and analgesics, PT for pulmonary rehab, strengthening, mobility training, WC or orthotic scrip, or asst device training.Huntington's DiseaseAutosomally dominant condition, characterized by degen and atrophy of basal ganglia ad cerebral cortex, causing neurotransmitters to be deficient and unable to modulate movement. Sxs: Involuntary choreic movements, alteration in personality, grimacing, protrusion of tongue, and ataxia w/choreoathetoid movements. Late stage--mental deterioration, IQ drop, depression, immobility Tx: Maximize endurance, strength, balance, postural control, and functional mobility.Multiple SclerosisAutoimmune disorder that attacks the proteins in the myelin sheath, decreasing efficiency of nerve impulse transmission. Sxs: Initial symptoms--visual problems, sensory changes, clumsiness,weakness, ataxia, balance dysfunction, fatigue. Disease has exacerbation and remissions, with frequency and intensity indicating course of disease process. Tx: Lessen length of exacerbations and maximize health of pt. Regulate activity level, relaxation, energy conservation techniques, normalization of tone, adaptive/assistive device training.Myasthenia GravisAutoimmune disease resulting in poor nerve transmission at neuromuscular junction. Antibodies block/destroy receptors for ACh uptake, preventing muscle contraction. Sxs: -Dysarthria -Dysphagia -Dysphonia -Diplopia -Daily fluctuations in fatigue -Proximal MSK weakness -Ptosis and facial weakness "Crisis" may include respiratory muscles, requiring vent. -75% of people with MG have thymus abormalities (hyperthyroidism, thyrotoxicosis, thymic tumor, overactive thymic gland) Tx: ACh drug therapy, plaspaheresis, immunosuppressive therapy. PT for pulmonary rehab, preventing secondary osteoporosis. AVOID HOT/COLD, as well as strenuous exercise. No eccentrics. Commonly confused with MS. Differentiate w/ fatigue as day progresses + improvement in strength post rest.Parkinson's DiseasePrimary degenerative disorder. Production of dopamine decreases in substantia nigra of basal ganglia, resulting in inability to modulate and control voluntary movement. Etiology: Primary--unknown. Contributing factors--genetics, CO toxicity, manganese or copper excess, vascular impairment of striatum, encephalitis, or other neurodegen disease (Alzheimer's, Huntington's) Sxs: Resting tremor in hands or feet increasing with stress and disappearing with sleep. Early--balance disturbances, impairment with fine manipulative movts (writing, dressing). Progression--Hypokinesia, sluggish movement, shuffling gait, bradykinesia, rigidity, freezing during gait. Tx: Dopamine replacement therapy. PT for strength, endurance, and functional mobility.Post-Polio Syndrome (PPS)a neurologic disorder marked by increased weakness and/or abnormal muscle fatigue in persons who had paralytic polio many years earlier -Slow, progressive weakness, muscle atrophy, swallowing issues.Transient Ischemic AttackTemporary interruption of blood supply, symptoms resolve in 24-48 hours. Most often at carotid and vertebrobasilar arteries.Cerebrovascular AccidentIschemia or hemorrhage causes lack of blood supply to a specific area of the brain.Transient Ischemic Attack (TIA)Temporary interruption of blood supply, symptoms resolve in 24-48 hours. Most often at carotid and vertebrobasilar arteries.Completed StrokeA CVA that presents with total neurological deficits at the onset.Stroke in EvolutionCVA usually caused by a thrombus that gradually progresses. deficits are not seen for one to two days after onset.Ischemic StrokeLoss of perfusion to portion of the brain, causing irreversible infarction. Caused by Embolus (20%), or ThrombusInfarctionArea of dead tissue (necrosis) caused by ischemiaEmbolus ischemic Stroke20% of CVAs - associated with CVD, embolus may be solid, liquid or gas and can originate in any part of body. Embolus travels through the bloodstream to cerebral arteries causing occlusion of blood vessel and a resultant infarct. MCA most commonly affected by embolus from internal carotid arteries. Tissues distal to the infarct can sustain higher permanent damage. Often presents with HA.Thrombusblood clotEmbolusA clot that breaks lose and travels through the bloodstream.Thrombus Ischemic StrokeAtherosclerotic plaque occludes an artery or branch causing an infarct. Sxs can appear in minutes or over several days. Usually occurs during sleep or waking up after myocardial infarction or surgical procedure.Hemorrhagic CVAAbnormal bleeding of brain from rupture. Accumulation of blood causes compression and disrupts oxygen flow to an area of the brain, causing infarction. HTN is a precipitating factor, causing rupture of an aneurysm or arteriovenous malformation. 50% of deaths occurin first 48 hrs. Sxs: Severe headache, vomiting, high BP, abrupt onset of symptoms.Left Hemisphere CVA SymptomsWeakness, paralysis of contralateral side Hemianopsia on contralateral side Increased frustration Decreased processing Possible aphasia (expressive, receptive, global) Possible dysphagia Possible motor apraxia Decreased discrimination between L and RRight Hemisphere CVA SymptomsWeakness, paralysis of contralateral side Hemianopsia on contralateral side Decreased attention span Decreased awareness and judgement Memory deficits Inattention to contralateral side Decreased abstract reasoning Emotional lability Impulsive behavior Decreased spatial orientationBrainstem CVA symptomsUnstable vital signs Decreased LOC Decreased ability to swallow Weakness on both sides of the body Paralysis on both sides of the bodyCerebellum CVA SymptomsDecreased balance Ataxia Decreased coordination Nausea Decreased ability for postural adjustment NystagmusExtensor Synergy UEscapular Protraction/depression shoulder adduction/internal rotation elbow extension, forearm pronation wrist and finer flexion/extensionFlexor synergy UEscapular Retraction & elevation shoulder abduction & external rotation elbow flexion, forearm supination wrist flexion, and finger flexionExtensor synergy LEhip abduction/extension/internal rotation knee extension ankle plantar flexion/inversion toe flexionFlexor Synergy LEhip flexion/abduction/external rotation knee flexion ankle dorsiflexion/inversion toe extensionCVA Tests and MeasuresNIH Stroke Scale: Assessment of acute CVA relative to impairment Functional Independence Measure: Assesses level of burden by measuring mobility and ADL management Stroke Impact Scale: Assessment of physical and social disability or level of impairment secondary to CVA Fugl-Meyer Assessment of Physical Performance: Motor, sensory, balance impairment, pain, ROMThree stages of Motor Learningcognitive stage, associative stage, autonomous stageCognitive Stage of Motor LearningInitial stage of learning. Conscious processing of information, problem solving. Many errors, inconsistent attempts/performance.Associative Stage of Motor LearningCan distinguish errors in performance, and errors decrease with performance. Decreased need for conscious concentration, and increased movt coordination.Autonomous Stage of Motor LearningFinal stage of learning, little need for cognitive control. Can perform task with interference from variable environment. Automatic response, error-free, can multi-task. Internal feedback dominant.Intrinsic feedbackFeedback that comes to the person through sensory systems as a result of the movement.Extrinsic feedbackRepresents info that can be provided while a task or movement is in progress, or after. Can be verbal or tactile.Concurrent feedbackGiven during task performance about quality of movement, usually during associative and autonomous stagesDelayed Feedbackfeedback provided several seconds or more following movement completion Provides brief period of introspection and self-assessment, improving retentionBandwidth FeedbackProvided only when patient's performance deviates outside boundaries of what is considered "correct", pre-determined at start of task. Prevents bad habit formation and keeps patient from safety risks.Summary FeedbackFeedback after a set number of trials, shown to dramatically improve skill retention while significantly delaying acquisition of the skill. Cognitive and associative learning stagesFaded feedbackProvided after every trial, then less frequently. Every trial-->every 3rd-->every 5th etc Used in early stages of motor learning to transition from acquisition to retentionKnowledge of Results (KR)A form of extrinsic feedback, includes terminal feedback regarding the outcome of a movementKnowledge of Performance (KP)extrinsic feedback given by clinicians to patients about performance variables such as ROM, muscular force, coordination of extremity's movement in space. Most effective KP is info about critical components of the actions and provides prescriptive info about how to correct errors.Massed practicepractice performed all at once, practice time is greater than amount of rest.Distributed practiceRest time in trials is equal or greater than practice time for each trialConstant PracticePractice of a given task under uniform conditionVariable practicePractice of a given task under differing conditionsRandom PracticeVarying practice amongst different tasksBlocked PracticeConsistent practice of a single taskWhole trainingPractice of an entire taskPart trainingPractice of an individual component or select componentsClosed system modelMULTIPLE feedback loops Nervous system actively initates movement (doesnt react to stimuli)Non-associative LearningOccurs when an organism is repeatedly exposed to one type of stimulus (haituation, sensitization)Associative Learninglearning that certain events occur together. The events may be two stimuli (as in classical conditioning) or a response and its consequences (as in operant conditioning).Procedural LearningTask is learned by forming movement habits through repetitive practice.Declarative LearningAttention, awareness, and reflection to attain knowledge that can be consciously recalled (mental practice)Open System ModelSingle transfer of information without any feedback loop. Nervous system is awaiting stimuli in order to react. (Reflexive hierarchical theory)Brunnstrom's Seven Stages of Recovery1. No volitional movement 2. Appearance of basic limb synergies, beginning of spasticity 3. Voluntary synergies, spasticity increases 4. Spasticity decreases, movement patterns not dictated solely by synergies 5. Further decrease in spasticity, independence from limb synergy patterns. 6. Isolated joint movements with coordination 7. Normal motor functionD1 Flexion UEClose your hand and pull up and across your body.. putting on earringD1 Extension UEextension, abduction, internal rotationD2 Flexion UEflexion, abduction, external rotation Pulling a sword out.D2 Extension UEextension, adduction, internal rotation. Sheathing the sword.D1 Flexion LEER, Flex, Add "Bring your foot up, turn and pull your leg up and across your body"D1 Extension LEextension, abduction, internal rotationD2 Flexion LEflexion, abduction, internal rotationD2 Extension LEextension, adduction, external rotationMobilityAbility to initiate movement through functional ROMStabilityAbility to maintain position or posture through cocontraction and tonic holding around a joint. Ex: Unsupported sitting.Controlled MobilityAbility to move within a weight bearing position or rotate around a long axis. Example: Activities on POE or weight shifting in quadruped.SkillAbility to consistently perform functional tasks with normal posture and balance reactions. Examples: ADLs and community locomotion.Agonistic Reversals (AR)Concentric contraction against resistance followed by alternating concentric/eccentric contractions w/resistance. Slow, sequential, used throughout range. Devt. Sequence: Controlled mobilty, skillAlternating Isometrics (AI)Isometric contractions performed alternating from muscles on one side of the joint to the other side without rest. Devt. Sequence: StabilityContract Relax (CR)Technique to increase ROM. When muscle reaches point of limitation, patient performs maximal contraction of antagonistic muscle group. Therapist resists movement for 8-10 seconds, then lets patient relax. Dev. Sequence: MobilityHold-Relax (HR)Isometric contraction to increase ROM at limiting point. Devt. Sequence: MobilityHold-Relax Active Movement (HRAM)Improves initiation of muscles at 1/5 or less. Isometric contraction once extremity is placed into shortened ROM. Upon relaxation, moved to lengthened with quick stretch, and patient returns extremity to shortened position with active contraction. MobilityJoint DistractionProprioceptive component to increase ROM around a joint.Normal Timing (NT)Improve coordination in all components of a task. Distal-->proximal sequence, with prox components restricted until distal components activated and initiate movt.Repeated Contractions (RC)-used when multiple muscle groups are weak -concentric until point of weakness then resist isometrically -apply a quick stretch then have patient continue actively into pattern -hold an isometric at end of range then concentrically contract antagonists with an isometric at the end of that range -mobilityResisted Progression (RP)Emphasizes coordinationof proximal components during gait. Resistance applied to pelvis, hips, or extremity during gait cycle to enhance coordination. SkillRhythmic Initiation (RI)Assists in initiating movement when hypertonia exists. Progresses from passive (let me move you) to active assistive (help me move you) to slightly resistive (move against the resistance). Movements must be slow and rhythmical and allow for full ROM Mobility/StabilityRhythmic Rotation (RS)Passive technique used to decrease hypertonia by slowly rotating extremity around longitudinal axis.Slow Reversal (SR)Slow and resisted concentric contractions of agonist and antagonists around a joint w/out rest between reversals. Used to improve control of movement and posture.Slow Reversal Holds (SRH)Slow reversal with the addition of isometric contraction at the end of each movementTiming for EmphasisUsed to strengthen weak component of a motor pattern. Isotonic and isometric contractions produce overflow to weak muscles.Agnosiathe inability to recognize familiar objects.Agraphesthesiainability to recognize symbols, letters or numbers traced on the skinAgraphiainability to writeAlexiainability to readAnosognosiadenial of illnessApraxiaimpaired ability to carry out motor activities despite intact motor functionConstructional ApraxiaThe inability to reproduce geometric figures and designs. A person is often unable to visually analyze how to perform a taskIdeational Apraxiadifficulty conceptualizing planned, multistep movementsIdeomotor ApraxiaCan plan a movement or task, but can't volitionally perform it.NeologismSubstitution in a word so severe it makes the word unrecognizable.Decerebrate rigidityExtension of trunk and all four extremities. Result of corticospinal lesion at brainstem level.Decorticate rigidityTrunk and lower extremities flexed. upper extremities in flexion. Result of corticospinal lesion at level of diencephalon.Hemiparesisweakness on one side of the bodyHemiplegiaparalysis of one side of the bodyhomonymous hemianopsiaThe loss of the right or left half of the field of vision in both eyes.Unilateral neglectInability to interpret stimuli and events on contralateral side of hemispheric lesion. L sided neglect most common with lesion to R inferior parietal.Spinal Cord InjuryPermanent damage to spinal cord, resulting in neurological deficits. MVA is largest cause, then stabbing, falls, sports injuries, high risk behaviors, axial loading, rotational injuries. Flexion injuries occur most often at C5-6, Extension injuries occur most at C4-5.Complete spinal cord lesionTotal loss of sensation and voluntary muscle control below level of lesionIncomplete spinal cord lesionScattered motor function, sensory function, or both below level of lesion.Anterior Cord SyndromeIncomplete lesion from compression and damage to anterior spinal cord. MOI is usually cervical flexion. Usually whiplash Loss of motor function and pain/temp sense due to damage of corticospinal and spinothalamic tracts. Everything but DCML, but no pain or motor. UE more than LEPosterior Cord SyndromeLoss of dorsal columns bilaterally, bilateral loss of proprioception, vibration, pressure, stereognosis, 2 point discrimination; preservation of motor function, pain and light touch; very rare!Cauda Equina Syndrome-Injury at the L1 level and below resulting in a LMN lesion -Can be complete, often are incomplete due to large number of nerve roots in area. Considered peripheral nerve injury. -Flaccid paralysis w/no spinal reflex activity, loss of bowel and bladder function Above L1 acts like UMN lesion. Can use suprapubic tapping to help void Below L1, will present as LMNCentral Cord SyndromeMost common type of SCI. Incomplete lesion from compression/damage to central portion of spinal cord, MOI is usually cervical hyperextension, but can be caused by spinal stenosis. -Spinothalamic, corticospinal, and dorsal column tracts are damaged -Greater UE involvement than lower extremities -Greater motor than sensory deficits -Minimal bowel/bladder loss -Should regain ability to ambulateASIA impairment scale Category AComplete No motor or sensory function in the sacral segments (S4-S5).ASIA impairment scale Category BIncomplete Sensory but NO MOTOR function below the neurological level and includes S4-S5.ASIA impairment Scale Category CIncomplete Motor function below the neurological level, and more than half of key muscles below the neurological level have a muscle grade of less than 3.ASIA Impairment Scale Category DIncomplete Motor function below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more.ASIA Impairment Scale Category ENormal Motor and sensory function are normal.Motor Level of SCIMost caudal muscles that have an MMT of 3 or greater with superior segment tested as 5Motor Index Scoring for SCITesting each muscle using 0-5 scoring, total of 25 points per extremity for total possible score of 100Sensory level for SCIMost caudal dermatome with a normal score of 2/2 for light pinprick. 0 is absent, 1 is impaired, 2 is intactMuscles tested in SCIC5: Elbow flexors C6: Wrist Extensors (ECRL and ECRB) C7: Elbow Extensors C8: Finger flexors (FDP) to middle finger T1: Small finger abductors (ADM) L2: Hip Flexors L3: Knee extensors L4: Ankle Dorsiflexors (TA) L5: Long toe extensors (EHL) S1: Ankle PFSensory Testing in SCIC2: Occipital Protuberance C3: Supraclavicular Fossa C4: Top of AC joint C5: Lateral antecubital fossa C6: Thumb C7: Middle Finger C8: Little Finger T1: Medial Antecubital Fossa T2: Apex of axilla T3: 3rd IS space T4: Fourth IS space @ nipple line T5: Fifth IS T6: Sixth IS T7: Seventh IS T8: Eighth IS T9: Ninth IS T10: Umbilicus T11: 11th IS T12: Midpoint of inguinal ligament L1: Half distance between T12 and L2 L2: Midanterior thigh L3: Medial Femoral Condyle L4: Medial Malleolus L5: Dorsum of foot at 3rd MTP joint S1: Lateral heel S2: Popliteal fossa S3: Ischial Tuberosity S4-5: Perianal areaDeep Vein ThrombosisFormation of blood clot that becomes dislodged (embolus). Patients w/ SCI are at greater risk of developing DVT due to decrease in normal pumping action from muscular contraction in LE. Homan's Sign to confirm presence of DVT. Prevention should include anticoagulants, positioning schedule, ROM, and elastic stockings. S/Sx: Swelling, pain, sensitivity over area of clot, warmth in area. Tx: Bed rest and anticoagulants. Avoid active or passive movement to avoid dislodging clot.Ectopic bone(or heterotopic ossification): spontaneous formation of bone in the soft tissue/muscle. occurs adjacent to larger joints such as knees or hips. Possibly due to tissue hypoxia or abnormal calcium metabolism. Early symptoms: Edema, decreased ROM, increased temp of involved joint. Tx: Diphosphates that inhibit etopic bone formation, focus on maintaining ROM and keeping pt independentOrthostatic HypotensionDecrease in blood pressure related to positional or postural changes from lying to sitting or standing positions. In SCI patients loss of sympathetic control of vasoconstriction in combo with absent muscle tone. Decrease of systolic 20mmHg after moving from lying to sitting or decrase in diastolic BP greater than 10 mmHg. Sxs: Complaints of dizziness, lightheadedness, nausea, blacking out when going from horizontal to vertical. Tx: Elastic stockings/ace wraps to LE, Gradual progression to vertical position.Pressure UlcersCompromised circulation secondary to pressure, friction, or shearing. Most common areas: -Coccyx -Sacrum -Ischium -Trochanters -Elbows -Buttocks -Malleoli -Scapulae -Prominent Vertebrae Symptoms: Reddened area that persists or open area of skin Treatment: Prevention is greatest importance. Change position frequently, proper skin care, appropriate cushion, consistent weight shift, proper nutrition and hydration.Autonomic DysreflexiaMost dangerous complication of SCI, can occur in T6 and above. Noxious stimuli below level of lesion triggers autonomic nervous system causing sudden elevation in BP. Can lead to convulsions, hemorrhage, or death. Cause: Full bladder, kink or blockage in catheter, bladder infections, pressure ulcers, extreme temp changes, tight clothing, ingrown toenails. Sxs: High BP, severe headache, blurred vision, stuffy nose, profuse sweating, goosebumps above lesionand flushing below level of injury. Tx: Do not lie patient down, will only elevate BP. Patient should be examined for irritating stimuli and bowel impaction.Bed Mobility SCI (rolling, supine/sit, scooting) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dependent (C1-4), Mod to max asst (C5). Mid Tet (C6): Min asst to mod independent w/equip Low Tet (C7-8): Independent Para: IndependentTransfers (bed, car, toilet, bath, WC) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dependent (C1-4), Max w/ sliding board (C5) Mid Tet (C6): Min asst to mod I for slidingboard, dependent with WC>car, dependent w/ floor transfers Low Tet (C7-8): ModI to I with sliding board, ModAsst to ModI with car, Max to mod with floor transfers Para: Independent with level surfaces/car transfers, min asst to independent w/ floor transfers and uprighting WCWeight Shifts (Pressure relief, repositioning) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): ModI with power recline tilt weight shift, dependent with manual recline/tilt/lean weight shift Mid Tet (C6): ModI with power recline weight shift, Min Asst to Mod I with side/side/forward lean weight shift Low Tet (C7-8): ModI with side to side/forward/depression weight shift Para: ModI with depression weight shiftWheelchair Mgmt (wheel locks, armrests, safety straps, cushion adjustment) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dependent with all Mid Tet (C6): Some asst required Low Tet (C7-8): May require asst with cushion adj and WC maint Para: Independent with allWheelchair Mobility (Smooth surfaces, up/down ramps/curbs, rough terrain, up/down steps) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Sup/ to modI with power WC on terrain. ModI with manual on smooth going forward, max Asst to dep with manual in all others (C5) Mid Tet (C6): ModI with terrain, Dep to max Asst up/down curb with pwr, max/mod asst with manual. Mod tomin asst on ramps with manual Low Tet (C7-8): ModI on terrain with power, Dep to Max Asst up/down curb with power, Mod/Min Asst with manual. Min asst on rough terrain. Dep/Max asst up/down steps on manual Para: ModI with curbs in manual WC, ModI with descending steps, Max to Min asst asending steps with WCROM/Positioning (PROM to trunk, legs, arms, bed positioning) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dependent Mid Tet (C6): ModAsst to ModI Low Tet (C7-8): MinAsst to ModI Para: IndependentFeeding (Drinking, finger and utensil feeding) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dependent (C1-4), Min Asst with adaptive equipment (C5) Mid Tet (C6): ModI with adapt equip Low Tet (C7-8): ModI with Adapt equip (C7) Para: IndependentGrooming (Face, teeth, hair, makeup, shaving face) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dependent (C1-4). Min Asst w/ adaptive equip for all but hair, with Max-mod asst for hair (C5). Mid Tet (C6): Mod I with adapt equip Low Tet (C7-8): Mod I Para: IndependentDressing (and undressing in bed or WC, upper body/lower body) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dependent Mid Tet (C6): ModI for upper in bed or WC, MinAsst with lower in bed. ModAsst with lower undressingin bed Low Tet (C7-8): ModI for upper/lower dressing in bed, MinAsst with lower body dressing/undressing in WC (C7), ModI for (C8) Para: ModIBathing (drying off, upper/lower body) High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dependent Mid Tet (C6): Min Asst for Upper body, Mod Asst for lower body. Use shower/tub chair Low Tet (C7-8): ModI with all using shower/tub chair Para: ModI with all on tub bench or tub bottom cushionBowel/Bladder High Tet (C1-C5): Mid Tet (C6): Low Tet (C7-8): Para:High Tet (C1-C5): Dep Mid Tet (C6): Min Asst male,Mod Asst female for bladder. Mod Asst with equip for bowel Low Tet (C7-8): ModI for male in bed or WC, ModI for female in bed and ModAsst for WC. Bowel: MinAsst to ModI with equip Para: ModIHead/Hips Relationshipmechanics used during mobility training with UE WB used as fulcrum for activity, head moves in opposite direction from hipsMyelotomysurgical procedure that severs certain tracts within the spinal cord in order to decrease spasticity and improve functionNeuroectomysurgical removal of a nerve to decrease spasticity and improve functionNeurogenic Nonreflexive bladderbladder is flaccid as a result of a cauda equina or conus medullaris lesion. sacral reflex arc is damagedNeurogenic Reflexive BladderThe bladder empties reflexively for a patient with an injury above the level of T12. The sacral reflex arc remains intact.Paradoxical BreathingAbdomen rises, chest is pulled inward during inspiration, and opposite on expiration. Common in tetraplegia.ParaplegiaInjury at Thoracic, Lumbar, or Sacral spineTetraplegiaInjury at cervical spinal cord.RhizotomySurgical resection of sensory component of spinal nerve to decrease spasticity and improve functionSpinal shockPhysiologic response that occurs between 30-60 min after trauma and can last up to several weeks, presenting as total flaccid paralysis and loss of all reflexes below level of injurySacral sparingIncomplete lesion where some of innermost tracts remain innervated. Sensation in saddle area is present, rectal sphincter can contract, and toe flexor movement is retained.Tenodesis GraspPatients with tetraplegia that do not possess motor control for grasp can utilize the tight finger flexors in combination with wrist extension to produce a form of graspTenotomySurgical release of tendon to decrease spasticity and improve functionZone of PreservationPoor or trace motor/sensory function up to three levels below neurologic level of injury.Types of TBIOpen Closed Primary SecondaryTraumatic Brain Injurya blow to the head or a penetrating head injury that damages the brain. Leading risk factor is MVA, then falls, high risk behaviors, and gunshot woundsOpen TBIDirect penetration through skull to brain (gunshot wound, knife, sharp object, skull fragments)Closed TBIBrain injury without penetration. Concussion, contusion, hematoma, injury to extracranial blood vessels, hypoxia, drug overdose, accel/decel injuriesPrimary Injury (TBI)Initial injury to brain sustained by impact (skull penetration, fracture, contusions to gray/white matter) Can be Coup: Direct lesion under point of impact with local brain damage or Contrecoup: Injury on opposite side of impact due to rebound effect of brain after impactSecondary Injury (TBI)Brain damage that occurs as a response to initial injury. Hematoma, hypoxia, ischemia, increased intracranial pressure, post-traumatic epilepsyLevels of Consciousness (LOC)Coma: Unconscious and unresponsive to internal/external stimuli Stupor: Unresponsive with arousal from repeated stimuli Obtundity: Sleep, reduced alertness to arousal, delayed response to stimuli Delirium: Disorientation, confusion, agitation, loudness Clouding of consciousness: Quiet behavior, confusion, poor attention, delayed response Consciousness: Alertness, awareness, orientation, memoryGrade 1 ConcussionNo LOC, some transient confusion. Symptoms resolve 15 min of event, with full memory of event. Return if symptom free after one week.Grade 2 ConcussionModerate head injury causing transient confusion lasting longer than 15 minutes. Poor concentration, retrograde, and anterograde amnesia. CT scan indicated if symptoms worsen. RTP deferred until athlete is symptom free for 2 weeks with exertion and rest.Grade 3 ConcussionAny head injury with LOC. Transport to emergency room for full neurological evaluation. Hospitalization for persistent symptoms. Held out of competition for a minimum of one month once symptom free. This type causes diffuse axonal injury and if severe, can result in a coma.Rancho Los Amigos Scale of Cognitive FunctioningI. No response II. Generalized Response (Same response regardless of stimulus) III. Localized Response (Responses directly related to type of stimulus, still inconsistent) IV. Confused-Agitated (Bizarre behavior, uncooperative, incoherent responses) V. Confused-Inappropriate (Can respond to commands, non-purposeful/random/fragmented responses) VI. Confused-Appropriate (Goal-directed behavior dependent on external stimuli. Can follow directions. May respond incorrectly.) VII. Automatic-Appropriate ("Robot-like", minimal to no confusion, but little recall of activities) VIII. Purposeful-Appropriate (Can recall and integrate past and recent events, aware/responsive with learning carryover)Glasgow Coma ScaleDetermines arousal and cerebral cortex function. Total of 4 for Eye opening, 6 for Motor Response, and 5 for Verbal response E+M+V=3-15 8 or less: Severe brain injury and coma. 9-12: is moderate brain injuries. 13-15: Mild brain injuriesIntracanial PressureNormal: 5-15 mmHg Abnormal: Above 20 Avoid cervical flexion, percusion/vibration, coughing, or trendelenburgGlasgow Coma Scale: Eye Opening.4 spontaneous 3 to speech 2 to pain 1 noneGlasgow Come Scale: Motor Response6: Obeys comands 5: Localizes pain 4: Withdraws 3: Abnormal flexion 2: Extensor response 1: NilGlasgow Coma Scale: Verbal Response5 - Alert and Oriented 4 - Confused, yet coherent, speech 3 - Inappropriate words and jumbled phrases consisting of words 2 - Incomprehensible sounds 1 - No soundsAnterograde amnesiaInability to form new memoriesRetrograde amnesiaInability to remember events prior to injuryPost-traumatic AmnesiaTime between injury and when patient is able to recall recent events.APGAR Scorea scale of 1-10 to evaluate a newborn infant's physical status at 1 and 5 minutes after birth. Considered good condition if 7-10. 3 or below requires immediate medical attention. Each score is 0-2. Appearance: Blue/Normal except for blue extremities/Pink Pulse: Absent/Below 100 bpm/Over Grimace: No response/Min response/Pulls away, sneeze Activity: Floppy/Flexing arms or legs/Active movement Respiration: Absent/Slow/Vigorous cryDevelopment happens:Cephalic to Caudal (head and UE before trunk and LE) Gross to Fine (Large muscle skill acquisition before small) Mass to specific (Simple to complex) Proximal to Distal (Trunk control is acquired before extremity controlPositive Support ReflexWhen weight is placed on balls of feet in upright, baby stiffens its legs and trunk into extension. Normal Age: 35 weeks gestation to 2 months Interferes with standing, walking, and balance, and can cause contractures of ankles into PFStepping ReflexWhen supported upright and feet flat, baby will reciprocally flex and extend legs. Normal age: 38 weeks to 2 monthsGalant ReflexWhen baby's trunk is touched from shoulder to hip, baby's trunk will laterally flex to side of stimulus. Normal age: 30 weeks of gestation to 2 monthsRooting ReflexTouch on cheek causes baby to turn head to same side with mouth open. Normal Age: 28 weeks of gestation to 3 months Interferes with oral motor devt, visual tracking, devt of midline control of headPalmar Grasp ReflexBaby will flex fingers and grab something with pressure in palm. Normal Age: Birth to 4 monthsMoro ReflexIf dropped into extension a few inches, baby will splay out with arms and fingers, then cross trunk into adduction and cry. Normal Age: 28 weeks of gestation to 5 months Interferes with balance reactions in sitting, eye-hand coordinationStartle Reflexsimilar to Moro but arms are flexed rather than extended and fingers are closed. Happens in response to loud sudden movement, integrated by 5 monthsAsymmetrical Tonic Neck Reflex (ATNR)When face is turned to one side, arm and leg on face side are extended, arm and leg on scalp side are flexed. Normal Age: 0-6 months Interferes with feeding, visual tracking, bilateral hand use, rollingTonic Labyrinthine ReflexIn supine: body and extremities in extension In prone: body and extremities in flexion Normal Age: Birth to 6 monthsSymmetrical Tonic Neck Reflex (STNR)When head is in flexion, arms are flexed and legs are extended. When head is in extension, arms extended and legs flexed. term-369 Normal Age: 6-8 months Arms follow the head, Legs go opposite.Plantar Grasp ReflexPressure to base of toes causes toe flexion. Normal Age: 28 weeks of gestation to 9 monthsPediatric Therapeutic Positioning: SupinePelvis/Hips: Pelvis in line with trunk, hips symmetrically abducted 10-20 deg Trunk: Straight, Shoulders in line with hips Head/Neck: Neutral, slight cervical flexion Shoulders/Arms: Fully supported, forward of trunk, forearms resting on pillow Legs/Feet: Knees supported in flexion, feet at 90Pediatric Therapeutic Positioning: PronePelvis/Hips: Pelvis in line with trunk, hips in EXT, hips symmetrically abducted 10-20 deg Trunk: Straight, shoulders in line with hips Head: Neck: Head in neutral position, facing one side w/ slight cervical flexion Shoulders/Arms: Arms fully supported, forward of trunk flexed Legs/Feet: Knees extended, feet at 90Pediatric Therapeutic Positioning: SidelyingPelvis/Hips: Pelvis in line with trunk, hips in FLEX, 10-20 deg ABD Trunk: Straight, shoulders in line with hips, slight sidebending Head/Neck: Head in neutral position, facing forward, slight cervical flexion Shoulders/Arms: Both arms supported, lower arm forward, not lying on point, in neutral. Upper arm 0-40 deg IR Legs/Feet: Knees in Flexion, Feet at 90, pillow between kneesPediatric Therapeutic Positioning: SittingPelvis/Hips: Pelvis in line with trunk, hips at 90 deg flexion, neutral rotation of pelvis, hips abd 10-20 deg Trunk: Straight, shoulders over hips, not rotated Head/Neck: Head neutral, facing forward Shoulders/Arms: Arms supported, elbows in FLEX, 0-45 deg IR Legs/Feet: Knees at 90, Ankles at 90, feet and thighs supportedArthrogryposis Multiplex CongenitaNon-Progressive neuromuscular disorder that occurs during 1st trimester, causing fibrosis of muscles and joints. Possibly caused by poor movement during early development. Can be genetic. Sxs: Cylinder-like extremities with little definition, contractures, joint dislocation, muscle atrophy Treatment: Attain max level of devt. skills through positioning, stretching, splinting, adaptive equipmentAutism Spectrum Disorder (ASD)Group of brain disorders characterized by difficulties w/ social interaction, communication, and repetitive behavior. Sxs: Apparent around 2 or 3. Nonpurposeful or absent speech/facial expressions, inability to understand nonverbal, lack of empathy, preoccupation with rituals. Treatment: Multidisciplinary, focusing on improving social comm and decreasing nonpurposeful movts and vocalizations. Sensory integration therapyCerebral PalsyMovement disorder caused by brain damage. Non-progressive, acquired in utero, birth, or infancy due to lack of oxygen, maternal infection, substance abuse, toxemia, prematurity. Can be acquired through meningitis, CVA, seizures, or brain injury. Sxs: Mild to severe loss of control, profound intellectual disability. Abnormal muscle tone, abnormal reflexes Can be Spastic: Lesion in motor cortex of cerebrum, UMN damage or Athetoid: Lesion involved basal ganglia Monoplegia: one extremity Diplegia: Bilateral lower extremity with some UE involveent Hemiplegia: Unilateral UE and LE Quadriplegia: Whole bodyAthetoid Cerebral PalsyA type of cerebral palsy in which movements are contorted, abnormal, and purposeless. Less likely to have contractures. PT emphasis is on cocontractures and voluntary controlDown SyndromeGenetic abnormality, extra 21st chromosome (trisomy 21). Sxs: Intellectual disability, hypotonia, joint hypermobility, flattened nasal bridge, narrow eyelids, feeding impairment, heart disease. Tx: Exercise, fitness, stability, respiratory functionDuchenne Muscular DystrophyProgressive disorder caused by absence of gene required to produce dystrophin and nebulin, causing muscle fiber membranes to weaken, become destroyed, and lose contractility. Fat and connective tissue replace muscle, death occurs from cardiopulmonary failure before 25. Sxs: First signs at 2-5. Progressive weakness, disinterest in running, toe walking, excessive lordosis, pseudohypertrophy of muscle. ADL usage begins around 5, inability to ambulate follows. Gower's sign usually present.Prader-Willi SyndromeGenetic condition diagnosed by physical attributes and patterns of behavior. Small hands feet, and sex organs, hypotonia, obesity, constant desire for food. Presents with coordination impairments and intellectual disability.Spina BifidaCongenital defect occurring in early pregnancy due to insufficient closure of neural tube by day 28 of gestation. Occurs in spine and affects CNS, MSK, and urinary systems. Classified as: Occulta: Non-fusion of spinous processes of vertebrae, with intact spinal cord and meninges. No associated disability Cystica: Cyst-like protrusion through non-fused vertebrae, resulting in impairment. Can be meningocele (herniation of meninges/CSF into sac that protrudes through defect) or myelomeningocele (severe, with spinal cord extending through defect in vertebrae. Cyst may/may not be covered by skin. Sxs: Motor loss below level of deficit, sensory deficits, hydrocephalus, Arnold-Chiari Type II malformation, osteoporosis, clubfoot, scoliosis, tethered cord syndrome, latex allergy, bowel/bladder dysfunction, learning disabilities PEAT NOTE: Hydrocephalus occurs in 25% or more of children with myelomeningocele, additional 60% post closure. Most will require a shunt.Spinal Muscular AtrophyProgressive degeneration of anterior horn cell, caused by genetic inheritance. Categories: -Acute Infantile SMA Type 1: Wernig-Hoffman Disease (birth-2 months, motor degeneration is quick and life expectancy is >1year) -Chronic Childhood SMA Type 2 Wernig-Hoffman Disease (6 months-1 year, slower progression than type 1. Child can survive into adulthood.) -Juvenile SMA Type 3: Kugelberg-Welander (4-17yrs. Will survive to adulthood) Sxs: Progressive muscle weakness, atrophy, diminished DTRs, normal intelligence, intact sensation, end-stage respiratory compromise PEAT Note: If unable to develop sitting ability, pt is unlikely to walk and will need power mobility.Erb's PalsyUpper brachial plexus injury that results from difficult birth. Most common avulsion is at Erb's point in anterolateral neck, damaging C5-C6 (axillary, lateral pectoral, upper/lower subscap, suprascapular, long thoracic, musculocutaneous). Loss of RC, delt, brachilais,coracobrachialis, and biceps function. Sxs: Waiter's tip deformity (loss of shoulder function, elbow flexion, supination, and hand positioned in pinch grip). May have GH subluxation/dislocation, skeletal deformity, poor bone growth, learned pattern of non-use.Klumpke's Palsylower brachial plexus injury resulting in claw hand deformity; usually improves btwn 3-6 months. Affects C7-T1Gross Motor Function Classification System5 level standardized assessment tool classifying a child with a motor disability (like CP). Based on "usual performance" eg what child does regularly rather than what they are capable of 1. Walks without limitations -Independent, climbs steps w/out railing, runs and jumps 2. Walks with limitations -Climbs steps with railing, requires AD for challenging environment -Wheeled mobility for long distance 3. Walks using Hand-held mobility device -Walking AD in most settings, wheeled mobility for long distances 4. Self-mobility with limitations, may use power -May ambulate with walking AD for short distance with assistance 5. Dependent--Transported in manual wheelchair.Bayley IIIassesses children birth to 3-4 in cognitive, language, motor, adaptive behavior, and social-emotional development.Peabody Developmental ScaleBirth to 72 months (6 years)Bruininks-Oseretsky Test of Motor Proficiency (BOT-2)Test of motor function for kids 4 to 21 years old. Assesses motor coordination and balanceLateral Medullary SyndromeAlso called Wallenberg Syndrome of PICA syndrome. Caused by blockage of VA or PICA leading to infarct of lateral medulla oblongata, which houses CN 9-12 Loss of pain and temp on contralateral side Lateral Medullary Syndrome is a BIG HANDFUL Bradycardia Ipsilateral Facial Loss Gag reflex dinimished Horner's sign (ptosis, meiosis, anhydrosis) Ataxia Nystagmus Double Vision (Diplopia) Faulty Speech (Dysphonia) Unable to swallow (Dysphagia) Loss of contralateral limb sensationBasilar Artery StrokeLocked in syndromeSpinal Shock Syndrome- occurs after major damage to the spinal cord - loss/depressed cord functions below the lesion for less the 24 hours to several weeks - subsequent recovery as shock wears off below the transection/damage, resulting in spasticity, exaggerated reflexes, etc.Tibial Nerve Tension testSLR with DF, EVCommon Peroneal Nerve Tension TestSLR with PF and INVSural Nerve Tension TestSLR with DF and INVObturator Nerve Tension TestSlump with Hip ABD +FLEX, knee ext and ankle DFFloor MarkersVisual aid to improve attention and reduce freezing of gait and hypokinesia in Parkinsonian GaitU Walker with laserAD to improve stability and upright positioning while reducing FOG and hypokinesiRhythmic Auditory StimulationA technique used to facilitate rhythmic movement, especially gait in Parkinsonian population Improve cadence, stride length, and gait speed (should be 25% faster than pts current gait speed)Manual ResistanceUsed to facilitate weak muscles, or facilitate desired motionQuick StretchUsed to activate muscles that have difficulty initiating contractionPusher SyndromePatient pushes with stronger extremities towards weaker hemiparetic side. Most often caused by posterolateral thalamus damage Use visual cues, vertical makings, cane in uninvolved side Guard involved side Have pt assess self (what direction are you tilted?)Sensorineural Hearing LossHearing loss caused by damage to inner ear, cochlea, or vestibulocochlear nerve (CN VIII) Ototoxicity, aging, TBI, acoustic neuroma, Meniere's Sxs: Soft sounds are difficult to hear, loud sounds are muffled, high frequency is inaudibleConduction Hearing LossPassage of sound is blocked in ear canal or middle ear -Ear wax -Otitis media -Otosclerosis -Cholesteatoma Sxs: Soft sounds hard to hear regardless of pitch, loud sounds are muffledWeber's TestTuning fork struck and placed on top of head. Pt reports which ear sound is heard louder in. Conductive: Louder on affected side Sensorineural: Louder on unaffected sideRinne's TestTuning fork struck and placed on mastoid bone of suspected side, while asking patient to report when sound is no longer heard. Then, tuning fork is placed 2 cm from auditory canal. Conductive: If pt is not able to hear tuning fork when moved from mastoid to outside ear Sensorineural: Patient is able to hear tuning fork outside ear longer than when held against mastoid, and reports sound has stopped before tuning fork stops vibratingUlnar nerve muscles*Flexor carpi ulnaris *1/2 flexor digitorum profundus *Palmaris Brevis *Abductor digiti minimi *Opponens digiti minimi *Flexor digiti minimi *Interossei *Lumbricales *Adductor pollicisTrigeminal Neuralgiaa condition characterized by sudden, intense, severe lightning-like pain due to an inflammation of the fifth cranial nerveMeralgia Paresthetica-compression of the *lateral femoral cutaneous nerve * -pain & tingling sensation in latearal thigh but *no motor loss* -cause: obesity, postural changes, tight clothing, pregnancyAge-appropriate Activities 4 year oldKicking a rolling ball, catching a small ball, hopping on one footAge-appropriate activities for 2-3 year oldCatching ball, riding tricicyle, running short distancesModified PlantigradeUpright position with UE supportTrendelenburg positionlying on back with body tilted so that the head is lower than the feetModified Trendelenburg positionused in the treatment of shock; the patient is positioned lying flat on the back with the legs elevated 12-16 inches above the head in an effort to improve the blood flow to the brainFowler positionan inclined position in which the head of the bed is raisedSemi Fowler's Positionthe head of the bed is raised 30 degrees; or the head of the bed is raised 30 degrees and the knee portion is raised 15 degreesHoehn and Yahr Scale (1-5)1-Unilateral disease with minimal dysfunction 2-Bilateral or midline impairment without balance dysfunction 3-Bilateral, mild to moderate postural dysfunction 4-Severely disabled but still able to stand and walk 5-Confined to bed and wheelchairFetal Alcohol SyndromeMaxillary hypoplasia, elongated midface, short upturned nose, short attention span, poor growth. Deficits in: -fine motor -Visuomotor -Balance -GraspInfant Head LagNormal until infant is in sitting (3 months)AortaThe large arterial trunk that carries blood from the heart to be distributed by branch arteries through the body. Begins at L Ventricle, descends within thorax, and passes into abdominal cavityInferior Vena CavaReturns venous blood from lower body and viscera to R atriumPulmonary arteriesCarry deoxygenated blood from R ventricle to lungsPulmonary VeinsDeliver oxygen rich blood from lungs to L atriumSuperior Vena CavaReturns venous blood from head, neck, and arms to R atrium.Heart Chambers and ValvesRight Atrium and Left Atrium separated by atrial septum Right Ventricle and Left Ventricle separated by ventricular septum Tricuspid Valve (Tri to be Right) separates R atrium and Ventricle Bicuspid Valve (Bi people are usually Left) separates L Atrium from L ventricleHeart blood flowVena Cava Right Atria Tricuspid Valve Right Ventricle Semilunar Pulmonary Valve Pulmonary Artery Pulmonary Vein Left Atria Bicuspid Valve Left Ventricle Semilunar Aortic Valve AortaCardiac Conduction SystemSA node, AV Node, Bundle of His, Purkinje fibers 60 bpm-->40 bpm-->20 or lessHeart innervationSympathetic: Release of Epinephrine and Norepinephrine to speed up contractions (chronotropic) and increase force (inotropic) Parasympathetic: ACh via Vagus nerve to slow HRBaroreceptor ReflexMechanoreceptors that detect changes in pressure. Arterial baroreceptors (carotid, aortic arch, R subclavian) are high pressure receptors Cardiopulmonary receptors are low pressure receptors Sympathetic activation leads to increased HR, vasoconstriction, increased BP and CO. Parasympathetic activation leads to decreased HR and contractility, and decreased BPBainbridge Reflex(also, called atrial reflex) autonomic reflex that responds to stretch receptors in the atria that send impulses to the cardioaccelerator area to increase HR when venous flow into the atria increasesChemoreceptor ReflexChemosensitive cells in carotid bodies and aortic body respond to changes in pH status and blood oxygen tension. Acidosis (>50mmHg spO2) causes respiratory center stimulation to increase depth and rate of ventilation Activation of parasympathetic system reduces HR and contractility. Hypoxia stimulates CNS to increase sympathetic activity (epinephrine)Valsalva ManueverForced expiration against closed glottis increases intrathoracic pressure +central venous pressure, decreasing venous return, CO, and BP, causing a reflexive increase of HR and contractility.Cardiac Cycleatrial systole/ventricular diastole, ventricular systole/atrial diastole, brief complete diastoleSystoleContractionDiastoleRelaxationPreloadTension in ventricular wall at end of diastoleAfterloadForce that impedes blood flow out of heartStroke VolumeVolume of blood ejected from the LV with each heartbeat. Normal is 60-80 mLCardiac OutputHeart rate x stroke volume. Amount of blood pumped from ventricles per minute. Normal is 4.5-5 and can increase up to 25 L/min during exerciseVenous ReturnAmount of blood returned to the R atrium each minute. Must equal CO when averaged over time.HypervolemiaIncreased blood volume due to increased blood plasma. Caused by excess intake of fluids (IV or blood transfusion) or sodium/fluid retention (heart disease, kidney disease). Sxs: Swelling in legs, Ascites, fluid in lungsHypovolemiaDecreased blood volume due to bleeding, dehydration from vomiting, diarrhea, sweating, burns, and diuretics to treat hypertension. Sxs: Orthostatic hypotension, tachycardia, elevated body tempPlasmaLiquid component of blood, contains blood cells and platelets. Accounts for more than half of total blood volume and important in regulating BP and tempRed blood cells (Erythrocytes)Make up 40% of blood volume and contain hemoglobin, which gives blood its red color and allows it to bind to oxygen. Normal count: 12-17 gm/dL Low RBCs = Anemia High RBCs = PolycythemiaAnemiaLack of RBCs, causing decrease in oxygen and overall fatigue and weaknessPolycythemiaHigh RBCs causing thick blood and increasing risk of stroke or heart attackBlood platelets (Thrombocytes)Assist in blood clotting by dumping at bleeding site to form a plug to seal the blood vessel. Normal level is 150,000-400,000 platelets per mL of bloodThrombocytopeniaLow platelet count increases risk for bruising and abnormal bleeding.ThrombocythemiaHigh platelet count increases risk of thrombosis, may result in a stroke or heart attackWhite blood cells (Leukocytes)Protect against infection. Normal count: 4,000-11,000 per microliter of bloodLeukopeniaLow number of WBCs, increasing risk of infection. Less than 4,000 per mLLeukocytosisAbnormally high WBC count, can indicate infection or leukemia. Higher than 11,000 per mLNeutrophilsWBC that ingest bacteria and debrisLymphocytesT lymphocytes and Natural killer cells protect against infections and cancer, and B lymphocytes produce antibodiesMonocytesIngests dead/damagedcells and defends against infectious organismsEosinophilsKill parasites, destroy cancer cells, involved in allergic responseBasophilsProduces histamine and is involved in allergic responseMuscles of inspirationdiaphragm (C3-C5), external intercostals (T2-T12), pectoralis minor, scalenes (C3-C7), sternocleidomastoid, serratus Diaphragm expands chest longitudinally and elevates lower ribs to allow for inspirationMuscles of ExhalationPassive unless forceful, then is rectus abdominis (T7-L1), external oblique, internal oblique, and transverse abdominis. These depress lower ribs and compress abdominal contents, pushing diaphragm upUpper Respiratory TractNose, Pharynx (nasopharynx, oropharynx, laryngopharynx), Larynx Humidify, cool/warm inspired air, filter out foreing matter. Hair in nostrils filters particles, the remaining settles on mucous membranesLower Respiratory TractLarynx, Trachea, Bronchi, Lungs. Trachia divides at carina into R and L main bronchi.Lobes of the lungTri to be Right: 3 for the right, 2 for the left R has Upper, Middle and Lower L has Upper and LowerLingula of left lung- Flat, medially-pointing projection of the inferior lobe, forming the base of the cardiac notch; Latin for "little tongue" - Believed to be homologous to a middle lobe (as in the right lung)alveolar capillary membraneOxygen diffuses across alveolar-capillary septum into RBCs in lung capillaries, where it combines with hemoglobin to be transported back to the heart. CO goes opposite direction.Visceral PleuraMembranous sac that covers each lung. Separated by serous fluid from other pleural layer.Parietal PleuraPleural layer covering the thorax walls, ribs vertebrae, diaphragm, and mediastinum. Separated by serous fluid from other pleural layer.Innervation of LungsVagus nerve for Parasymatpethc innervation, Postganglionic sympathetic fibers for sympatheticTotal Lung Capacity (TLC)Volume of air after maximum inhalation. Sum of all lung volumes. Residual Volume (RV) + Vital Capacity (VC) OR Functional Residual Capacity (FRC) + Inspiratory Capacity (IC)Vital Capacity (VC)The total volume of air that can be exhaled after maximal inhalation. Approximately 75% of total lung volume. Tidal Volume (TV) + Inspiratory Reserve Volume (IRV) + Expiratory Reserve Capacity (ERV)Tidal Volume (TV)Amount of air that moves in and out of the lungs during a normal breath. Approximately 10% of total volumeInspiratory Reserve Volume (IRV)the maximal amount of additional air that can be drawn into the lungs by determined effort after normal inspiration. Approx 50% of total lung volumeInspiratory Capacity (IC)Max volume of air that can be inhaled after normal tidal exhalation. Approximately 60% of lung volume. Tidal Volume (TV) + Inspiratory Reserve Capacity (IRVResidual Volume (RV)Amount of air remaining in lungs after max exhalation. Approx 25% of lung volumeExpiratory Reserve Volume (ERV)Max volume of air that can be exhaled after normal inhalation. Approx 15% of lung volumeForced Expiratory Volume (FEV)amount of air exhaled in the 1st, 2nd, and 3rd second of a forced vital capacity testForced Vital Capacity (FVC)Volume of air expired during max expiration after a forced inspirationMinute Volume Ventilation (VE)Amount of air expelled in one minute, equal to Tidal Volume x Respiration RatePeak Expiratory Flowmax flow of air during the beginning of a forced expiratory maneuverControl of BreathingCentral control in brainstem, peripheral receptors in lungs, airways, chest walls and blood vessels. - medulla - CO2 ^ --> medulla --> impulse to diaphragm & chest muscles --> breathing rate ^AneurysmBallooning of weakened portion of arterial wall due to congenital defect, chronic hypertension, trauma, infection, or connective tissue disease (Marfan) Sxs: Aortic can be asymptomatic or ab or low back pain. Abdominal aortic will cause pulsations near navel. Cerebral will cause sudden/severe headache, nausea, vomiting, stiff neck, seizure, LOC, double vision Tx: Antihypertensives, surgery to replace large aneurysms with synthetic graft.Angina PectorisChest pain from myocardial ischemia due to inadequate blood flow usually from coronary artery disease. Can be Stable: Predictable level of exertion, exercise, or stress brings it on, responds to stress or nitroglycerin. Unstable: More intense, lasts longer, precipitated by less exertion, occurs spontaneously at rest, is progressive Prinzmetal: Occurs due to coronary artery spasm. Sxs: Pressure, heaviness, fullness, burning, or aching behind sternum or neck, back, jaw, shoulders, arms. Can be associated with breathing issuee, fear, anxiety. Tx: Oxygen, nitroglycerin, rest for acute. Long acting nitrates, beta blockers, and calcium channel blockers for chronic.HypercalcemiaCaused by hyperparathyroidism, malignant tumors, thiazide diuretics, or acute kidney failure Sxs: WEAK Weakness of muscles EKG changes Absent/diminished reflexes Kidney stone formationHypocalcemiaHypoparathyroidism, decreased intake, post parathyroidectomy, Vitamin D deficiency Sxs: CRAMP Confusion Reflexes are hyperactive Arrhythmias Muscle spasms Positive Trousseau sign (hand spasm with inflated BP cuff)AtherosclerosisProgressive accumulation of fatty plaque on inner walls of arteries, due to damage or injury to inner wall of artery (HTN, high cholesterol, smoking, diabetes), causing plaque made of waste products to build up at the site of injury. This narrows blood flow and causes a blood clot. Sxs: Angina if coronary arteries are affected. Numbness or weakness of arms/legs, slurred speech, drooping face for cerebral arteries. Intermittent claudication for peripheral arteries. Tx: Lifestyle changes, meds, (antihypertensives, antiplatelets, antilipidemics), surgery (angioplasty, endarterectomy, bypass surgery)Cardiomyopathythe term used to describe all diseases of the heart muscle (myocardium). Broken into three types: -Dilated (Expanded ventricles -Hypertrophic (thickened ventricular walls) -Restrictive (Stiff but not thickened) Sxs: None in early stages, As condition progresses sxs include breathlessness with exertion or rest, swelling of LE, bloating of abdomen, dizziness, faintingChronic Venous Insufficiency (CVI)Weak or damaged valves in veins can't keep blood flowing to the heart, causing veins to remain filled with blood. Risk factors: female, obese, pregnant, prolonged sitting/standing Sxs: Leg swelling, varicose veins, aching, heaviness, cramping, itching, redness or skin ulcers of legs/ankles Tx: Compression stockings, elevation of legs to decrease chronic swelling. Varicose vein stripping for persistent leg pain or skin ulcers.Arterial InsufficiencyInadequate arterial blood flow. Common in DM, HTN, obese, smokers. Stop smoking, then exercise and weight control PALLOR Pallor Abnormal Nail Growth Little leg hair (gone) Lateral Malleolar Wounds Overly dry/shiny skin Rest pain, intermittent claudicationCongenital Heart DefectsMalformation of interior walls or valves of heart or major arteries/veins near heart that are present at birth, causing blood flow through heart to be slowed, blocked, or misdirected. Atrial Septal Defect Coarctation of the Aorta Patent Ductus Areteriosus Ventricular Septal Defect Tetralogy of FallotAtrial Septal DefectCongenital defect in wall dividing R and L atria, foramen ovale does not close at birth, causing blood to shunt from L to R atrium or R to L in severe cases. Sxs: Small/moderate defects have no sxs or appear after 30. Large defects cause heart murmur, SOB, fatigue, LE and abdomen swelling, heart palpitations, lung infections, stroke, cyanosisof skin. Tx: Surgical closure if defect is large.Coarctation of the aortaAorta is narrowed near ductus arteriosus, ranging from mild to severe and may not be detected until adulthood. Usually occurs with PDA, ventricular septal defect, bicuspid aortic valve. Sxs: Severe--SOB, pale skin, sweating soon after birth. Most common sign in adults/older children is high BP in arms, low BP in legs. other sxs are SOB in exercise, intermittent claudication, weakness, headache. Tx: Surgical repair of aorta or balloon angioplasty.Patent Ductus Arteriosus (PDA)an abnormal opening between the pulmonary artery and the aorta caused by failure of the fetal ductus arteriosus to close after birth Sxs: Small may be asymptomatic. Large causes tachycardia, respiratory distress, poor eating, weight loss, and congestive heart failure Tx: Diuretics, indomethacin, surgical repair. Left untreated, can cause pulmonary HTN or heart failureVentricular Septal DefectHole in septum separating R and L ventricles. If hole is too large, too much blood is pumped to lungs, leading to heart failure. Sxs: Large defect can cause cyanosis of skin/lips/fingernails, poor eating, failure to thrive, fast breathing, fatigue, swelling of legs, feet or abdomen, and rapid HRTetralogy of FallotCombination of 4 heart defects: 1. VSD 2. Pulmonary STenosis 3. R Ventricular Hyprertrophy 4. Aorta overriding VSD Sxs: Cyanosis, SOB during feeding, fainting, finger/toe clubbing, poor weight gain, tiring easily, heart murmur Tx: Surgery placing patch over VSD and widening pulmonary valve and arteries. Untreated casesdevelop infective endocarditis, resulting in death or disability by early adulthoodCor PulmonaleHypertrophy of R ventricle due to pulmonary hypertension. R ventricle hypertrophies due to increased force needed to overcome resistance in pulmonary circulation. Sxs: Progressive SOB with exertion, fatigue, palpitations, LE swelling, dizziness, syncope Tx: Supplemental oxygen to maintain O2 sat over 90 or PaO2 over 60 mmHg.Coronary Artery DiseaseNarrowing or blockage of coronary arteries due to plaque, resulting in diminished blood flow. Damaged inner wall of coronary artery (HTN, trauma, smoking, etc) gains accumulation of fatty plaque at site of injury, and if plaque ruptures, platelets clump at the site to repair the artery, blocking it and causing an MI. Risk factors: High LDL, low HDL, Type 2 DM, smoking, obesity, inactivity, HTN. Sxs: Angina, SOB. Complete blockage causes MI Tx: Aggressive modification of risk factors to slow progression and induce regression of plaques. ACE inhibiters, Aspirin for antiplatelet, statins.Deep Vein Thrombosis (DVT)Blood clot formed in deep veins of lower extremities caused by any condition that impairs normal circulation or clotting. Risk factors: prolonged sitting/bed rest, inherited blood clotting disorders, venous injury or surgery, pregnancy, cancer, birth control, obesity, smoking Sxs: Mostly asymptomatic, but can present with swelling, pain, redness, warmth. Confirmed with Homan's sign. Tx: Prevent blood clot from getting bigger or breaking loose to cause PE. Anticoagulants, thrombolytics. Compression Stockings.EndocarditisInflammation of inner lining of heart and cardiac valves due to bacteria that enters the blood rom catheters, needles, dental procedures, gum disease, STDs, or IBS. Individuals with damaged or artificial heart valves are at greatest risk Sxs: Develop slowly. Fever, chills, heart murmur, fatigue, SOB, weight loss, blood in urine, skin petechiae. Tx: Antibiotics.Congestive Heart FailureProgressive condition where heart is unable to maintain CO to meet demands for blood/oxygen due to damage from other conditions (CAD, HTN, DM, MI, cardiomyopathy). Ventricles weaken and dilate, heart can't pump efficiently. Blood "backs up" into liver, abdomen, LE, and lungs. Sxs: Tachycardia, SOB, fatigue, weakness, swelling in legs, feet, and abdomen, rapid/irregular heartbeat with S3 or S4 heart sound, persistent cough or wheeze Tx: Sometimes treating underlying cause can correct heart failure, most tx is balance of meds, devices, and lifestyle changeHeart murmurAbnormal swishing or swooshing sound by auscultation in cardiac cycle. May be "innocent" due to blood flowing rapidly through heart from activity, or due to turbulent blood flow through a damaged or narrowed heart valve or hole in heart walls. May also be caused by rheumatic fever, endocarditis, mitral valve prolapse. Sxs: Cyanosis, limb edema, SOB, distended neck veins, weight gain, chest pain, dizziness, fainting. Tx: Digoxin, anticoagulants, diuretics, antihypertensives.HypertensionHigh blood pressure. Can be primary (idiopathic) or secondary (identifiable cause, usually renal disease). Elevated: 120-129/80+ Stage 1: 130-139 OR diastolic 80-89 Stage 2: At least 140 Systolic OR at least 90 Diastolic Hypertensive Crisis: 180/120 Sxs: Asymptomatic until complications develop. S4 heart sound is early sign. Severe (DBP 120+) can cause CNS symtpoms, CV symptoms, and renal involvement Tx: Activity, smoking cessation, low sodium diet. Meds: Diuretics, beta blockers, calcium channel blockers, ACE inhibitors, AII receptor blockers, direct vasodilators.Myocardial Infarction (MI)Blood flow through one or more coronary arteries is reduced or cut off completely by a plaque or blood clot, or by spasm. This causes irreversible necrosis to the portion of myocardium supplied by the artery. Sxs: Chest discomfort, SOB, discomfort in upper body (arms, shoulder, neck, back), nausea, vomiting, dizziness, sweating, palpitations. Labs: Elevated creatine phosphokinase, aspartate transferase. EKG: Inverted T wave = myocardial ischemia, elevated ST segment = acute infarction, depressed ST segment - pending subendocardial infarction. Treatment: Meds (anticoagulants, thrombolytics, antihypertensives, cholesterol lowering meds), Coronary angioplasty, coronary bypass, lifestyle changes.MyocarditisInflammation and weakness of myocardium, due to virus (flu, coxsackie virus, adenovirus), or bacterial (polio, rubella, Lyme disease). Myocardium becomes thick and swollen, leading to sxs of heart failure. Sxs: Arrhythmias, chest pain, SOB, fatigue, fever (headache, muscle aches, sore throat, diarrhea, rashes). Tx: Antibiotics, antiinflammatories, diruetics, beta blockers, calcium channel blockers. Severe may need VAD or intra-aortic balloon pump.PericarditisInflammation of pericardium due to viral infections (HIV, coxsackie, flu), bacterial infections, fungal infections, MI, chest trauma, immunosuppressive meds, or chest radiation. The inflammation causes pericardial effusion which can disrupt heart's normal rhythm. Sxs: Chest pain, SOB, dry cough, anxiety, fatigue, fever. Tx: Analgesics,antiinflammatories, antibiotics if it was for a bacterial infection. Most cases are mild and clear up on their own.Peripheral Artery DiseaseStenotic, occlusive, and aneurysmal diseases of aorta and peripheral arteries caused by atherosclerosis and thromboembolicprocesses Sxs: Fatigue, aching, numbness, pain in LE at rest or when walking, poorly healing wounds of legs or feet, distal hair loss, trophic skin changes, hypertrophic nails Tx: Lifestyle changes, lipid lowering meds, control of diabetes and HTN. Disabling intermittent claudication, revascularization procedures (angioplasty, stent, atherectomy), and surgery (aortobifemoral bypass, iliofemoral bypass)Rheumatic FeverInflammatry disease that develops as a complication of untreated or poorly treated strep throat from streptococcus bacteria. Can damage heart valves and cause heart failure. Sxs: Fever, painful joints, CHF symptoms Tx: Destroy bacteria, relieve symptoms, control inflammationValvular Heart DiseaseDamage to heart valve resulting in regurgitation (insufficiency), where blood leaks backward through damaged valve, or or stenosis of blood flow where valves do not open wide enough to allow adequate blood flow through the valve. Caused by congenital defects, calcific degeneration, MI, rheumatic fever. Sxs: Palpitations, SOB, chest pain, coughing, ankle swelling, fatigue Tx: Moderate cases require digitalis, diuretics, antiplatelet/anticoagulants, beta blockers, calcium channel blockers.Acute Respiratory Distress Syndrome (ARDS)Sudden respiratory failure due to fluid accumulation in alveoli, usually in people who are already ill. Etiology is fluid leaking from blood vessels in lungs into alveoli due to inflammation compromising membrane integrity. This inflammation can be caused by: -Pneumonia -Infection spreading through blood (sepsis) -Heart failure -Blood transfusions -Smoke inhalation or chemical (ammonia/chlorine) inhalation) -head/chest injury, or fracture of long bones -Near drowning -Drug overdose, shock, or adverse reaction to medication Sxs: Severe SOB, labored breathing, hypotension, confusion, fatigue, cough, fever Tx: Supplemental O2, vent. Fatal in 25-40% of those who develop it, survivors may not regain full lung function for 1+ yrsAsthmaChronic inflammation of airways due to airway hypersensitivity from allergens (pollen, mold, dust), exposure to cold air or temp change, smoke, exercise, stress. Sxs: Mild presents as wheezing, chest tightness, SOB. Severe presents as dyspnea, flaring nostrils, diminished wheezing, anxiety, cyanosis, inability to speak. Can result in respiratory failure Tx: Anti-inflammatories (inhaled corticosteroids, leukotriene mods) and bronchodilators (Anticholinergics, methylxanthines, beta-adrenergicagnoists)AtelectasisComplete or partial collapse of a section of a lung due to blockage of bronchioles or due to pressure on the lung. Can be caused by pleural effusion, tumor, ARDS, asthma, COPD, cystic fibrosis. Sxs: Cyanosis, SOB, increased RR and HR. Tx: Deep breathing, changing positions, airway clearance techniques, supplemental oxygen, Positive End-Expiratory pressure (PEEP) or CPAP to keep airways and alveoli open. Bronchoscopy to remove foreign objects.BronchiectasisProgressive lung disease that produces abnormal dilation of bronchus due to infection, aspiration, cystic fibrosis, or immune system impairment. Sxs: Consistent productive cough, hemoptysis, weight loss, anemia, crackles, wheezes, loud breath sounds Tx: Antibiotics, bronchodilators, expectorants, mucolyticsBronchitisInflammation of bronchi, characterized by larger and more active mucus glands, decreasing oxygenation. Acute caused by cold viruses, exposure to smoke, air pollutants. Cigarettes or air pollutants in workplace contribute to chronic. Sxs: Persistent cough with production of thick sputum, accessory muscles in breathing, increased pulmonary artery pressure. Chronic--cough worse in morning, in damp weather, and have frequent respiratory infections Tx: Rest, fluids, cough suppressants, lifestyle changes.Chronic Obstructive Pulmonary Disease (COPD)Group of lung diseases that block airflow due to narrowing of bronchial tree (emphysema and chronic bronchitis are main). Disease can progress to alveolar destruction Sxs: Excessive mucus, chronic cough, wheezing, SOB, fatigue Tx: Bronchodilators, inhaled steroids, antibiotics, supplemental oxygen.Cystic Fibrosisa genetic disease that causes the body to produce unusually thick, sticky mucus that leads to life threatening lung infections, obstructs pancreas, and inhibits normal digestion/absorption of food. Most common complication is exacerbation of obstructive pulmonary disease Sxs: Salty tasting skin, persitent/productive cough, frequent lung infections, failure to thrive, frequent greasy/bulky stools PFT: Decreased FEV1 and PVC, increased FRC and RV. Tx: Antibiotics, muculytics, bronchodilators, airway clearance, breathing techniques, ventilatory msucle training.EmphysemaPathologic accumulation of air in the lungs found with chronic obstructive pulmonary disease. Alveolar walls are gradually destroyed due to smoking, can be partially genetic. Alveoli are turned into large pockets with gaping holes. Elastic fibers holding bronchioles open are destroyed, so they collapse during exhalation, so air cannot escape from lungs, causing alveoli to be permanently overinflated. Sxs: Barrel chest, wheezing, coughing, SOB, accessory muscle use, fatigue PFT: Obstructive, so-- Tx: Lung volume reduction surgery, bullectomy, lung transplant. Pulmonary rehab (airway clearance, breathing exercises, endurance/strength training)Pleural EffusionBuildup of fluid in pleural space between lungs and chest cavity, due to viral infection, pneumonia, PE, or autoimmune disease (lupus, RA). Excess fluid pushes pleura against lungs, and may cause atelectasis. Fluid may be infected, turning into abscess (empyema) Sxs: SOB. Empyma presents as dry cough, chills, and fever. Tx: Underlying condition. May need chest tube to drain fluid.PneumoniaInflammation of the lungs -Bacterial -Fungal -Viral -Aspiration Presents with: -Tachypnea, fever, fatigue, chest discomfort -Tachycardia, dull percussion -Crackles, Ronhchi, Bronchial sounds over consolidation -Dry cough progressing to productive Tx: Antibiotics for bacterial/mycoplasma pneumonia, Antivirals/antifungals PT: Incentive Spirometer, Bronchopulmonary HygienePulmonary Edemafluid accumulation in the alveoli and bronchioles, most often seen with L Ventricular heart failure. Pressure increases in L atrium, then into pulmonary veins and capillaries, causing fluid to be pushed through capillary walls into alveoli. Can be noncardiac due to increased capillary permeabilityfrom pneumonia, toxins, meds, RDS. Acute pulmonary edema is life threatening. Sxs: SOB, feeling of suffocating, wheezing, coughing w/blood tinged sputum, chest pain and irregular pulse Tx: Supplemental O2 and medsPulmonary Embolism (PE)One or more arteries in lung blocked by blood clots from lower extremities. Sxs: Vary greatly depending on size of clot. Sudden onset of SOB, chest pain that becomes worse with deep breathing, coughing, eating or bending; coughing up bloody sputum. Can include LE swelling, irregular heartbeat. Tx: Anticoagulants, thrombolytic agents. Preventing clot formation in deep leg veins reduces risk of PE.Pulmonary FibrosisMicroscopic damage to alveoli causes irreversible scarring of interstitial tissue, decreasing tissue elasticity and increases difficulty of breathing. Cause is unknown (idiopathic) or can be from exposure to toxic elements (dust, silica, asbestos, grain, animal droppings), radiation to lungs, chemo drugs, antiarrhythmic medications, ad some antibiotics. Sxs: SOB, especially during/afer physical activity and dry cough. Fatigue, weight loss, aching muscles/joints Tx: Scarring is irreversible, but corticosteroids and immunosuppressives can help, Lung transplantation may be required.Restrictive Lung Dysfunction (RLD)Abnormal reduction in lung expansion and pulmonary ventilation caused by abnormal lung parenchyma (atelectasis, pneumonia, pulmonary fibrosis, pulmonary edema), abnormal pleura, (pleural effusion/fibrosis) and disorders affecting pulmonary lung function (neuromuscular diseases, connective tissue disorders) Sxs: Dyspnea on exertion, non-productive cough, increased RR, hypoxemia, vital capacity, abnormal breath sounds, reduced ex tolerance PFT: Impaired VC, FVC, and TLC. Normal RV, decreased ERV and FRC. Tx: depending on etiology.Restrictive vs Obstructive lung diseaseObstructive (impaired expiration) : COPD, Asthma, Emphysema, Cystic Fibrosis -TLC, RV up (can't blow out air) -FEV1 down, VC Down -FEV1/FVC below 70% affects FEV1 Restrictive (reduced volumes and limited inspiration) : Musculoskeletal disorders, Tumors, Lung resection, ILD, pneumonia, pulmonary fibrosis, pneumothorax, pulmonary edema, thoracic trauma -TLC and RV down (lungs can't expand) -Normal FEV1Normal Adult pH Acidemia Alkalemia7.35-7.45 Acidemia: lower than 7.35 Alkalemia: Higher than 7.45Normal adult PaCO2 Eucapnia Hypercapnia HypocapniaEucapnia: 35-45 Hypercapnia: Over 45 mmHg Hypocapnia: Under 35 mmHgNormal Adult PaO2 Mild Hypoxemia Moderate Hypoxemia Severe Hypoxemia80-100 mmHg Mild Hypoxemia: 60-79 mmHg Moderate Hypoxemia: 40-59 mmHg Severe Hypoxemia: Under 40 mmHgNormal Adult HCO3-22-26 mEq/LNormal Adult SaO295-98%ABG resultspH-->PaCO2-->PaO2-->HCO3- 7.4/40/97/24Cardiac Enzyme studiesbattery of blood tests performed to determine the presence of cardiac damage Creatine Phosphokinase (CK-MB) appears in blood 4 hours post infarction, peaks at 24 hours, declines over 72 hours Cardiac Troponin-I remains elevated for 5-7 days. (Over 0.10) Brain Natriuretic Peptide (BNP): Peptide hormone released with heart stress. Indicates HEART FAILUREAlanine Amino-Transferase (ALT)Found within liver cells. Damage to liver cells releases this into blood stream. Can be caused by alcoholism, celiac, Cirrhosis, hepatitis, and liver cancer.Normal HDL levels40-60 High is goodNormal LDL levelsLess than 100 mg/dL is optimal. 100-129: Near optimal 139-159: Borderline 160-189: High Over 190: Very highTotal Cholesterol (TC)200 mg/dL is desirable Borderline: 200-239 High: over 240Normal Erythrocyte count4.0-5.6 million per mLNormal Leukocyte Count4,500-11,000 per mm3 Lower than 5,000 with fever or 1,000 with no fever is CUTOFFNormal Neutrophil Range40-70%Normal Lymphocyte Range20-50%Normal monocyte count4-8%Normal Eosinophil Count0-6%Normal Basophil Count0-2%Normal Platelet Count150,000-450,000 50k-100k: You can exercise, stop if signs of bleeding 20k-50k: Weights are ok but no breath holding 10k-20k: Strength training with NO WEIGHTS OR STRAIN Below 10k is NO EXERCISE Clotting FactorNormal Hematocrit Level35-55% 25% is cutoff point for exerciseNormal Hemoglobin Level12-18 gm/dL 8 is cutoff point for exerciseNormal Triglyceride LevelLess than 150Arterial Blood Gas Analysis1. *pH over 7.40 = alkalosis *pH under 7.4 = acidosis 2. *CO2 = 35-45 means no respiratory problem and no respiratory compensation for metabolic problem. *CO2 over 50 mmHg = alveolar hypoventilation/failure to get rid of CO2 *CO2 under 30 mmHg = alveolar hyperventilation (getting rid of too much CO2) 3. Rule: if pH and CO2 are outside norms in same direction, it's a compensation for metabolic OPPOSITE of what pH says it is (high pH = compensated acidosis). If outside norms in opposite direction, CO2 is causation (Acidosis/Alkalosis) *Low pH and High CO2 = Respiratory Acidosis *High pH and High CO2 = Retention of CO2 to compensate for metabolic alkalosis *High pH and Low CO2 = Respiratory Alkalosis *Low pH and Low CO2 = Elimination of CO2 to compensate for metabolic acidosis 4. HCO3 22-26 = no metabolic problem or compensation. Rule: If HCO3 and pH are outside norms in same direction, HCO3 is causation. If outside norms in opposite direction, it's a compensation for respiratory OPPOSITE of what pH actually is (low pH = Compensated Alkalosis, etc). *Low pH and Low HCO3 = Metabolic Acidosis *Low pH and High HCO3 = Renal compensation for respiratory alkalosis *High pH and High HCO3- = Metabolic Alkalosis *High pH and Low HCO3- = Renal Compensation for Respiratory AcidosisRespiratory AcidosisCARBS Confusion Agitation Restlessness Blurred Vision SeizuresRespiratory AlkalosisNO CARDS Numbness/Tingling Orthostatic Hypotension Confusion Anxiety Rapid Breathing (Hyperventilation) Dizziness SeizuresMetabolic AcidosisSHAMED Stupor Hyperkalemia Arrhythmias Muscle twitching Emesis Decreased CO Kussmaul Respirations (compensatory hyperventilation)Metabolic AlkalosisQuad T's Tetany Tachycardia Tremors TinglingAmbulatory ECG• AKA Holter monitoring • Recorded for 24-48 hours or longer to evaluate cardiac rhythm, efficiency of meds, and pacemaker function; then correlated w/ diary of pt's symptoms/activitiesAngiographyX ray imaging of blood vessels after injection of contrast material to show location of plaque in coronary arteries and extent of occlusionBronchoscopyDirect visualization of bronchial tree for diagnostic purposes using a fiber optic video camera. Can identify tumors, bronchitis, foreign bodies, and bleeding. Can remove specimens for biopsy.Cardiac Catheterizationthin, flexible tube is guided into the heart via a vein or an artery. Can evaluate occlusion of coronary arteries and measure heart BP and oxygenation. Coronary Angioplasty is performed using cardiac catheterization.Carotid UltrasoundUses soundwaves to examine carotid arteries to screen for blockages, evaluate stent placement, or function of artery post endarterectomyChest Radiograph• Visualizes location/size/shape of heart,lungs, blood vessels, ribs, bones of spine • Can also reveal fluid in lungs/pleural space, pneumonia, cancerCT Scana series of x-ray photographs taken from different angles and combined by computer into a composite representation of a slice through the body. *Allows for pictures of coronary arteries to be taken without need for catheterizationEchocardiographyan ultrasonic diagnostic procedure used to evaluate the structures and motion of the heart Transthoracic Echocardiography (TTE) uses a handheld transducer. Transesophageal (TEE) uses a transducer passed into esophagus to give more detailed image of heartElectrophysiologic Testing• Evaluates rhythm or electrical conduction abnormalities of heart using 3-5 catheters inserted into a blood vessel and threaded to the heart • Help to locate abnormal tissue that causes cardiac arrhythmiasFlouroscopyContinuous x ray shows heart and lungs using contrast medium. Has been replaced with ECG due to high radiation dosesInvasive Hemodynamic MonitoringBalloon catheter (Swan-Ganz) is placed in pulmonary artery to obtain pulmonary artery pressure and L Atrial pressure, a CVP line measures pressure in vena cava or R atrium, and thermodilution catheter measures CO. Measures pressure, volume, and temp continuously.Magnetic Resonance Imaging (MRI)Uses magnetic field and radio waves to create 3D images of heart and blood vessels to assess size and function of chambers, thickness and movement of walls, extent of damage from MI, structural problems, presence of plaques.Myocardial Perfusion Imaging (MPI)AKA Radionuclide Stress Test or Nuclear Stress test. Shows how well heart is perfused at res adn under exercise stress by injecting radionuclide agent into blood at rest and at max exercise. Images reveal areas of reduced blood supply due to coronary artery narrowing.Pharmacologic Stress TestCardiovascular stress induced by meds when routine stress test is contrindicated or if pt is unable to complete due to injury. Used in combo with MPI and ECG. Agents used: adenosine, dipyridamole, dobutaminePhonocardiography• Diagnostic test that creates a graphic record of sounds produced by heart/great vessels • Phonocardiogram supplements auscultation and *improves detection of S3/S4 heart sounds* in diagnosis of heart failurePleuroscopyExamination of lung surfaces, pleura, and plural space using a small video camera inserted between ribs into pleura spacePositron Emission Tomography (PET)Imaging test where a small amt of radioactive material is swallowed, injected, or inhaled. Used to evaluate for heart disease or cancer.ThoracentesisRemoval of fluid from pleural space with a needleVentilation-Perfusion Scan (Lung Scan or VQ scan)radioactive substance is injected IV; scan views blood flow to lungs (perfusion) OR radioactive substance is inhaled showing how well O2 is distributed in lungsVenographyradiography of a vein after injection of a contrast medium to detect incomplete filling of a vein, indicating an obstructionAlpha Adrenergic Antagonist AgentsZosins Reduce peripheral vascular tone by blocking Alpha-1-adrenergic receptors, causing dilation of arterioles and decreasing BP Indications: HTN, BPP PT: Caution when rising from sitting or lying bc of dizziness/orthostatic hypotension. Examples: Cardura/doxazosin, Minipress (prazosin), Hytrin (Terazosin)ACE InhibitorsPrils Decrease BP by suppressing enzyme that converts Angiotensin I to Angiotensin II. Change the o on Indications: HTN, CHF Captopril, Enalapril, Lisinopril, RamiprilINR (International Normalized Ratio) value:2.0-3.0. if on warfarin. Target of 2.5. Higher the number bleeding disorder. Lower the number clotting disorder.Angiotensin II Receptor Blockers (ARBs)-Sartans Block Angiotensin II receptors which limit vasoconstriction and stimulation of vascular tissue Indications: HTN, CHF Losartan, Candesartan, ValsartanClass I Antiarrhythmic AgentsSodium channel blockers Quinidine, LidocaineClass II Antiarrhythmic AgentsBeta Blockers inhibit sympathetic activity by blocking beta adrenergic receptors. Atenolol (Tenormin)Class III Antiarrhythmic AgentsProlong repolarization by inhibiting both potassium and sodium channels, considered to be the most effective antiarrhythmic Amiodarone (Cordarone)Class IV AntiarrhythmicsDepress depolarization to slow conduction through AV node. Diltiazem (Cardizem)Anticoagulant Agents-arins Inhibit platelet aggregation and thrombus formation Indications: s/p coronary angioplasly or Coronary Artery Bypass Graft, preventing thromboembolism in patients with A-fib and prosthetic heart valves Sides: Hemorrhage, increased risk of bleeding, GI distress with orals Heparin, Warfarin (Coumadin), Enoxaparin (Lovenox)Antihyperlipidemia AgentsStatins Inhibit enzyme action in cholesterol synthesis (stops cholesterol formation), breaks down LDLs, decrease triglycerides, increase HDLs. Aerobic exercise can increase HDLs and maximize effects of drug therapy Indications: Hyperlipidemia, atherosclerosis, prevent coronary events in pts with existing DM, PVD, or coronary disease Atorvastatin (Lipitor), Simvistatin (Zocor), Fenofibrate (Tricor)Antithrombotic (Antiplatelet) AgentsInhibit platelet aggregation and clot formation post MI or a-Fib, and prevent arterial thrombus formation. Aspirin, Plavix (clopidogrel), Persantine (Dipyridamole)Beta Blocker AgentsClass II antiarrhythmic agents. the -olols Decrease myocardial oxygen demand by increaseing HR and contractility by blocking beta-adrenergic receptors. Used for HTN, angina, arrhythmias, heart failure, migraines. If on these, HR and BP will be diminished, use RPE to monitor exercise intensity. Atenolol (Tenormin), Metoprolol (Lopressor), Inderal (Propanolol)Calcium Channel Blocker AgentsClass IV antiarrhythmics. Decrease entry of calcium into vascular smooth muscle, decreasing contraction, vasodilation, and oxygen demand of the heart. Used for HTN, angina, arrhythmias, CHF. Norvasc (amlodipine), Procardia (nifedipine), Calan (Verapamil), Cardizem (diltiazem)Diuretic AgentsIncrease excretion of sodium and urine, causing a reduction in plasma volume, decreasing BP. Classifications include thiazide, loop, and potassium sparing agents. Used for HTN, edema associated with heart failure, pulmonary edema, glaucoma Thiazide: Chlorothiazide (Diuril) Loop: Lasix (Furosemide) Potassium sparing: Triamterene (Dyrenium)Nitrate AgentsDecrease ischemia by relaxing smooth muscle and dilating peripheral vessels. Used for angina pectoris. Administer sublingually. Nitroglycerin (Nitrostat), Isordil (Isosorbide dinitrate), Amyl nitrate solution for inhalationPositive Inotropic AgentsIncrease force and velocity of myocardial contraction, slow HR, decrease conduction velocity through AV, decrease sympathetic activation. Used for heart failure and A-Fib Digoxin (Lanoxin)Thrombolytic AgentsFacilitate clot dissolution through conversion of plasminogen to plasmin, which breaksdown clots and allows occluded vessels to reopen. Used for acute MI, PE, ischemic stroke, arterial/venous thrombosis Kinlytic (urokinase), Activase (Alteplase)Antihistamine Agents-ines Block effects of histamine to decrease nasal congestion, mucosal irritation and symptoms of cold, sinusitis, conjunctivitis, allergies. Can also be used for seasonal allergies, motion sickness, and Parkinson's. Benadryl (Dipenhydramine), Allegra (Fexofenadine), Zyrtec (Cetirizine HCL), Claritin (Loratadine)Anti-inflammatory agents for bronchospasm and asthmaCorticosteroid: Qvar (beclomethasone dipropionate), Pulmicort (Budesonide), AeroBid (Flunisolide) Leukotrine Modifier: Zyflo (Zileuton) Mast-cell stabilizer: Nasalcrom (Cromolyn Sodium)Bronchodilators for asthma/COPDAnticholinergic: Atrovent (Ipratropium), Spiriva (Tiotropium) Sympathomimetics: Ventolin (Albuterol), Primatene mist (Epinephrine), Serevent (Salmeterol) Xanthine Derivative: Theo-Dur (Theophylline), AminophyllineExpectorant AgentsIncrease respiratory secretions to loosen mucus, and reducing viscosity of secretions. Improves efficiency of cough reflex. Used for cough associated with respiratory tract infections and related (sinusitis, pharyngitis, bronchitis) Mucinex (Guafinesin), Terpin HydrateMucolytic AgentsDecrease viscosity of mucus secretions by altering composition and consistency, making them easier to secrete. Administered with a nebulizer. Perform airway clearance within one hour after drug admin. Pulmozyme (Dornase Alpha), Mucosil or Mucomyst (Acetylcysteine)Atherectomysurgical removal of plaque buildup from the interior of an arteryAutomatic Implantable Cardioverter-Defibrillator (AICD)Surgically implanted device similar to pacemaker that monitors HR and delivers shocks to restore normal HR when necessaryBalloon ValvuloplastyUses balloon tipped catheter to open narrow valve and increase blood flowCardiac AblationUses radio frequencies or chemicals to destroy areas of myocardium identified by electrophysiologic testing to be causing cardiac arrhythmia. Is an optino for pts with tachyarrhythmias that cannot be controlled by meds, or Wolff-Parkinson-White syndromeCardiac PacemakerSurgically implanted, battery powered device placed under the skin in L anterior chest wall to treat slow HR and arrhythmias. By preventing slow HR, pacemakers can treat fatigue, lightheadedness, and fainting.Cardioversionrestoration of a normal heart rhythm by electric shockCoronary Artery Bypass Graft (CABG)surgical technique to bring a new blood supply to heart muscle by detouring around blocked arteries. Procedure joins patient's own saphenous vein, internal thoracic/mammary artery or radial artery to connect the affected artery above and below occlusionEnhanced Extracorporeal Counterpulsation (EECP)A noninvasive procedure in which inflation of pressure cuffs on the lower extremities compresses the veins and assists with venous return to the heart.Heart TransplantFailing, diseased heart is replaced with healthy, donor heart. Reserved for patients with end-stage heart failure that fail other more conservative measures. (cardiomyopathy, coronary artery disease, valvular disease, congenital heart disease)Intra-Aortic Balloon Counterpulsation (IABP)Inflation and deflation of balloon in aorta provides circulatory assistance for patients after infarction or with cardiogenic shockValve replacementProsthetic valve replaces narrowed or leaky valve. May be mechanical (ball in cage, tilting disc, bileaflet) or tissue grafts from the same patient, a cadaver, or a pigVentricular Assist Device (VAD)Pump implanted in chest to provide mechanical support to the ventricle. RVAD attaches to R atrium and pulmonary artery, bypassing R ventricle. LVAD attaches to L atrium, bypassing L ventricle. BiVAD bypasses both ventricles. Commonly used as a temp treatment for those waiting for heart transplant or permanent treatment for heart failure.Airway AdjunctsDevices that aid in maintaining an open airway in mechanical ventilation Oral Pharyngeal Airway: Holds tongue away from back of throat Nasal Pharyngeal Airway: Tube through nose Endotracheal tube: Tube inserted in trachea from mouth or nose Tracheostomy Tube: Artificial airway in trachea from incision in neck below vocal cords for patients needing prolonged ventAirway SuctioningMechanical aspiration of secretions from the nasopharynx, oropharynx, or trachea using a suction catheter.BullectomyOne or more Bullae (large air spaces formed when alveoli are destroyed from emphysema) are removed to improve breathingLobectomySurgical removal of a lobe of a lungLung Volume Reduction SurgeryPortion of lung tissue damaged by emphysema is removed, creating extra space in chest so remaining lung tissue and diaphragm can work more efficientlyMechanical VentilationUsing a machine to move air into and out of the lungs, using positive pressure to increase intrathoracic pressure.Oxygen TherapyLiquid or gaseous oxygen for treatment of acute and chronic hypoxemia in pts with PaO2 less than 55 mmHg, or SaO2 less than 88% at rest. Nasal cannula, face mask, partial rebreathing mask, nonrebreathing mask, aerosol face ask, venturi mask, transtracheal catheterThoracotamySurgical incision cutting chest wall to access heart, lungs, esophagus, and diapragm. May be: Axillary thoracotomy Median Sternotomy Posterolateral Thoracotomy Anterolateral ThoracotomyTracheostomySurgical hole through neck into trachea below level of vocal cords. Indications: Airway obstruction at or above level of larynx, or respiratory failure requiring prolonged mechanical vent.Angina Pain Scales1: mild, barely noticeable 2: moderate, bothersome 3: moderately severe, very uncomfortable 4: most severe or intense pain ever experiencedAnkle-Brachial IndexCompares Systolic BP at ankle and arm. Calculated by dividing ankle measurement by arm measurement. Normal is 1.0 to 1.3. Greater than 1.3: Rigid arteries, should check for PAD using ultrasound 0.8-0.99: Mild blockage, beginnings of PAD 0.4-0.79: Moderate blockage, may be associated with intermittent claudication Less than 0.4: Severe blockage, severe PAD, may have claudication at restAreas of Heart AuscultationAll People Enjoy Time Magazine Aortic Area (2nd intercostal space at right sternal border) Pulmonic Area (2nd intercostal space, L sternal border Erb's Point (3rd intercostal space, L sternal border Mitral Area (5th intercostal space, medial to L midclavicular line) Tricuspid area (4th intercostal space at L sternal border)S1First heart sound, closure of atrioventricular valves at onset of ventricular systole High frequency sound, low pitch and longer duration than S2 "Lub"S2Second heart sound, closure of aortic and pulmonic valves at onset of ventricular diastole Higher pitch and shorter duration "Dub"S3Third heart sound, also called "ventricular gallop". Vibrations from distended ventricle walls due to passive flow of blood from atria during filling phase of diastole. Normal in healthy young children, called "physiologic". May be associated with heart failure in adults.S4Fourth heart sound. Atrial Gallop. Sound of vibration of ventricular wall with ventricular filling and atrial contraction. May be associated with HTN, stenosis, hypertensive heart disease, MILung AuscultationProcedure - 7 POINTS Listen to the breath sounds with the diaphragm of the stethoscope Positive Findings and Indications (+) Decreased breath sounds; Indication: Obstructed lung disease, pleural effusion, pneumothorax, or COPD (+) Crackles; Indication: pneumonia, fibrosis, CHF, bronchiectasis. (+) Wheezes; Indication: asthma, COPD, bronchitis. (+) Rhonchi; Indication: secretion in large airways. (+) Stridor; Indication: bronchial obstruction.Normal breath soundsTrachial and bronchial sounds: Loud, tubular sounds heard over trachea Vesicular: High pitched breezy sounds over distal airwaysCracklesAbnormal, discontinuous high pitched popping sound heard in inspiration. Indication: Restrictive or obstructive respiratory disorders (Pulmonary edema, atelectasis, pneumonia, bronchiectasis, pleural effusion)Pleural Friction Rubcontinuous, dry grating sound caused by inflammation of pleural surfaces and loss of lubricating pleural fluid. Indication: Inflamed visceral or parietal pleuraRhonchicontinuous low pitched, rattling lung sounds that often resemble snoring. Caused by air passing through an airway which is obstructed by inflammatory secretions or liquid, or neoplasm.Stridorstrained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx (upper airway)Wheezewhistling or sighing sound heard on auscultation that results from narrowing of the lumen of the respiratory passageway. Indication: Bronchospasm, edema, collapse, secretions, foreign body, neoplasmBronchial breath soundWhen heard NOT over trachea, can indicate pneumoniaDecreased/diminished Breath soundsless audible sound may indicate severe congestion, emphysema or hypoventilationAbsent Breath Soundsmay indicate pneumothorax or lung collapseBronchophonythe spoken voice sound heard through the stethoscope, which sounds soft, muffled, and indistinct over normal lung tissue (999)EgophonyA form of bronchophony in which the spoken long "E" sound changes to a long, nasal-sounding "A"Whispered Pectoriloquya whispered phrase heard through the stethoscope that sounds faint and inaudible over normal lung tissueNormal Voice SoundsSoft, muffled, and indistinct syllables. Increases in loudness or distictness indicate consolidation, atelectasis or fibrosis, all of which improve vibrations through lung tissue.BMI Classificationsunderweight: <18.5 normal: 18.5-24.9 overweight: 25-29.9 obese: >30 Class 1 Obesity: 30-34.9 Class 2 Obesity: 35.0-39.9 Class 3 Obesity: 40+Capillary RefillA test that evaluates distal circulatory system function by squeezing (blanching) blood from an area such as a nail bed and watching the speed of its return after releasing the pressure. Normal: 2 seconds to full color return Abnormal: Greater than 2 secondsClaudication TestPatient walks on flat track at max speed or tread mill at 2.0 mph at constant grade between 0-12% Initial Claudication Distance: Pain-free walking distance Absolute Claudication Distance: Max distance walked when test is terminated due to pain. Location of symptoms corresponds to the site of most proximal stenosis (tibial/peroneal arteries, femoral/popliteal arteries, aortic/iliac arteries) Grade 1: Initial or modest disfomfort of pain Grade 2: Moderate discomfort or pain, patient can be distracted Grade 3: Intense pain, patients attention cannot be diverted Grade 4: Excruciating, unbrearable painBorg Dyspnea Scale0 - no breathlessness at all 0.5 - very, very slight 1 - very slight 2 - slight breathlessness 3 - moderate 4 - somewhat severe 5 - severe breathlessness 6 - 7 - very severe breathlessness 8 - 9 - very, very severe breathlessness 10 - maximalElectrocardiogramRecord of heart's electrical activity. Used to asses cardiac rhythm, diagnose location, extent, and acuteness of ischemia and infarction.ECG LeadsLimb Leads: RA, LA, LL, RLWaveforms of ECGP wave: Atrial Depolarization PR Interval: Conduction from SA to AV. QRS: Ventricular depolarization, atrial repolarization QT: Time for both ventricular depolarization and repolarixation ST segment: both ventricles are depolarized T wave: Ventricular depolarizationNormal Sinus RhythmHR 60-100 bpmSinus BradycardiaSinus rhythm with HR less than 60 BPMSinus TachycardiSinus rhythm with HR more than 100 BPMSinus ArrhythmiaSinus rhythm with quickening and slowing of impulse formation, slight beat-to-beat variation of rateSinus ArrestSinus Rhythm with intermittent failure of SA node or AV node ECG: Occasional complete absence of P or QRS waveAtrial dysrhythmias include:Premature Atrial Contractions Atrial Flutter Atrial FibrillationPremature Atrial Contraction (PAC)P wave is premature, abnormal configuration Can occur in normal heart (caffeine, stress, smoking, alcohol), or any type of heart disease.Atrial FlutterSaw tooth P waves are characteristic. Rapid but regular atrial tachycardia Often occurs with valvular disease, HTN, MI, obstructive lung disease, pulmonary emboli. Sxs: Palpitations, lightheadedness, angina. Stagnation of blood may predispose to thrombi in atriaAtrial FibrillationRapid, irregular EXG without discrete P waves. Sxs: Palpitations, fatigue, dyspnea, lightheadedness, syncope, chest pain -New onset should be reported to physician -Pts should be taking blood thinners to reduce stroke risk -Not medical emergency unless life threatening sxs arise (LOC, confusion)1st Degree AV BlockDelayed contraction of ventricles caused by impaired AV node. Can be normal in athletes. prolonged PR interval, but constant beat to beat. No symptoms. Benign if no symptoms.2nd Degree AV Block Mobitz type 1 (Wenckebach)Impulses between atria and ventricles fail intermittently. Longer delays between P wave and QRS until one QRS complex is missed. -Benign if asymptomatic -If symptomatic refer to physician -May require pacemaker2nd Degree AV Block Mobitz IIIntermittent skipping of QRS complex. -All pts with this will have pacemaker -If abnormality is found without pacemaker, with symptoms present, CALL EMS -If abnormality is found without symptoms, stop exercise and call physician -Can become Third Degree if not handled3rd degree AV BlockComplete heart block. All impulses blocked at AV node, none transmitted to ventricles. Atria and ventricles paced independently. Considered medical emergency, pacemaker required. If ventricular rate is too slow, CO drops and patient may faint.Ventricular ArrhythmiasPVC V tach V fib Ventricular AsystolePremature Ventricular Complex (PVC)Absent P wave with wide and bizarre QRS complex. Couplet: Two consecutive PVCs Triplet: Three consecutive PVCs Bigeminy: Every other QRS is a PVC Trigeminy: Every third QRS is a PVC Commonly occurs in healthy and diseased hearts. -If one in isolation, continue exercise and monitor vitals -If 6 in one strip, call EMS -3 consecutive in a row is V-tach, call EMS -PVC that lands on a T wave impairs heart's ability to fill with blood, call EMSVentricular TachycardiaA rapid heart rhythm in which the electrical impulse begins in the ventricle (instead of the atrium), which may result in inadequate blood flow and eventually deteriorate into cardiac arrest. 3 or more consecutive PVCs at greater than 150 bpm. Causes: MI, cardiomyopathy, valvular diseaseVentricular FibrillationUncoordinated contraction of ventricles, asynchronous and ineffective. No cardiac output, patient becomes unconscious. This arrhythmia is lethal and requires immediate defib.Ventricular AsystoleStraight line pattern, no rhythm. Requires immediate CPR. MI, ventricular rupture, cocaine use, lightning, electrical shock.ST segment DepressionSign of myocardial ischemia, can be due to digitalis toxicity or hypokalemia. -2mm ST depression is significant. Stop exercise and monitor vitals. (True for exercise, not for exercise TEST) -Use clinical judgement (signs, symptoms, vitals)ST segment elevationMyocardial infarction (STEMI) Greater than 1 mm is indicative -True STEMI = terminate exercise and alert EMS -If STEMI is observed on monitor without symptoms, check the leadQ waveMarker of infarction, signifies loss of positive voltage due to necrosis. Longer than 0.04 or larger than 1/3 amplitude of R waveT wave inversionOccurs hours or days after MI as a result of delay in repolarization produced by injuryExercise Stress Test Absolute Indications for stopping-Drop in SBP greater than 10 despite increase in workload WTIH evidence of ischemia -3/4 angina -Nervous system symptoms (ataxia, dizziness) -Poor perfusion (cyanosis, pallor) -Sustained V-tach -1.0 mm ST elevation without diagnostic Q wavesExercise Stress test Relative Indications for Stopping-Drop in SBP greater than 10 despite increase in workload WITHOUT evidence of ischemia -greater than 2 mm ST segment depression -Arrhythmias OTHER THAN sustained V-tach, including multifocal PVCs, SVTs, heart block, bradyarrhythmias -Fatigue, SOB, claudication -Increasing chest pain -Hypertensive response (over 250 SBP or DBP over 115)Vital Response to ExerciseHR and RR increase with workload SBP increase 10 per MET DBP can change +/- 10 UE exercise causes 30-40% less O2 demand than LE at same workloadHoman's SignPassive dorsiflexion of foot at ankle. Positive for DVT if maneuver produces deep pain in calf or popliteal space.Mediate Percussion: DullNeoplasm, atelectasis, or consolidation of lung if heard over upper lungMediate Percussion: ResonancePercussion sound from normal lungMediate Percussion: Hyper-resonantBetween resonant and tympany. Suggests pulmonary emphysema or pneumothorax.Tympanyhigh-pitched, musical, drumlike percussion note heard when percussing over the stomach and intestine. If heard over lungs, almost exclusively signals large pneumothoraxNormal infant HR and RR100-130 BPM, 33-45 RR newborn, 25-35 RR 1 yrNormal Child HR and RR80-100 BPM 15-20 RRNormal Adult HR60-100 BPM 12-20 RRPulse Amplitude Scale0 = absent 1 = small or reduced 2+ = Normal or average 3+ = large or boundingForced Vital Capacity (FVC) Testmeasures the amount of gas expelled when a subject takes a deep breath and then forcefully exhales maximally and as rapidly as possibleFEV1/FVC ratiodividing of value for FEV1 by value for FVC; useful in differentiation obstructive and restrictive pulmonary dysfunction.Obstructive Ventilatory ImpairmentDecreased expiratory flows. Primary indicator is PEV1/FVC less than 70%. Asthma, Emphysema, Chronic Bronchitis 100%: Possible normal 70%: Mild Obstruction 60%: Moderate Obstruction 50%: Moderate to severe Obstruction Less than 50%: Severe ObstructionRestrictive Ventilatory ImpairmentReduced Lung Volumes (TLC, FEV1, FVC) and normal expiratory flow rates. Tumor, interstitial lung disease, pleural disease, chest wall deformities, obesity, pregnancy, neuromuscular disease Spirometry: Reduced FVC, normal FEV1/FVCLevel of SpO2 to stop at90% for acutely ill patients, 85% for patients with chronic lung disease.Normal Respiration rhythm vs COPDNormal: Inspiration is half as long as Expiration (1:2) COPD: Longer Expiration phase (1:3, 1:4)Active Cycle of Breathing (ACB)Three phases: 1. Breathing control (Gentle relaxed breathing for 5-10 sec) 2. Thoracic Expansion (3-4 slow deep inhalations) 3. Forced Expiration (1-2 huffs) Assists with secretion clearance in patients with asthmaAutogenic DrainageControlled breathing to remove secretions without using postural drainage positions or coughing. Can be performed anywhere. Sitting upright in chair w/ back support 1. Unsticking Phase: Slow breath in through nose, 2-3 sec hold, exhale down to ERV. 2. Collecting Phase: Breathe at tidal, interspersed with 2-3 sec holds 3. Evacuating Phase: Deep inspiration from low-mid IRV, breath hold followed by huffDirected Cough and HuffingCough compensates for physical limitations to elicit max exhalation. Huffing is forved expiratory maneuver with glottis open, similar to fogging glasses. Lower potential for airway collapse. "Ha ha ha"High Frequency airway oscillation• *Acapella and Flutter* are handheld devices that combine *positive expiratory pressure and high frequency airway vibrations to mobilize mucus secretions in airways* • W/ device in mouth, inhale slowly to 75% full breath; hold breath 2-3 seconds; exhale through device 3-4 seconds, repeat 10-20 breaths • Remove device and perform 2-3 coughs or huffs to raise secretionsPostural Drainage: Apical segments right and left upper lobesThe patient is in a sitting position, leaning back 30-40 degrees. Percussion and vibration are performed above the clavicles.Postural Drainage: Posterior Segment Right upper lobeThe patient is turned 1/4 from prone on the left side with the bed horizontal and the head and shoulders raised on a pillow. Percussion and vibration are performed around the medial border of the right scapula.Postural Drainage: Posterior segment left upper lobeThe patient is turned 1/4 from prone on the right side with the head of the bed elevated 45 degrees and the head and shoulders raised on a pillow. Percussion and vibration are performed around the medial border of the left scapula.Postural Drainage: Lingula Left upper lobeThe patient is turned 1/4 from supine on the right side with the foot of the bed elevated 12 inches. Percussion and vibration are performed over the left chest between the axilla and the left nipple.Postural Drainage: Anterior Segments right and left upper lobesThe patient is in supine with the bed horizontal. Percussion and vibration are performed below the clavicles.Postural Drainage: Right middle lobeThe patient is turned 1/4 from supine on the left side with the foot of the bed elevated 12 inches. Percussion and vibration are performed over the right chest between the axilla and the right nipple.Postural Drainage: Superior segments left and right lower lobesThe patient is prone with the bed horizontal. Percussion and vibration are performed below the inferior border of the left and right scapulae.Postural Drainage: Anterior basal segments left and right lower lobesThe patient is in supine with the foot of the bed elevated 18 inches. Percussion and vibration are performed over the lower ribs on the left and right sidePostural Drainage: Posterior basal segments left and right lower lobesThe patient is in prone with the foot of the bed elevated 18 inches. Percussion and vibration are performed over lower ribs on left and right side of chest.Postural Drainage: Lateral basal segments lower lobesthe patient is in sidelying with the foot of bed elevated 18 inches. percussion and vibration performed over the lower ribs. L sidelying for R lobe and R sidelying for L lobe.Diaphragmatic Breathingbreathing with the use of the diaphragm to achieve maximum inhalation and slow respiratory rate. Cue: "Breathe into your belly" Who: Restrictive lung condition, Hypoxemia, Tachypnea, Atelectasis, Anxiety, Excess Pulmonary Secretions When: To improve O2 sats, resolve atelectasis, decrease anxiety, mobilize secretionsInspiratory Muscle Trainingused for patients that exhibit decreased chest expansion, SOB, bradypnea, and decreased breath sounds. attempts to increase ventilating capacity and decrease dyspnea through strengthening of diaphragm and intercostal muscles. Threshold or PFLEX.Paced Breathing and exhale with effort.strategy to decrease work of breathing and prevent dyspnea during activity. Allows those who experience SOB during activity to participate. EWE is a breathing strategy to prevent patients from holding their breath.Pursed Lip BreathingReduces respiratory rate, reduces dyspnea, and maintains positive pressure on bronchioles to prevent airway collapse in patients with emphysema. "Inhale through your mouth and exhale through tightly pressed lips" Who: Obstructive Lung condition (FEV1/FVC less than 70%) who has dyspnea at rest or with exertion/wheezing Why: to relieve dyspnea, improve activity tolerance, and reduce wheezing.Mechanical Insufflation-Exsufflation Device (CoughAssist)Stimulates natural cough by delivering large positive pressure followed by a sucking negative pressure that pulls air out of the lungs. Who: Severely involved pt with impaired ab function that can't produce effective cough to clear secretions (ALS, MS, PD, MD, GB, SCI). Can be used with Trach.Endotrachial SuctioningMechanical removal of pulmonary secretions from pt who is on a vent Who: Severely involved pt with trach on mechanical vent (ALS, GB, high SCI). Pt with audible lung secretions, sesat, and/or signs of ARDHigh Frequency Chest Wall Oscillation VestInflatable vest attached to air pulse generator machine that vibrates at high frequencies Who: Cystic fibrosis with Mucus plugs, or ALS Why: Mobilize solidified mucus in airways, relieve dyspnea, improve activity tolerance, improve oxygenation, and reduce wheezing.Positions to Relieve Dyspnea-forward leaning with arm support optimized length tension of diaphragm and allows piece minor and major muscles to assist with elevating rib cage during inspiration. -reverse trendelenburg (supine with head above trunk and LE) -semi fowlers - supine head of bed evaluated 45 degrees.Six Minute Walk TestAssesses walking endurance and aerobic capacity 100 feet long hallway, floor markers every 3 feet Pt must walk as far as possible for 6 min, and can slow down and rest as necessary. Notes: -Can use AD but must be least restrictive w/out jeaporizing safety -Alerted after each min how much time is left (you have 5 min left) -Accepted verbal encouragement "Keep up the good work" -Therapist should walk a half step behind the patient and not beside or in frontHigh Altitude1,500-3500 m (5000 ft to 11,500 feet) Atmospheric pressure is low, partial pressure of O2 is high (PaO2) Increased HR, CO, BP, RR Decreased performance, SV, Arterial PaCO2 Altitude sickness: HA, nausea, vomiting, edema, dyspneaAquatic TherapyWhen submerged below xiphoid process, hydrostatic pressure increases difficulty of breathing, leading to increased RR. Pts with dyspnea should avoid submersion above Xiphoid MS should avoid water temp above 84 degrees Water temp above 95.9 deg causes peripheral vasodilation + increase HR, and decrease BP Water temp below 80.6 degrees will cause peripheral vasoconstriction + decrease HR and CO to reduce oxygen demand and preserve organs. BP increases bc of vasoconstrictionHemodialysisFilters waste products from patient's blood due to Renal Disease robbing kidneys of that ability -Exercise is best on non-dialysis days -RPE is best measure, stay between 9-13 -Weight/pressure should never be placed on ateriovenous fistula arm -BP should never be taken in the arm with arteriovenous fistula -LE exercises can be performed in 1st 1/2 of dialysis but nothing last 1/2. NO EX immediately post dialysisInternational Normalized RatioAssesses risk of bleeding or coagulation. High means risk of bleeding. Normal is 0.9-1.1. Over 2.5: Caution, guard for falls Over 3: At risk for hemarthrosis 4:GlucoseIdeal Range: 100-250 Below 70: Give 15g snack 70-100 with syptoms, give 15g carb snack, recheck in 15. If no symptoms, continue ex and give snack, recheck in 15 250-300 WITH ketones: No ex, call EMS 250-300 without ketones: Ex with caution, retest in 15 Over 300: No ex, call EMSErythrocyte Sedimentation Rate (ESR)timed test that measures the rate at which red blood cells settle through a volume of plasma Increased in presence of rheumatics, HIV, infections, and collagen vascular diseaseC-Reactive ProteinIndication of acute inflammation if over 3 Arthritis, Lupus, rheumatic conditions, vasculitis, meningitis,Cheyne-Stokes Breathinga distinct pattern of breathing characterized by quickening and deepening respirations followed by a period of apnea. -Crescendo and decrescendo -end-of-life transitioning -stroke, TBI, CHF, brainstem, opioid.Paradoxical BreathingChest contracts with inhalation, and expands during expiration Normal in some infants, pathological in children and adults -Fall, sports injury, car accident, damage to lungs or rib cage -Sleep apnea, upper airway blockage, electrolyte imbalance, diaphragmatic neuro issue.Junctional Rhythm40-60 Regular! -impulse from AV node w/ retro/antegrade transmission - P wave often inverted/buried/follow QRS - slow rate - narrow QRS (not wide like ventricular)Segmental Breathingused to prevent accumulation of fluid and to increase chest mobility by directing inspired air to predetermined areas. Posterior low ribs: Posetrior basal segment of ower lobes Lower lateral costal area: lateral basal segments of lower lobes Anterior midchest: Anterior segments of upper lobes Anterior low ribs: Anterior basal segments of lower lobesGlossopharyngeal Breathing"Frog breathing" Use tongue to push air into airway - swallow air. USED FOR: High SC injury (if ventilator fails)Metabolic Equivalent (MET)concept expressing the energy cost of physical activity; for example, 3 METs means three times the amount of energy expended at rest Moderate risk for mortality if capacity is less than 5-6 METsPhases of Wound HealingInflammatory (1-10 days) Proliferative (3 to 21 days) Maturation/Remodeling (7 days to 2 years)Inflammatory Phase of Wound Healing1-10 days Initial response to wound, Platelet activation, clotting cascade. WBCs kill bacteria. Re-epithelializationin 24 hoursProliferative Phase of Wound Healing3-21 days Formation of new tissue Capillary buds and granulation tissue fill the wound bedMaturation Phase of Wound Healing7 days to 2 years Initiated when granulation tissue and epithelial differentiation appear in wound bed.Primary Intention Healingtissue surfaces are approximated (closed) using staples, sutures, or adhesive, and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring Common in acute wounds with minimal tissue loss. -Superficial partial thickness wounds (blisters, abrasions) -Punctures -Surgical Incisions -LacerationsSecondary Intention HealingWounds close on their own without superficial closure, edges are not approximated. Usually significant tissue loss or necrosis, irregular or nonviable wound margins. Require ongoing wound care and have larger scars. Neuropathic, arterial, venous, pressure ulcers Most Full-thickness wounds Chronically inflamed woundsTertiary Intention (Delayed Primary Intention) HealingWound remains open, and when risk factors for complications have been alleviated, wound is closed with primary intention. Risk factors for complications like sepsis or dehiscence: wounds with significant edema, debris contamination, high risk for infection, questionable vascular integrity.ContaminationNon-replicating bacteria on wound surface. No additional tissue injury, does not stimulate inflammatory immune responseColonizationReplicating bacteria on wound surface that does not invade or injure tissue, does not stimulate inflammatory immune response. May delay wound dealing, may benefit wound healing by preventing worse organisms from proliferating in wound bedInfectionPresence of replicating bateria that invades tissue beyond wound surface. Visible inflammatory immune response. Will significantly delay wound healing, can progress to sepsis, osteomyelitis, and gangreneAbrasionFriction and shear forces over a rough surface, scraping away at the skin's layersAvulsion (degloving)Skin becomes detached from underlying structuresIncisional woundMost often associated with surgery and is created intentionally by means of a sharp object such as a scalpel or scissorsLacerationWound or irregular tear of tissue associated with trauma. Can result from shear, tension, or high force compressionPenetrating woundWound that enters interior of organ or cavityPuncture wounda deep hole made by a sharp object such as a nail. Typically little tissue damage beyond wound tract, but risk of contamination and infection are highArterial Insufficiency Ulcersoccur secondary to ischemia from inadequate circulation of oxygenated blood (ischemia) and typically linked to PAD. often due to complicating factors such as atherosclerosis Presentation: -Located usually on distal third of leg, toes, webbed spaces, and lateral malleolus. -Severely painful, and more painful with limb elevation. -Pedal pulses are diminished or absent, decreased skin temp -ABI of 0.79 or less is indicative of moderate blockage -Deep wound, smooth and well defined edgesVenous Insufficiency Ulcersoccur secondary to inadequate functioning of the venous system resulting in inadequate circulation and eventual tissue damage and ulceration Presentation: -Located proximal to medial malleolus -Irregular, shallow shape, with moderate to heavy exudate -Normal pedal pulse and skin temp -Leg elevation decreases pain, dependent position increases painNeuropathic ulcersA secondary complication usually associated with a combination of ischemia and neuropathy. Often associated with diabetes mellitus, or any form of peripheral neuropathy. Presentation: -Located on areas of foot susceptible to pressure during weight bearing -Looks like an oval with a callused rim -Loss of protective sensationPressure ulcersResult from sustained pressure on tissues at levels greater than capillary pressure. Skin over bony prominences are very susceptible to ischemia and necrosis. May initially present as bruising or blisters under intact skin to deeper tissues before opening to reveal full thickness damage.Superficial WoundTrauma to the skin, epidermis remains intact. Will heal with inflammatory process -non-blistering sunburnPartial Thickness WoundExtends through epidermis and possibly into dermis (but not through). Will heal by re-epithelialization or epidermal resurfacing. -Abrasions -Blisters -Skin tearsFull-thickness woundExtends through dermis into deeper structures such as subcutaneous fat. Deeper than 4 mm = full-thickness, healing by secondary intention.Subcutaneous WoundExtends through integumentary tissues and involves subcutaneous fat, muscle, tendon, or bone. Requires healing by secondary intention.Stage 1 Pressure UlcerIntact skin, non-blanchable redness.Stage 2 Pressure UlcerPartial thickness skin loss with exposed dermis. Wound bed is pink or red, no exposed adipose, no granulation tissue, slough or eschar.Stage 3 Pressure UlcerFull thickness skin loss, with visible adipose and granulation tissue present, often with visible slough or eschar. Possible undermining and tunneling. Fascia, muscle, ligament, tendon, bone NOT exposed. If slough or eschar obscures tissue loss, it is unstageable.Stage 4 Pressure InjuryFull thickness skin and tissue loss, WITH exposed or directly palpated fascia, muscle, tendon, ligament, cartilage, or bone in ulcer. Slough or eschar may be visible. Unstageable if slough or eschar obscures tissue lossUnstageable Pressure InjuryFull thickness skin and tissue loss, extent of tissue damage within ulcer cannot be confirmed by slough or eschar. Stable eschar (dry/intact, without erythema) should not be removed.Deep Tissue Pressure InjuryIntact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. If necrotic tissue, subcutaneous tissu, granulation tissue, fascia, or muscle are visible, indicates full-thickness pressure injury.Supine Bony Prominences (Pressure Injury)-Occiput -Spine of scap -Inferior angle of scap -Vertebral spinous processes -Medial epicondyle of humerus -Post iliac crest -Sacrum -Coccyx -HeelProne Bony Prominences (Pressure Injury)-Forehead -Anterior acromion process -anterior head of humerus -Sternum -ASIS -Patella -Dorsum of footSidelying Bony Prominences (Pressure Injury)Ears Lateral Acromion Process -Lateral head of humerus -Lateral humeral epicodyle -GT -fibular head -Lateral malleolus -Medial MalleolusSitting Bony Prominences (Pressure Injury)Spine of scapula -Vertebral Spinous Processes -Ischial tuberositiesSerous ExudateClear, light color Thin watery consistency Normal in healthy healing wound through inflammatory and proliferative stages of healingSanguineous ExudateRed color Thin, watery consistency May be indicative of new blood vessel growth or disruption of blood vessels.Serosanguineous ExudateLight red or pink Thin, water consistency Normal in healthy healing wound through inflammatory and proliferative stagesSeropurulent ExudateCloudy/Opaque, yellow or tan color Thin, watery consistency Early warning sign of impending infection, always considered abnormalPurulent ExudateYellow/Green color Thick, viscous consistency Indicator of wound infection, always considered abnormalNecrotic TissueDead tissue from localized enzymatic changes associated with cell death. -Eschar -Gangrene -Hyperkeratosis -SloughEschar TissueBlack or brown, thick, hard and leathery necrotic tissue that tends to be firmly adhered to the wound bedGangreneDeath of tissue caused by loss of blood supply. Most commonly affects extremitiesHyperkeratosisWhite/gray in color, can vary in texture from firm to soggy. Also called callus.Slough TissueYellow green, or grey necrotic tissue described as moist, stringy, or mucinous. Tends to be loosely attached in clumps to wound bedSelective DebridementRemoval of only nonviable tissue from a wound -Sharp -Enzymatic -AutolyticSharp DebridementUse of scalpel, scissors, or forceps to remove devitalized tissue, foreign material, or debris from wound Used for wounds with large amounts of necrotic tissue, or in presence of cellulitis or sepsis Most expedient form of removing necrotic tissueEnzymatic Debridementtopical application of enzymes to surface of necrotic tissue -can be used on infected and non-infected wounds with necrotic tissue -may be used in wounds that have not responded to autolytic debridement or in conjunction with other debridement techniques -can be slow to establish a clean wound bed and should be discontinued after removal of devitalized tissues in order to avoid damageAutolytic DebridementUsing the body's own enzymes to remove nonviable tissue. Establishes moist wound environment that rehydrates necrotic tissue and eschar, facilitating enzymatic digestion. -Transparent films -Hydrocolloids -Hydrogels -Alginates Requires longer healing period, should not be performed on infected woundsNon-selective (Mechanical) DebridementRemoval of both viable and non-viable tissues from a wound. -Wet-to-dry -Wound Irrigation -Hydrotherapy (whirlpool)Wet-to-dry DressingsApplication of moistened gauze dressing over necrotic tissue. Dressing is allowed to dry and then removed with any necrotic tissue still adhered. - Used for wounds with mod amounts of exudate and necrotic tissue - Viable tissue can removed as well in the process, so use sparingly - Can cause bleeding and can be very painfulWound IrrigationRemoval of necrotic tissue using pressurized fluid. Ideal for infected wounds or wounds with loose debris. -Pulsed lavage uses pressurized stream of irrigation solutionHydrotherapy wound careWhirlpool tank with agitation toward wound requiring debridement softens and loosens adherent necrotic tissue. -May cause maceration of viable tissue, edema from dependent LE positioning, HypotensionNegative Pressure Wound Therapy (Vacuum Assisted Closure) or Wound VACUses suction to remove drainage and speed wound healing. -Used for wounds that can't be closed by primary intention (dehisced surgical incisions, full-thickness wounds, heavily draining granular wounds, ulcers) -Don't use over areas of malignancy, insufficient vascularity, large amounts of eschar, or fistulas.Hyperbaric OxygenInhalation of 100% oxygen at pressure over 1 atm to reduce edema and hyperoxygenate tissues. Has antibiotic effects and stimulates fibroblast production and collagen synthesis -Used for osteomyelitis, diabetic wounds, thermal burns, radiation necrosis, compromised flaps/grafts -Do not use for active malignancyGrowth FactorsDerived from naturally occurring protein factors to stimulate specific cells in a topical wound healing application. Increases growth rate of new tissues, promotes cell division.Alginate DressingSoft, absorbent, cotton like, for wounds with exudate, require packing and absorption, absorb a TON Highly absorptive, highly permeable -used on infected wounds for excessive drainage -May require frequent changes and requires secondary dressing. -Can be used to stop blood flow -Enables autolytic debridementFoam Dressings-composed from a hydrophilic polyurethane base. -hydrophilic at wound contact surface -hydrophobic on the outer surface -allows exudates to be absorbed into the foam through the hydrophilic layer -most commonly available in sheets or pads with varying degrees of thickness. -Encourages autolytic debridementGauze DressingA woven, flexible absorbent cloth applied to a wound Can be "impregnated" with petroleum, zinc, or antimicrobials Used for infected or non-infected wounds -Has tendency to adhere to wound bed -Increased infection rate compared to occlusive dressingHydrocolloidsGel-forming polymers (gelatin, pectin, carboxymethylcellulose) backed by a strong film or adhesive. Dressing does not attach to wound, but attaches to intact surrounding skin and absorbs exudate by swelling into gel-like mass. Used for partial or full thickness wounds -Enables autolytic debridement -Protects from contamination -Can't be used on infected wounds.Hydrogel DressingGel used to regulate fluid exchange and relieve pain during wound healing -Minimally adheres to wounds -Enables autolytic debridement -Moisture retentive -Commonly used on superficial/partial thickness wounds (abrasions, blisters) with minimal drainageTransparent Film DressingThin membrane made from transparent polyurethane. Permeable to vapor and oxygen, impermeable to bacteria and water. Used for superficial or partial thickness wounds with minimal drainage -Allows for easy visual inspection -Provides moist environment for wound healing -Allows for autolytic debridementMoisture and OcclusionDry wound bed = slow wound healing, risk for cracks or fissures Excessive moisture = maceration damage or erosion of tissue Occlusion = ability of dressing to transmit moisture between wound bed and atmosphere. Fully occlusive would be impermeable (latex gloves), non-occlusive substance is completely permeable (gauze pad)Occlusive Dressings from Most to Least Occlusive1. Hydrocolloids 2. Hydrogels 3. Semipermeable foam 4. Semipermeable Film 5. Impregnated Gauze 6. Alginates 7. Traditional GauzeMoisture Retentive Dressings from Most to Least Moisture Retentive1. Alginates 2. Semipermeable Foams 3. Hydrocolloids 4. Hydrogels 5. Semipermeable FilmContusionBruise. Injury caused by blow that does not disrupt skin integrity. Pain, edema, discoloration from blood seepage under skinDehiscenceBursting open of a wound closed by primary intentionDesiccatedDried up or dehydrated wound from dressing selection that does not control for evaporation of wound bed moistureDesquamationPeeling or shedding of outer layers of epidermis Usually occurs in small scalesEpidermisOuter layer of skinErythemaRedness of skin from capillary dilation or inflammationFriableTissue that is easily torn, fragmented, or bleeding when gently palpatedHematomaMass of clotted blood confined to a tissue or organ caused by a break in a blood vesselHypergranulationIncreased thickness of granular layer of epidermis exceeding the surface height of the skinGranulation Tissuenew tissue that is pink/red in color and composed of fibroblasts and small blood vessels that fill an open wound when it starts to healHyperpigmentationdarkened areas of skin caused by excessive amounts of melaninKeloid ScarAbnormal scar made up of irregularly distributed collagen bands Red, thick, firm, and raisedMacerationSkin softening and degeneration from prolonged exposure to water or other fluidsTurgorSpeed at which distended skin resumes natural appearance after being lightly pinched. Indication of skin elasticityThermal BurnCaused by conduction or convection -Hot liquid, fire, or steamElectrical BurnCaused by electrical current passing through body. -Entrance and exit wound -Can include cardiac arrhythmias, respiratory arrest, renal failure, neurological damage, and fracturesChemical BurnOccurs when chemical contacts skin and will continue until compound is diluted at site of contact -Sulfuric acid -Lye -Hydrochloric Acid -GasolineRadiation BurnMost common with exposure beam radiation therapy. Ischemic injury may be irreversible due to altered DNA in exposed tissues. -Severe blistering -Desquamation -Non-healing wounds -Tissue fibrosis -Permanent discolorationZone of coagulationArea of burn receiving most severe injury with irreversible cell damagezone of stasisArea of less severe injury that possesses reversible damage surrounding zone of coagulationZone of hyperemiaArea surrounding zone of stasis that presents with inflammation but will fully recover without interventionRule of NinesHead and Neck= 9% Each upper ext= 9% Each lower ext= 18% Front trunk= 18% Back trunk= 18% Genitalia= 1%Anterior neck burnPossible flexion and lateral flexion deformity Use soft, molded, or Philadelphia collarAnterior chest and axilla burnPossible shoulder ADD, EXT and IR deformity Use axillary or airplane splint, or shoulder abduction braceElbow burnFlexion and pronation deformity Use a gutter splint, conforming splint, three point splint, or an air splintHand and wrist burnEXT or hyperEXT of MCP, FLEX of IP, ADD and FLEX of thumb, Flexion of wrist Use wrist splint, thumb spica splint, palmar or dorsal extension splintHip burnFlexion and adduction deformity Anterior hip spica, abduction splintKnee burnFlexion deformity Conforming splint, three point splint, air splintAnkle BurnPlantar flexion deformity Posterior foot drop splint, posterior ankle conforming splint, anterior ankle conforming splintAllograftTemporary skin graft taken from a cadaver to cover a burned areaAutograftPermanent skin graft taken from donor site on patient's own bodyEscharotomyProcedure to open or remove eschar from burn site to reduce tension on surrounding structures, relieve edema pressure, and enhance circulationFull thickness graftSkin graft containing dermis and epidermisHeterograftSkin transplant taken from another species (usually pig)Mesh graftA skin graft that is altered to create a mesh-like pattern in order to cover a larger surface areaSheet grafta skin graft that is transferred directly from the unburned donor site to the prepared recipient siteSplit thickness graftAll epidermis and some dermisZ plastya surgical procedure to eliminate a scar contracture, an incision in the shape of a z allows the contracture to change configuration and lengthen the scarCellulitisInflammation that occurs as a result of bacterial infection of the skin and connective tissues. Develops anywhere under skin but typically extremities. Caused by streptococci or staphylococci. Can lead to sepsis or gangrene. Sxs: Localized redness that spreads quickly, skin that is warm or hot to touch, local abscess or ulceration, ttp, chills, fever. Tx: Systemic antibiotics.Contact DermatitisSuperficial irritation of skin from local irritation (poison ivy, latex, soap, jewelry). Can be acute or chronic. Sxs: Intense itching, burning, and red skin Tx: Identifying and removing the source of the irritation.EczemaGroup of disorders taht cause chronic skin inflammation due to an immune system abnormality, allergic reaction, or external irritant. Sxs: Red or brown-gray itchy, lichenified skin plaues exacerbated by some topical agents like soaps or lotions. Younger population will experience oozing and crusting. Tx: Topical/oral steroids, oral antibiotics and histamines.Gangrene (Dry)Loss of vascular supply resulting in local tissue death, usually from DM or atherosclerosis. Fingers, toes, limbs most often affected. May result in auto-amputation. -Infection not present Sxs: Dark brown or black nonviable tissue that eventually becomes hardened mass. Cold or numb skin Tx: Pharmacologic intervention, surgery, hyperbaric oxygen therapyGangrene (Wet)Swelling from bacterial infection causes a sudden stoppage of blood flow, resulting in loss of vascular supply to local tissue. Bacterial infection can develop after a burn, frostbite, or injury. Spreads quickly and can be fatal. Sxs: Swelling and pain at site of infection, change in skin color from red to brown to black, blisters that produce pus, fever, general malaiseOnychomycosisFungal infection of nail. Happens at manicures or pedicures with unsterile utensils, excess skin moisture, closed toed shoes, ipaired immune response Sxs: Yellow or brown nail discoloration, hyperkeratosis and hypertrophy of nail causing it to partially detach from nailbed Tx: Manual debridement of nail and topical antifungalPlaque PsoriasisChronic autoimmune disease of skin from genetics, injury, sunlight (insufficient or excess), stress, alcohol, HIV, smoking. Sxs: Red raised blotches bilaterally. Complications include arthritis, pain, itching, secondary skin infections Tx: Control symptoms, prevent secondary infection. Life long, can only be managed through exacerbationsTinea Pedis (Athlete's Foot)Superficial fungal infection causing epidermal thickening due to warm and moist environment. Happens due to closed toed shoes with no airflow, prolonged moisture or sweating, small nail or skin abrasions. Infectious. Sxs: Itching, redness, peeling skin, pain, odor, breaks in skin continuity Tx: Topical or oral antibioticsComplex Regional Pain SyndromeIntense, chronic, burning pain in affected extremity that spreads proximally after trauma, surgery, CVA, TBI, or peripheral nerve injuries. Stage I (Acute): Edema, thermal changes, discoloration, stiffness, dryness Stage II (Dystrophic): Worsening and constantpain, continued edema, and Stage III (Atrophic): Hardened edema, decreased limb temp, atrophic changes to fingertips or toesAnkylosing Spondylitischronic, progressive arthritis with stiffening (ankylosis) of joints, primarily of the spine and hip, but ossification can happen in all affected joints. Sxs: Recurrent and insidious episodes of LBP, morning stiffness, impaired spinal extension, limited ROM. Progresses to severe, consistent and extending to midback and neck. Natural lumbar curve flattens, thoracic kyphosis increases. On x-ray, may see SI fusion, ossification of outside of intervertebral disks (syndesmophyte)Metabolic System Functions-Conversion of food to energy to run cellular processes -Conversion of food to fuel for proteins, lipids, nucleic acids, and carbs -Elimination of metabolic waste Catabolism breaks down organic processes Anabolism combines simple molecules for tissue growthMetabolic ratespeed at which an organism carries out its metabolic processInherited Metabolic DisordersClassified by particular building block that is affected. -Enzyme deficiency leads to accumulation of substrate and deficiency in the product of the enzyme Diagnosis: Amniocentesis in utero, or chorionic villus sampling -Phenylketonuria -Tay-Sachs disease -Mitochondrial disorders -Wilson's Disease Must have awareness of dietary restrictionschorionic villus sampling (CVS)Prenatal diagnostic technique that involves taking a sample of tissue from the chorion (outermost membrane of embryo)Phenylketonuria (PKU), amino acid metabolic disorderInherited deficiency in phenylalanine hydroxylase, which normally converts phenylalanine to tyrosine. Excess buildup of phenylalanine leads to brain damage resulting in behavioral and cognitive deficits Sxs: Intellectual disability, hyperactivity, psychoses, abnormal body order, lighter features than family members. Tx: Dietary restriction of phenylalanine (diet drinks, anything with aspartame, breast milk, eggs, chicken, beef, liver, milk.)Tay-Sachs Disease (Lysosomal storage disorder)Inherited deficiency of Hexosaminidase A, producing an accumulation of gangliosides (GM2) in the brain, typically in Eastern European (Ashkenazi) Jewish population Sxs: At 6 months of age, child will start to miss developmental milestones and continue to deteriorate in motor and cognitive skills. Patient will develop significant intellectual disability and paralysis, dying by age 5 Tx: No effective treatment. Genetic testing in high risk pops.Mitochondrial disordersLHON (Leber Optic Atrophy), MELAS, Leigh syndrome Caused by mutations in DNA that lead to impaired mitochondrial protein function, resulting in loss of muscle coordination or strength, visual/hearing problems, learning disabilities, heart/liver/kidney disease, respiratory, neuro and GI disorders, dementiaWilson's disease (hepatolenticular degeneration)Inherited disorder most common in eastern Europeans, Sicilians, and southern Italians that appears in people under 40, usually between 4 and 6 years old. Inherited defect in body's ability to metabolize copper, which accumulates in brain, liver, cornea, and kidney. Sxs: Kayser-Fleischer rings surrounding iris of eye, degenerative changes in basal ganglia, hepatitis, cirrhosis of liver, athetoid movements, ataxic gait patterns, emotional/behavioral changes as copper accumulates. Over time, deformities in msk system, fractures, osteomalacia, contractures Tx: Vitamin B6 and D-Penicillamine, and treatment of hepatic diseaseMetabolic AlkalosisIncrease in bicarbonate accumulation or abnormal loss of acids, leading to pH rising above 7.45. Can be a result of vomiting too much, taking too many antacids, or diuretic therapy. Sxs: Nausea, diarrhea, vomiting, confusion, fasciculations, muscle cramping, hypoventilation. Can result in coma, seizures, and respiratory paralysisMetabolic AcidosisAccumulation of acids or deficit in bicarbonate results in pH dropping below 7.35. Can be a result of renal failure, lactic acidosis, diabetic/alcoholic ketoacidosis, diarrhea, or poison. Sxs: Compensatory hyperventilation (to blow off excess CO2), vomiting, diarrhea, headache, weakness, hyperkalemia, cardiac arrhythmias. Can lead to coma and death.Trousseau's signA sign of hypocalcemia and early stages of tetany. Carpal spasm caused by inflating a blood pressure cuff above the client's systolic pressure and leaving it in place for 3 minutes.Metabolic Bone Disease- Disruption in normal skeletal metabolism - Results in deformity, bone loss, fx's, softening of the bones, arthritis, and pain. -Skeletal system uses calcium and phosphorous to balance remodeling of cortical and trabecular bone to optimize skeletal structure -Osteomalacia -Osteoporosis -Paget's DiseaseOsteomalaciaBones become soft secondary to calcium (decreased intestinal absorption) or phosphorous deficiency (increased renal excretion) or deficiency in vitamin D. Bone matrix is adequate, insufficient calcification of matrix. Sxs: Vague presentation of aching, fatigue, weight loss. Myopathy and sensory polyneuropathy with periarticular tenderness and pain, thoracic kyphosis and bowing of lower extremities. Tx: Fix underlying etiology.OsteoporosisDecrease in trabecular and cortical bone mass leading to increased risk of fracture. Can be idiopathic, post-menopausal, or involutional (senile) osteoporosis. Declining osteoblast function coupled with loss of calcium and bone salts will cause bones to be brittle Sxs: Compression and other bone fractures, low thoracic/lumbar pain, loss of lumbar lordosis, kyphotic deformity, decrease in height, dowager's hump, postural changes Tx: Vitamin and pharmacological interventionPaget's DiseaseHeightened osteoclast activity, causing excess bone formation that lacks true structural integrity. Bone is large but lacks strength. Sxs: MSK pain, bony deformities at skull, clavicle, pelvis, femur, spine, and tibia. Progresses to HA, vertigo, hearing loss, mental deterioration, fatigue, increased CO and heart failure Tx: Biphosphonates to limit bone resorption and improve quality of involved bone.Endocrine Systemthe body's "slow" chemical communication system; a set of ductless glands that secrete hormones directly into the bloodstream. Hormones travel through the body to target organs, where they selectively bind to receptor cells. Hormones travel to virtually every area of the body. Key Glands: -Hypothalamus -Pituitary Gland -Thyroid Gland -Parathyroid Gland -Adrenal Gland -Pancreas -Ovaries -TestesHypothalamusA neural structure lying below the thalamus; it directs autonomic nervous system, the feed & breed (hunger, thirst, sexual behavior, body temperature), helps govern the endocrine system via the pituitary glandPituitary GlandLocated at base of brain below hypothalamus, and is controlled by the hypothalamus. Consists of two glands (adenohypophysis anterior, and neurohypophysis in posterior). Considered the "master gland" and releases hormones that regulate other endocrine glands, and is influenced by seasonal changes or emotional stress. Creates sex hormones, controls ovulationThyroid GlandControls body's metabolism. Produces thyroxine and triiodothyronine to control the rate at which cells burn fuel from food. Increased thyroid hormones increases rate of chemical reactions in body.Parathyroid Glands-Produce parathyroid hormone, which is an antagonist to calcitonin and helps maintain normal blood levels of calcium and phosphate -Increased PTH increases reabsorption of calcium and phosphate from bones to blood. -Low blood calcium stimulates PTH, high blood calcium inhibits it. -Calcium levels control clotting, neuromuscular excitability, and cell membrane permeability.Adrenal Glands-Adrenal Cortex: Corticosteroids that regulate water/sodium balance, stress response, immune system, sexual development, and metabolism -Adrenal Medulla: Epinephrine that increases HR and BP in response to stressPancreasHoused in upper left quadrant of abdominal cavity. -Functions mostly as endocrine organ but also an exocrine gland, secreting bicarbonate and enzymatic pancreatic juice to neutralize stomach acid in intestines and break down food. -Islets of Langerhans are the hormone-producing cells of pancreas, containing Alpha cells to produce glucagon and Beta cells tp produce insulin -Those two hormones regulate glucose in bloodstreamGlucagonA hormone secreted by the pancreatic alpha cells that increases blood glucose concentration, and is released into bloodstream when blood glucose is low.InsulinA protein hormone synthesized in the pancreas that regulates blood sugar levels by facilitating the uptake of glucose into tissues. High blood glucose levels increase this hormone's activity to achieve homeostasis.OvariesLocated in pelvic cavity on each side of uterus, providing estrogen and progesterone that contribute to regulation of menstrual cycle and pregnancy. Ovarian follicles secrete estrogen, responsible for female sex characteristics Corpus Luteum secretes progesterone, which maintains uterus liningTestesLocated in scrotum. Secrete androgens such as testosterone that regulate body changes associated with sexual development and support sperm productionSteroid Hormones (prostaglandins)Do not circulate in blood, just exert effects where they are produced. All cells create prostaglandins from phospholipids of cell membrane Can produce wide variety of effects: inflammation, pain, vasodilation/constriction, nutrient metabolism, blood clottingAmine hormones (catecholamines)Epinephrine Norepinephrine Dopamine Synthesized from chromaffin cells in adrenal medulla, and released into the bloodstream after sympathetic nervous system stimulation to activate glycogen breakdown for fuel, block insulin, increase metabolic rate, and dilate lung airways.EpinephrineNeurotransmitter secreted by the adrenal medulla in response to stress. Also known as adrenaline. Targets cardiovascular and metabolic systems.Sarcoidosischronic inflammatory disease in which small nodules (granulomas) develop in lungs, lymph nodes, and other organsHypothalamus DysfunctionTumors (ependyomas), inflammatory process (sarcoidois), surgical transection, trauma (skull fracture)HypopituitarismDecreased/absent secretion from anterior pituitary gland, causing dwarfism, delayed growth/puberty, diabetes insipidus. Often caused by pituitary adenoma (usually benign tumor) or a pituitary infarctionHyperpituitarismExcess secretion of growth hormone, causing gigantism, acromegaly, hirsutism (excess hair growth), galactorrhea (abnormal lactation), amenorrhea, infertility, or impotence.Addison's DiseaseAdrenal Hypofunction. Occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone Sxs: Hyperpigmentation, GI pain, nausea, hypotension, weakness, fluid/electrolyte imbalance secondary to aldosterone dysfunction, metabolic dysfunction secondary to cortisol deficiencyAldosterone"salt-retaining hormone" which promotes the retention of Na+ by the kidneys. na+ retention promotes water retention, which promotes a higher blood volume and pressureCushing's SyndromeAdrenal Hyperfunction. Excessive amounts of cortisol production. Sxs: Moon Face, buffalo hump, hyperglycemia, truncal obesity, acne, hypertension, depression, memory lossHypothyroidismDecreased thyroid hormon secretion, slowing metabolic processes in the body. Hashimoto's or underdeveloped thyroid gland. Sxs: Fatigue, weight gain, decreased HR, constipation, slowed growth PT implications: Risk of rhabdomyolsysisHyperthyroidismExcess thyroid hormones in bloodstream. Most specific cause is Grave's disease, an autoimmune disorder. Sxs: Increase in nervousness, excess sweating, exophthalmos weight loss, increased BP, myopathy chronic periarthritis, enlarged thyroid gland PT implications: Avoid treatments that exacerbate, avoid hot settings, avoid cardiovascular stressHypoparathyroidismHypofunction of parathyroid gland Sxs: Hypocalcemia, seizures, cognitive deficits, tetany, cramps, muscle pain, cardiac arrhythmias. May see Trousseau's Sign Tx: Intravenous calciumHyperparathyroidismHyperfunction of the parathyroid gland Sxs: Renal stones, kidney damage, depression, memory loss, muscle wasting, bone deformities and vertebral compression fractures Tx: Lowering serum calcium with diuretics or antiresorptive medsType I Diabetes MellitusPancreas fails to produce enough insulin due to genetic disposition and/or exposure to trigger causing an immune reaction. Also called insulin-dependent or juvenile diabetes. Sxs: Rapid onset, weight loss, ketoacidosis, polyuria (urination), polydipsia (thirst), polyphagia (hunger), blurred vision, dehydration, fatigue Tx: Insulin injections to maintain glucose blood levels.Type II Diabetes MellitusTypically occurs over age of 45. Resistance to insulin action at receptor site, inadequate insulin secretion, and hyperglycemia when body cannot properly respond to insulin. Exacerbated by obesity. Sxs: Polyphagia, polydipsia, polyuria, dehydration, fatigue, no ketoacidosis. Tx: Blood glucose control through diet, exercise, and medications.HyperglycemiaBlood glucose over 180-200 mg/dL. Increased thirst and frequent urination, dyspnea, fruity breath odor, dry mouth, nausea, confusion, LOC.Ketoacidosisexcessive production of ketones, making the blood acidicHypoglycemiaBlood glucose less than 70 mg/dL Sweating, shaking, dizziness, clumsiness, headache. May lose consciousness. Counteracted with glucose or carb rich substace (sugar, honey, crackers, juice)Diabetes InsipidusLarge amounts (almost 20 L per day) of urine, excessive thirst. Variety of causes Central: lack of anti-diuretic hormone Nephrogenic: Kidneys don't respond to ADH Dispogenic: Hypothalmic thirst mechanism is damaged from trauma or medsGestational diabetesIncrease in insulin resistance and blood glucose levels during pregnancy, usually last trimester. Babies born to women with gestational diabetes have increased levels and are usually big, increasing difficulty of delivery. Baby will have breathing difficulties, jaundice, or hypoglycemia following birth In childhood, will be more likely to have insulin resistance, obesity, behavioral healthy disorders, delays in fine/gross motor skillsFasting Plasma Glucosemeasures circulating glucose level in a patient who has fasted at least 8 hours. Positive for DM if blood glucose level is over 125 mg/dL (normal is 100)Oral glucose tolerance testGlucose testing after two hours post injection of sugary drink. positive for DM if level is 200 mg/Dl or higher (normal is less than 140)A1C TestingBlood test based on attachment of blood glucose to hemoglobin, measuring patient's glucose level over 2-3 months. Positive if A1C level is 6.5% or higher (normal is below 5.7%)Male HypogonadismPrimary hypogonadism: deficiency of testosterone secondary to failure of testes to respond to FSH and LH. Most common cause is Klinefelter's Secondary hypogonadism: Failure of hypothalamus or pituitary to produce hormones to stimulate testosterone production. Sxs: Pre-puberty--sparse body hair, underdeveloped msk, long arms/legs secondary to no growth plate closure Adult-onset--decreased libido, ED, infertility, decreased cognitive skills, mood changes, sleep disturbances.Female HypogonadismPrimary: Gonads do not produce the amount of sex steroid sufficient to supress secretion of LH and FSH at normal levels. Most common cause is Turner's (X). Secondary: Failure of hypothalamus or pit to produce the hormones which will subsequently stimulate estrogen production. If this happens before puberty symptoms will include gonadal dysgenesis, short stature, failure to progress through puberty or primary amenorrhea and premature gonadal failure. The main post-puberty symptom is secondary amenorrhea.Bone mineral regulating agents- Prevent bone loss - Examples: calcium (calcium carbonate Tums, Calderol), calcitonin (Cibacalcin), biphosphonate (Fosamax), anabolic agents (Premarin) - Indications: Paget's disease, osteoporosis, hyperparathyroidism, rickets, hypoparathyroidism, cardiac arrhythmias - Implications for PTs: Risk for fractures and side effectsUpper GI functionMouth, Esophagus, and Stomach mechanically and chemically digest food. Stomach uses HCl acid and digestive enzymes from liver, pancreas, and gallbladder to assist digestionSmall Intestine FunctionAbsorbs most nutrients; Main absorption organ of the digestive tract Duodenum: Neutralizes stomach acid Jejunum: Absorbs water, electrolytes, nutrients Ileum: Absorbs bile and intrinsic factors to be recycledLarge Intestine FunctionReabsorbs water and stores and eliminates undigested food as feces Ascending colon Transverse Colon Descending colon Sigmoid Colon Rectum AnusGallbladderStores and releases bile into duodenum to assist digestionLiverProduces bile which emulsifies fat, produces RBCs and vitamin K, regulates serum level of carbs, proteins, and fatsgastroesohageal reflux disease (GERD)Incompetent lower esophageal sphincter allows gastric contents to move backward, causing esophageal tissue injury over time. Occurs in 20-30% of adults and some newborns or infants Sxs: Heartburn, belching, chest pain, coughing, esophagitis, hematemesis. If untreated, may develop esophageal strictures, esopaghitis, aspiration pneumonia, asthma, and esophageal adenocarcinoma PT Rehab Considerations: Avoid certain exercises, recumbency will induce symptoms. Head/neck discomfort secondary to perception of lump in throat and subsequent compensation. Tight clothing, exercise, and constipation may precipitate it. Chronic bronchitis, asthma, and pulmonary fibrosis may present with GERD. Have them sleep in left sidelying with pillows elevated (lower esophagus bends to left, so reflux is minimized)GastritisInflammation of gastric mucosa (stomach lining) with similar symptoms to GERD but greater intensity. Can be erosive (acute) or non-erosive (chronic type B). Patients should avoid all aspirin containing compounds. If blood in stool, initiate physician referral.Erosive GastritisInflammation and bleeding of gastric mucosa due to stress, NSAIDs, alcohol, viral infection, or direct trauma. Sxs: Dyspepsia, nausea, vomiting, and hematemesis. Pt may be asymptomatic. May progress to gastric ulcerNon-erosive GastritisInflammation of gastric mucosa as a result of H.Pylori bacterial infection. Sxs: May be asymptomatic, but will show symptoms in progression. Tx: H. Pylori is a carcinogen and should be treated with aggressive pharmacological intervention, including proton pump inhibitor and antibioticsPeptic Ulcer DiseaseDisruption or erosion in GI mucosa due to imbalance between protective mechanisms of stomach and secretion of acids in stomach. Causes include H pylori, chronic NSAId use, stress, alcohol, some meds and food, smoking Sxs: Dependent on location and severity. Can include epigastric pain, burning or heart burn, nausea, vomiting, bleeding, bloody stools, pain in waves that is relieved by eating. Specific to H. Pylori: halitosis, rosacea, and flushing. HR increase or BP decrease may be signs of bleeding Perforated ulcer on posterior wall of stomach may present as back pain! Midthoracic to Right upper quadrant and shoulder may signify blood in peritoneal cavity secondary to perforated ulcerMalabsorption SyndromeGroup of pathologies where intestinal absorption and nutrition are inadequate. Occurs secondary to defects in digestion, or inability of intestinal mucosa to absorb nutrients -Celiac -CF -Pancreatic Carcinoma -Pernicious Anemia -AIDS -Crohn's -Addison's Disease Risk for osteoporosis and fractures, and swelling/spasms secondary to electrolyte imbalances and protein depletion.Irritable Bowel SyndromeColon or large intestine are sensitive to certain foods or stress. Symptoms may be triggered by anxiety, caffeine, smoking, alcohol, or fat intake. Sxs: Abdominal pain/bloating/distension, nausea, vomiting, changes in form/frequency of stool, passing of mucus in stool Tx: Diagnosis of exclusion from other GI diagnoses. Change in lifestyle, nutrition, stress, adequate sleep and exercise. Avoid milk, wheat, rye, barley, alcohol, and caffeine.DiverticulitisInflammation in diverticula (pouch-like protrusions in colon). 80% of diverticulosis is asymptomatic, but 20% may progress to diverticulitis. May be a result of low fiber diet. Sxs: Abdominal pain, with tenderness over left side of lower abdomen. Cramping, constipation/diarrhea, nausea, fever, chills, vomiting. Tx: Diet modification, lower internal colonic pressure through increased fiber. Nasogastric tube for severe cases.Hepatitis AEnds in a vowel, comes from the bowel. Transmission is by close personal contact with someone who has the infection or through fecal-oral route (contaminated water or food source). Flu like symptoms, usually does not progress to chronic disease or liver cirrhosis. Pts recover in 6-10 weeksHepatitis BB= blood and body fluids (hep c is the same) Transmitted via blood and bodily fluids (sharing of needles, intercourse, exposure to blood, semen, or maternal-fetal exposure) 10% of cases progress to chronic Hep Tx: Hepatitis B Immunoglobulin, then vaccination series.Hepatitis CBlood, semen, or bodily fluid transmission. 90% of post-transfusion hep cases. Often asymptomatic, acute infection can be mild Increased frequency of hashimoto's, DM, and corneal ulceration. No vaccine available. Chronic hep occurs in 50% of cases, 20% of those progress to liver cirrhosisCirrhosis of the LiverHealthy tissue of liver replaced with scar tissue which blocks blood flow through liver and prevents liver from properly functioning. Etiology: Alcoholism (over a decade), hep C, B, D, certain drugs, infections, toxins, heredity, steatohepatitis, blocked bile ducts. Alcohol blocks normal metabolism of protein fats and carbs. Cirrhosis occurs after >a decade of alcoholism. Hep C causes inflammation - results in cirrhosis after > 2 decades. Sxs: Fatigue, decreased appetite, abdominal pain, spider angiomas, weight loss. Ascites, LE edema, jaundice, gallstones, bleeding, immune system dysfunction, varices.CholecystitisInflammation of the gallbladder, usually associated with cholelithiasis (gallstones). Sxs: Can be asymptomatic, but most common symptom is RUQ pain. If gallstone is lodged in cystic duct, patient can have severe pain that radiates to interscapular region. Tx: Low fat diet to decrease gallbladder stimulation. Lithotripsy if symptomatic to break up stones. Can use laparoscopic cholecystectomy to completely remove gallbladder. Acute cholecystitis resolves in a week.Antibiotics for H. PyloriClarithromycin Amoxicillin Tetracycline MetronidazoleAntacids for GERD, peptic ulcer, gastric indigestionBasaljel (Aluminum carbonate) Tums (Calcium carbonate) Milk of magnesia (magnesium hydroxide) Bromo Seltzer (sodium bicarbonate)AntidiarrhealsPepto Bismol (bismuth subsalicylate) Motofen (difenoxin) Imodium (loperamide) Donnagel (attapulgite) Kapectolin (Kaolin)AntiemeticsMeclizine Scopolamine Dolasetron PhenerganEmeticsApomorphine, IpecacH2 Receptor BlockersPrevents the release of stomach acid to promote ulcer healing Pepcid (famotidine) Zantac (ranitidine) Tagamet (cimetidine)LaxativesMetamucil (Psyllium) Colace (Docusate) Glycerin Suppository Milk of Magnesia Correctol (Bisacodyl) Senokot (Senna) Citrucel (Methylcellulose)Proton Pump InhibitorsInhibit the action of the gastric proton pump, thereby reducing gastric acid production. They usually have the suffix "PRAZOLE". Used for dyspepsia and GERD Nexium (Esomeprazole) Prilosec (Omeprazole) Protonix (Pantoprazole) Prevacid (Lansoprazole) AcipHex (Rabeprazole)LUQ painGastric Ulcer Pancreatitis Perforated Colon Spleen injury or rupture Pneumonia Aortic AneurysmRUQ painCholecystitis Hepatitis Duodenal Ulcer Biliary StonesLLQ painKidney stone, ureteral stone Intestinal Obstruction Sigmoid Diverticulitis Perforated ColonRLQ painAppendicitis Kidney stone/Ureteral Stone Meckel Diverticulum Cholecystitis Intestinal ObstructionKidneysFilter water, salt, and metabolic waste from blood through urine excretion Contributes to homeostasis--acid/base balance, regulation of electrolytes, blood volume control, BP control via hormoneUretersthe tubes connecting the kidneys to the bladderEndometriosisDevelopment of endometrial tissue normally lining the uterus in extrauterine locations in abdomen and pelvis, most commonly the uterosacral ligaments. Each menstrual cycle the tissue bleeds, causing scarring and adhesions. Sxs: Mod to severe abdominal, pelvic, or LBP before/during menstruation, irregular cycles, PM spotting, dyspareunia, pain during defecation, infertility Tx: Manual therapy to break up scar tissue/adhesions, mobility to sustain elongation of tissues, surgery to remove endometrial tissue or total hysterectomyUterine ProlapseDescent of uterus and cervix into vagina due to genetics, denervation, or muscular trauma from labor and delivery. -Classified using Baden-Walker system using 5 point grading scale (0 = no prolapse, 5 = max descent of tissue outside body) Sxs: Pelvic pressure with exertion, urgency/frequency, urinary incontinence, incomplete bladder emptying, discomfort, vaginal dryness, dyspareunia, lower back pain relieved by lying down Tx: Pessary for severe cases. Positioning and pelvic floor trainingProstatitisInflammation of prostate gland due to bacterial infection, or back up of prostate secretions in the gland. I. Acute Bacterial II. Chronic Bacterial III. Chronic Pelvic Pain Syndrome IV. Asymptomatic Inflammatory Prostatitis Sxs: Urgency, frequency, discomfort with urination and pain with ejaculation. -Chronic pelvic pain syndrome--pain in perineum, rectum, prostate, penis, testicles, abdomen. -Asymptomatic inflammatory prostatitis--prostate inflammation in absence of genitourinary tract symptomsErectile DysfunctionInability of adult male to achieve or maintain an erection. Caused mainly by diabetes, CHD, HTN, hypothyroidism, hypopituitarism, MS, excess alcohol, hormonal imbalancesRenal FailureKidneys experience a decrease in glomerular filtration rate, and fail to adequately filter toxins and waste from blood. Occurs due to DM or HTN, or from poison, trauma, and genetics, damaging nephrons so they cannot filter blood. Can be: Acute Chronic End-stage Sxs: Nausea, vomiting, lethargy, pruritus, GI ulcers, sleep disorder, anemia, PE, seizure, comaAcute Renal FailureSudden decline in kidney function increase in BUN and creatine, oliguria, hyperkalemia, and sodium retention -Prerenal--Shock, hemorrhage, burn, or PE -Postrenal--Neoplasm, kidney stone, prostate hypertrophy -Intrarenal--Toxins, intrarenal ischemia, vascular disordersChronic Renal FailureProgressive deterioration in renal function due to DM, severe HTN, glomerulopathies, obstructive uropathy, interstitial nephritis, or polycystic kidney diseaseStages of Kidney Disease1 - Kidney damage with normal GFR (>90) 2 - Mild decrease in GFR (60-89) 3 - Moderate decrease in GFR (30-59) 4 - Severe reduction in GFR (15-29) 5 - Kidney failure (GFR <15)HemodialysisTreatment process for patients with advanced and permanent kidney failure. This process removes blood from the body, cleanses the blood, and returns it to the body. Patient must attend 3x/week for 3-5 hours at a time. Side effects may include anemia, pruritus, sleep disorders, and amyloidosis (amyloid deposits in organs and tissue)Neurogenic BladderDamage to cerebral control of bladder from diabetes, CVA, or nerve damage, and allows for urinary dysfunction that can increase UTIs and kidney damage. Sxs: Frequent UTIs, urine leakage, inability to empty or los of urge to urinate with full bladder. Urodynamics to diagnose.`Urinary IncontinenceInvoluntary loss of urine great enough to be problematic for the person, typically when bladder pressure exceeds sphincter resistance. Classified as: Stress Urinary Incontinence Urge Urinary Incontinence Overflow Urinary Incontinence Functional Urinary IncontinenceStress Urinary IncontinenceLoss of urine due to activities that increase intra-abdominal pressure, such as sneezing, coughing, laughing, running, and jumping.Urge Urinary Incontinenceloss of urine after a sudden, intense urge to void due to the detrusor muscle of the bladder involuntarily contracting during bladder filling. Common in geriatric population and among residents in long-term care facilities Sxs: Urination triggered due to conditioned reflex, i.e. "key in lock" syndrome or running water Tx: Behavior modification, biofeedback, pelvic floor strengthening, and bladder retraining via scheduled voidingDetrusorthe smooth muscle that forms most of the bladder wall and aids in expelling urineOverflow Urinary IncontinenceLoss of urine when intra-bladder pressure exceeds the urethra's capacity to remain closed due to urinary retention. Caused by outflow obstruction secondary to narrow/obstructed urethra from prolapsed pelvic organ, stricture, enlarged prostate, chronic constipation, or neurological disease. Sxs: Difficulty initiating urine stream, weak stream with post-void dribble when initiated. Tx: Double voiding for patients with weak detrusor. Surgical intervention for obstructionFunctional Urinary IncontinenceLoss of urine due to inability or unwillingness of a person to use the bathroom prior to involuntary bladder release Cause: decreased level of mental awareness or decrease in mobility. Rarely seen without another bladder issue or neuro involvement. Sxs: Impaired cognition or mobility Tx: Modify mobility, clothing, independence with ambulationUrinary Tract Infectionmicrobial infection of any part of the urinary tract due to infiltration of bacteria into urethra or bladder. If untreated, can spread to kidneys and cause pyelonephritis. Sxs: Increased frequency of urination, pain/burning with urination, cloudy urine, pressure above pubic bone in women, shakiness, fever, back pain, fatigue. Confusion in elderly population. Tx: Drink an excess of fluid, bacteria-specific antibioticsCoccydyniaHypermobility between coccyx and sacrum during or after childbirth causes a subluxation or tissue damage to soft tissue around coccyx. Sxs: Difficulty sitting on hard surfaces, referred pain to LBP, hip, SI, buttock, groin, or rectum, pain with bowel movements, dyspareunia, hemorrhoidsDiastasis RectiSeparation of rectus Abdominis along linea alba during pregnancy. Sxs: Separation greater than width of two fingers when woman lifts head and shoulders off plinthSymphysis Pubis PainResults from effects of relaxin and progesterone. Joint widens by 4 to 10mm. Sxs: Severe pain in symphysis pubic and SI joints as well as urine in the blood due to injury to urethra or bladder neckOveractive Bladder AgentsDitropan (oxybutynin Chloride) Detrol (Tolterodine Tartrate)Urinary Anti-infective AgentsCinobac (Cinoxacin) Furadantin (Nitrofurantoin)Relative contraindications to Exercise during Pregnancy-Severe Anemia -Unevaluated maternal cardiac dysrhythmia -Chronic bronchitis -Poorly controlled Type I diabetes -Extreme morbid obesity or underweight (BMI less than 12) -History of extremely sedentary lifestyle -Intrauterine growth restriction in current pregnancy -Poorly controlled hypertension -Orthopedic limitations -Poorly controlled seizure disorder -Poorly controlled hyperthyroidism -Heavy smokerAbsolute Contraindications to Exercise During pregnancyHemodynamically significant heart disease Restrictive Lung disease Incompetent Cervix/Cerclage Multiple gestation at risk for premature labor Persistent 2nd or 3rd trimester bleeding Placenta previa after 26 weeks Premature labor during current pregnancy Ruptured membranes Preeclampsia/pregnancy-induced hypertensionAnuriaInadequate urine output in 24 hour period (less than 100 ml)Benign Prostatic HypertrophyA non-cancerous enlargement of the prostate gland that is progressive. Common in males over 60 and can interfere with normal voiding.CystoceleBulging of bladder into vaginaEctopicImplantation of fertilized ovum outside uterus, most common site being fallopian tubeGlomerular Filtration Rate125 mL/min is normal Estimate of filtering capacity of kidneys, volume of filtrate produced per minute by kidneysGlomerulusCapillaries needed for filtration of fluid as blood passes through arterioles of the kidneysHematuriaBlood in urine (cancer, faulty catheterization, serious disease)NephrolithiasisCondition of developing kidney stonesOliguriaInadequate urine output in 24 hour period, less than 400 ml, due to acute renal failure or DMPolyuriaExcesive production of urineRectoceleProtrusion of rectum into vaginaSeminiferous TubulesCoiled tubes found in each lobe of the testes where spermatogenesis takes placeUreamajor nitrogenous waste excreted in urineHuman Immunodeficiency VirusRetrovirus that invades and destroys immune system cells (CD4+ T lymphocytes). Transmitted through blood, semen, vaginal secretions, and breast milk (sexual, perinatal, bodily fluid contact). Stage 1: Acute HIV infection -2-4 weeks post transmission, asymptomatic to flu like symptoms. Pt at highest risk of transmission Stage 2: Clinical Latency -10 years of asymptomatic living until progressing to AIDS, several decades for those on Antiviral RetroTherapy or ART Stage 3: AIDS -3 year survival rate, less if contracting an opportunistic ilness. Can lead to malignancies, infections, neuro dysfunction, cognitive decline, and cardiopulmonary pathologiesJuvenile Rheumatoid Arthritisan autoimmune disorder that affects children aged 16 years or less with symptoms that include stiffness, pain, joint swelling, skin rash, fever, slowed growth, and fatigue Diagnosed based on presence of RF or ANA and systemic involvement.Systemic Lupus ErythematosusChronic autoimmune inflammatory disease due to genetics, environmental (UV exposure, infection, antibiotics, stress), viral, or hormonal factors. Sxs: Butterfly rash across cheeks and nose, arthralgias, kidney involvement, malaise, seizuresGenitourinary DifferentialProstatitis: Inflammation of prostate in men over 40, typically from bacterial infection. -Perineal pain, burning during urination and fever BPH: Increase in size of prostate gland in men over 50 -dribbling at end of urine, weak stream, incomplete emptying -Non-systemic so fever/chills/malaise uncommon Prostate Cancer: Presents similar to BPH, but with sudden moderate to high fever, sciatica, and changes in bowel/bladder function.Peritoneal IrritationSet of abdominal examination findings that indicate inflammation of the visceral or parietal peritoneum Low back pain with rebound tenderness during palpation of abdomenPeptic Ulcer-Burning, gnawing, cramping stomach pain especially when empty, between meals, and in early AM. -Coffee Ground Emesis -Pain is midline, in epigastrum, may radiate to costal margins, into the back and rarely to right shoulder -Pain is usually relieved by food and/or antacidsUlcerative Colitischronic inflammation of the colon with presence of ulcers. Diarrhea and rectal bleeding.Referred pain from SpleenLeft upper quadrant, Left shoulder MOI: left side impact (usually MVA)Referred pain from DiaphragmUpper trap and shoulder, or costal margins/lumbar area MOI: pneumonia, infection, compressionReferred Pain from Urinary TractSuprapubic region or diffuse LBP (bladder/urethra) LBP, pelvis, sacrum, perineum, inner thighs, testes (prostate) MOI: Bacterial infection, renal calculiReferred pain from Large IntestinePain in lower mid-abdomen with referral to sacrum when rectum is stimulated by passing gas or defecation MOI: diverticulitis, IBS, Chron'sReferred pain from HeartPain in substernal region, referral to mid-thoracic, jaw, L upper trap, L shoulder, and down L arm In women, can present as epigastric pain, R shoulder pain, indigestion. MOI: MI, pericarditisSeptic ArthritisRapid onset, over hours or days, of monoarthritis with swollen, tender, adn warm joint, with limited ROM due to pain.Lymphatic System-Primary functions: Immune system defense, maintenance of fluid balance in body, collection and transportation of fluids not reabsorbed by venous system. -Lymphatic system collects 10-20% of interstitial fluid, venous system collects other 80-90% -Under control of autonomic nervous system, contractions of smooth muscle in vessel walls move lymph along -Skeletal muscle contractions compress vessels and move lymph along its one way valvesLymphFluid transported by lymphatic system, originates as interstitial fluid and is made up of water, proteins, fatty acids, and cellular componensLymph vesselcarrier of lymph throughout the body; lymphatic vessels empty lymph into veins in the upper part of the chestMain lymphatic ductsright lymphatic duct: drains lymph from right side of arm and head thoracic duct: drains lymph from rest of body These vessels dump directly into venous system via subclavian veinsLymph NodesBean-shaped filters that cluster along the lymphatic vessels of the body. They function as a cleanser of lymph as wells as a site of T and B cell activationComponents of Lymphatic Systemlymph, lymphatic vessels, lymphatic tissue, lymphatic organs (thymus, bone marrow, spleen, tonsils, Peyer patches in small intestine)Lymphedema-Chronic, incurable condition -Accumulation of lymph in the body, causing edema that presents typically in extremities, but can occur anywhere on body (face, neck, abdomen, trunk, genitalia) -Fluid buildup occurs secondary to damage to lymph structures -Categorized as Primary or Secondary -Patients complain of achiness, fullness, and heaviness of affected limb, which eventually becomes fobrotic, resulting in further chronic inflammation and increased risk for infectionPrimary LymphedemaHereditary abnormal development of lymphatic system -Absence of lymph vessels, decrease in number or size of lymph vessels, or increased size of lymph vessels making them incompetent -Occurs more frequently in females, typically in LESecondary LymphedemaLymphedema caused by disease or injury causing damage to lymph vessels -Trauma, surgery, radiation, tumor growth, chronic venous insufficiency, infection. -Breast cancer surgery and treatment is most common cause in USA (higher risk with axillary lymph node dissection or radiation therapyDynamic insufficiencyLymph in system exceeds transport capacity, resulting in pitting edema -Most common type of insufficiencyMechanical InsufficiencyTransport capacity of lymphatic system is reduced due to damage to lymph system, resulting in non-pitting edemaCombined InsufficiencyIncrease in lymph fluid and decrease in transport capacityImaging techniques for lymphedema-Direct Lympography: injection of contrast medium into lymph vessel to visualize entire system. Not often used -Indirect lymphography: injection of contrast medium just under skin to observe superficial lymph vessels -Lymphoscintigraphy: Injection of contrast material for visualization of lymphatic system through nuclear medicine injury. Fewer complications than Direct -MRI and CT scan to identify tumorsLymphedema ClassificationMild: Less than 3 cm between affected and unaffected limbs Moderate: 3-5 cm difference between affected and unaffected limb Severe: Greater than 5 cm difference between affected and unaffected limbLymphedema Stage 0Latent (pre-clinical) stage No visible edema, but transport capacity of lymph system has been affectedLymphedema Stage 1Reversible Stage Pitting edema present, increases with activity or heat, but diminishes with activity and restLymphedema Stage 2Spontaneously Irreversible Stage Non-pitting, does not change with elevation or rest. Skin begins to demonstrate fibrotic changes and risk for infection increases. Stemmer's Sign positive at this stage.Lymphedema Stage 3Lymphostatic Elephantiasis Stage -Extensive, non-pitting edema, significant fibrotic changes to skin, presence of papillomas, deep skinfolds, and hyperkeratosis -Infection is common at this stage -Stemmer's sign remains positive at this stageComplete Decongestive Therapy (CDT)Phase I: Intensive acute treatment phase, outpatient setting by certified lymphedema therapist or 4-6 weeks Phase II: Self-management phase, long-term management of symptoms utilizing various components of CDT. May return to phase 1 if significant change in symptoms is noted Four parts of Treatment: -Manual Lymphatic Drainage -Compression Therapy -Exercise -Skin CareManual Lymphatic Drainage (MLD)gentle manual treatment which improves the activity of the lymph vascular system; re-routes lymph flow around blocked areas into more centrally located healthy lymph vessels. Treatment first directed at uninvolved areas to prepare for new lymph flow, then towards involved areas.Compression Therapy for LymphedemaMaintains reduction in edema achieved with MLD, and reduces limb size by improving reabsorptive ability of capillaries and reduces filtration of fluids into interstitium. Can also soften fibrotic tissue, Phase I: Compression bandages, usually short stretch for low resting pressure (not long-stretch, they constrict lymph flow) Phase II: Combo of compression garments in the day and bandages during the night. -Compression garments should only be fitted once edema levels have plateaued. -Bandages/garments should have higher pressure in distal regions (graded compression)Exercise for LymphedemaCan help improve lymph flow by: -increasing lymph vessel contractions -increasing fluid uptake in initial lymph -Improving muscle pump to stimulate lymph flow Low impact, aerobic activities recommended for onset. Start with trunk exercises, work proximal to distal. Deep breathing eercises to enhance lymphatic flow Wear compression bandages/garments while exercisingSkin Care for LymphedemaInspection and cleansed thoroughly each day, with frequent application of moisturizer with low or neutral pHFilariasisdisease caused by parasitic roundworm that occurs in tropic and subtropic regions that can lead to elephantiasisHyperkeratosisThickening of the skin caused by a mass of keratinocytes, occurs in stage 3 lymphedemaLymphadenomegalyEnlargement of lymph nodes, commonly occurs secondary to cancer, infections, or allergic reactionsLymphangitisInfection and inflammation of the lymphatic system pathwaysMilroy's DiseaseCongenital Lymphedema that presents in infancy. Bilateral LE edema is most common symptomStemmer's Signdorsal skin folds of the toes or fingers are resistant to lifting; indicative of fibrotic changes and lymphedemaCancerany malignant growth or tumor caused by abnormal and uncontrolled cell division. Malignant cells can grow uncontrollably, invade other tissues, remain undifferetiated, initiate growth at distant sites. Most common cancer is carcinomaCarcinomaa malignant tumor that occurs in epithelial tissue. More specifically named by characteristics (large cell carcinoma, adenocarcinoma, squamous cell carcinoma are all lung carcinomas) 80% of all cancer in the USA is carcinomaRisk factors for cancerIncreasing age, poor diet, stress, alcohol/tobacco use, environmental exposureGeneral signs and symptoms of CancerCAUTION Change in bowel/bladder routine A sore that will not heal Unusual bleeding or discharge Thickening or lump develops Indigestion, or difficulty swallowing Obvious change in wart or mole Nagging cough, hoarseness Other sxs are unexplained weight loss, fatigue, anemia, pain or weaknessEpithelial CancersCarcinomasPigmented Cell CancersMelanomaConnective Tissue Cancers (muscle, blood vessel, cartilage, fat)Sarcoma Fibrosarcoma Liposarcoma Chondrosarcoma Osteosarcoma Hemangiosarcoma Leiomyosarcoma RhabdomyosarcomaNerve Tissue Cancers (Brain, nerves, spinal cord, retina)Astrocytoma Glioma Neurilemma Neuroblastoma RetinoblastomaLymphoid cancersLymphomaHematopoietic Cancers (Bone marrow, Plasma Cells)Leukemia Myelodysplasia Myeloproliferative Syndromes Multiple MyelomaNational Cancer Institute StagingStages 0-IV, with 0 being early malignancy and IV being most malignantNCI Stage 0Early malignancy, present only in layer of cells in which it began (in situ). Not all cancers have stage 0NCI Stage IMalignancy limited to tissue of origin with no lymph node involvement or metastasis.NCI Stage IIMalignancy spreading into adjacent tissues, possible lymph nodes show micrometastasesNCI Stage IIIMalignancy spreading to adjacent tissues showing fixation to deep structures. High likelihood of lymph node metastatic involvementNCI Stage IVMalignancy that has metastasized beyond the primary site, for example, bone to another organClinical staging of cancer1- Localized to tissue of origin. 2- Limited local spread. 3- Extensive local or regional spread 4- Metastasis. Estimated extent of malignancy based on examination, lab values, imaging, and biopsy.Pathologic staging of cancerStaging based on pathology findings of tissue samples obtained during surgery. This may differ from clinical stage (may reveal cancer has spread more than expeted) and gives more precise information to predict treatment responses and prognosisAstrocytomaPediatric brain tumor, usually either cerebellar (clumsiness, ataxic gait, change in personality, vomiting) or Supratentorial (headache, seizures, change in personality, visual impairments, vomiting) Accounts for 50% of pediatric brain tumorsNeuroblastomamalignant tumor composed mainly of cells resembling neuroblasts that occurs most commonly in infants and children. Most common malignant tumor in children. Abdominal mass, change in personality, anemia, sweating, pain, diarrheaOsteogenic SarcomaMalignant tumor in epiphyses of long bones. Most common form of bone cancer with peak incidence between ages 10-20Oncology treatment optionsSurgery (resection) Radiation (ionizing or particle) Chemotherapy Biotherapy (immunotherapy to strengthen host's biological response to malignant cells, using bone marrow or stem cell transplant Antiangiogenic therapy (thalidomide, treats multiple myeloma)Alkylating agents (cancer)synthetic chemicals containing alkyl groups that attack DNA, causing strand breaks. Indicated for malignancies Mustargen (Mechlorethamine) Busulfex (Busulfan) Leukeran (Chlorambucil)Antibiotics (Cancer)-cins Adriamycin (doxorubicin) Mithracin (plicamycin) Cosmegen (DactinomycinAntimetabolite Agents (Cancer)Leustatin (Cladribine), Adrucil (Fluorouracil), Fludara (Fluradabine), Trexall (Methotrexate)Hormones for cancer treatmentNolvadex (tamoxifen citrate) Lupron (leuprolide acetate) Casodex (bicalutmide)Lipedemaa chronic abnormal condition that is characterized by the accumulation of fat and fluid in the tissues just under the skin of the hips and legs Normally functioning lymphatic system!!! -Female Dominant -Bilateral/Symmetrical (lymphedema is unilateral) -Often due to hormonal imbalance -Negative Stemmer's sign -Swelling stops at wrists/anklesEnteral Administration of drugsAdministration of drugs using the gastrointestinal tract (rectal, oral, sublingual)Parenteral administration of drugsAny form of administration not involving GI tract (intramuscular, intravenous, subcutaneous, inhalation, transdermal)Sublingual administrationPassage of drug through sublingual or buccal mucosa, where it travels from venous circulation directly to heart to enter venous circulation. Faster introduction of drug in cases of acute pain (angina) and bypasses liver so as not to be overly metabolized before reaching targetOral AdministrationDrugs by mouth. Most common and easiest. Absorption by GI allows for gradual increase in drug lvels throughout the body, but must be lipid soluble so intestines can absorb it. Gastric irritation, metabolism of liver before reaching target tissue are downsidesRectal administrationInsertion of suppository into rectum and absorption of drug within rectal cavity. Advantageous for patients that cannot take drugs orally (unconscious, vomiting) Bypasses the liver, but not absorbed as wellInhalation administrationGaseous or aerosol. Lungs have large surface area, and can enter systemic circulation rapidly. Used when treating pulmonary pathologiesTopical administrationApplication of drug directly to skin or mucous membrane (nasal mucosa). Poorly absorbed, so reserved for localized epithelial disorders.Transdermal administrationApplication of drug in patch form, where it absorbs through the skin and enters systemic circulation. Allows for slow, controlled release of drug into circulation over long period of time. Fentanyl, iontophoresis and phonophoresisInjectionCan be intravenous (IV), intramuscular, subcutaneous, intra-arterial, or intra-thecalIntravenous administrationInjection of medication into peripheral vein to enter bloodstream. Drug enters circulation rapidly. 100% bioavailableIntra-arterial administrationInjection of medication into an artery. Difficult to perform, but may be necessary where drug is intended to act at a specific site without affecting other tissues. (chemotherapy)Subcutaneous administrationInjection of a drug directly under the skin into the subcutaneous fat or connective tissue. Useful when slow release is required (insulin). Pts can self-administerIntramuscular AdministrationInjection of drug into skeletal muscle, used to treat local muscular problems (botulinim toxin for spasticity). More rapid absorption than subcutaneous, while still allowing for steady release of drug into systemic circulation. Tend to cause soreness and pain at injection siteIntrathecalInjection of drugs into a sheath, like subarachnoid space of spinal meninges. Advantageous because it allows for introduction of drugs into CNS without having to pass blood brain barrier.BioavailabilityPercentage of drug that makes it into systemic circulation from site of original administration.Dose-response curveGraphic representation of relationship between dosage of a drug and the body's response. As the dosage increases, more receptors become activated, increasing the body's response to the drug, but the body's response will plateau at a certain dosage. Can compare potency of two drugs.Half-lifeRate of elimination of a drug, or how long it takes to eliminate half of an administration.PharmacodynamicsHow a drug exerts therapeutic effect on the body at a cellular levelPharmacotherapeuticsThe treatment of pathologic conditions through the use of drugsPharmacokineticsStudy of how drugs are absorbed, distributed, and metabolized and eliminated by the body. Four major parameters: 1. Absorption 2. Distribution 3. Metabolism 4. Excretion *Note, in geriatric population, drugs are not excreted as quickly due to low GFR, so meds act on body for longerTherapeutic IndexMeasurement of the safety of a drug. Calculated as a ratio, compares effectiveness of a drug against lethal effects. Median Toxic Dose/Median Effective Dose Low TI indicates that a drug is less safe, and will result in more adverse effectsDrug Development StagesPreclinical Testing: Cellular, organ, animal testing Phase 1: Safety. First stage of human testing, small number of patients. Toxicity and safe dosing range established Phase 2: Effectiveness. Small number of patients, determines effective dosing level and adverse effects Phase 3: Same as Phase 3, but larger sample size Phase 4: Real life scenarios (post-marketing surveillance)Baclofen (Kemstro)CNS-acting muscle relaxant used for muscle spasms. Sides: Drowsiness, dizziness, weaknessFentanyl (Sublimaze)Opioid Analgesic for mod to severe pain. Sides: Bradycardia, RR depression, low BPAspirinNSAID for pain, fever, HA, inflammation Sides: Bloody/tarry stools, nausea, vomiting, peptic ulcersMethylprednisone (Medrol)Corticosteroid for inflammation, severe allergies, or flare-ups of chronic illnesses. Sides: Mood changes, visual changes, rapid weight gainMethotrexate (Folex/Trexall)Disease Modifying Anti-Rheumatic Drug (DMARD). for cancer, auto-immune conditions Sides: Mouth sores, anemia, bloody or tarry stoolsFurosemide (Lasix)Diuretic for swelling (edema), CHF, liver or kidney disease, HTN Sides: Tinnitus, jaundice, severe pain in upper stomachMetoprolol (Lopressor)Beta blocker for chest pain, HTN, CHF or arrhythmia. Sides: Dizziness, depression, dry mouthEnalapril (Vasotec)ACE Inhibitor for HTN and CHF Sides: Dry cough, swelling, confusion, tachycardiDiltiazem (Cardizem)Calcium Channel blocker for HTN, chest pain, arrhythmia Sides: Dizziness, drowziness, mood changes, SOB, swellingDigitalis/Digoxin (Lanoxen/Digox)Cardiac Glycosides for CHF Sides: Bradycardia, bloody/tarry stools, Halos-asoneCorticosteroid (dexamethasone, flucatisone)-afilphosphodiesterase inhibitor (PDE inhibitor) ex. sildenafil (Viagra) -Tx of erectile dysfunction **do not give with other vasodilating agents-bitalbarbiturate (sedative) Phenobarbital-caineLocal anesthetic Lidocaine, bupivicaine-cilinPenicillin antibiotic Amoxicillin, ampicillincortCorticosteroid Cortisone, hydrocortisone-CyclineAntibiotic Tetracycline, doxycycline-DipineCalcium Channel Blocker (nifedipine, amlodipine) Therapeutic Use: Angina, HTN. Dilates blood vessels-dronateBone resorption inhibitor for osteoporosis Alendronate, risedronate-fenacNSAID Diclofenac, bromenac-mustinealkylating agent (antineoplastic) Carmustine, estramustine, lomustine-mycinantibiotic/antibacterial Erythromycin-ololBeta Blocker (reduces HR) atenolol, metoprolol, propanolol-nacinmuscarinic antagonist (anticholinergic) darifenacin, solifenacin-nazoleantifungal Miconazole, terconazole-oloneCorticosteroid or anabolic steroid Triamcinolone; Nandrolone-oprazoleProton Pump Inhibitor for GERD, peptic ulcers, and H. Pylori Omeprazole (prilosec)-ParinAnticoagulant (blood thinner) Heparin, Warfarin, dalteparin-phyllinebronchodilators asthma or colds dilate large air passages Aminophylline, theophylline-praminetricyclic antidepressant (TCA) ClomipraminePredCorticosteroid Prednisone-prilACE inhibitor to lower BP Lisinopril, Enalapril-profenNSAID Ibuprofen-sartanAngiotensin II Receptor Antagonist to lower BP Valsartan, LosartanSemideLoop diuretic Furosemide-StatinAntilipidemic to reduce cholesterol Atorvastatin, pravastatin, pitavastatin, simvastatinsulfa-antibiotic; anti-infective; anti-inflammatory Sulfadiazine, sulfasalazine-tadineAntihistamine Loratadine-terolBeta antagonist, bronchodilator Albuterol, Formeterol-ThiazideDiuretic Chlorothiazide, hydrochlorothiazide-trelfemale hormone (progestin) Desogestrel, etonogestrel-triptanAntimigraine Sumatriptan-virAntiviral Acyclovir-zepamBenzodiazepine Clonazepam, diazepam, flurazepam-zodoneAntidepressant Ex: nefazodone, trazodone, vilazodone-ZolaBenzodiazepine Alprazolam, midazolam-zosinAlpha blocker to treat BPH and HTN Doxasoin, PrazosinSchedule I drugsHigh potential for abuse, high risk for addiction Only used for research and not medical treatment -Heroin, LSDSchedule II DrugsHigh potential for abuse and high risk for addiction Allowed for medical use, but no auto refills -Opioids, amphetamines, barbituratesSchedule III DrugsModerate risk for physical dependence, high risk for psychological dependence Auto refills allowed with limitations -Opioids combined with non opioids and anabolic steroidsSchedule IV DrugsMild risk for physical or psychological dependence Some limitations set on auto refills -Anti-anxiety drugs, some barbiturates (phenobarbital)Schedule V DrugsLowest potential for abuse and addiction, may be available without prescription -Cough and cold medicines with low doses of opioidsPatient that is dependent must be repositioned in bed every ___ hours and must be lifted when changing positions to avoid ____2, shearingIndependentNo assistance requiredSupervisionPatient requires therapist to observe through completion of taskContact GuardPatient requires therapist to maintain contact with the patient to complete the task. Usually needed if LOBMinimal Assistpatient requires 25% assist from therapist to complete taskModerate AssistPatient requires 50% assist from therapist to complete taskMaximal AssistPatient requires 75% assist from therapist to complete taskDependentPatient is unable to participate and therapist must provide all effort to perform taskWheelchair Seat HeightHeel to popliteal fold Add 2 inchesWheelchair Seat DepthPosterior buttock to popliteal fold Subtract 2 inchesWheelchair Seat WidthWidest aspect of hips Add 2 inchesWheelchair Back HeightSeat of chair to floor of axilla with shoulder flexed to 90 deg Subtract 4 inches Should be below inferior angles of scapulaeWheelchair Armrest HeightSeat to olecranon process with user's elbow flexed to 90 deg Add 1 inchUltralight Wheelchair framehighly active, no need for postural supports, used for sportsStandard/Lightweight wheelchair framePt able to self propel with both UEs, adequate LE ROMHemi Frame WheelchairPatient able to self propel using LEOne hand drive Frame wheelchairPatient can self propel with one UEAmputee Wheelchair framePt able to self propel, COG shifted posteriorly due to amputationPower wheelchairPatient not able to self propel but can safely operate a power mobility devices. May have transfer, sitting, or UE functional limitationsGeri ChairSpecial chair that assists in positioning a resident to increase body alignment and comfortReclining FramePt unable to perform weight shifting tasks, unable to sit upright for extended periodsBackward tilt-in-space framePatient unable to sit upright or perform weight shifts, also has issues with sliding or extensor tonePlanar posterior headrestFor reclining or tilt in space frame, or PT tends to maintain hyper EXT head/neck position in uprightCurved Headrestpatient tends to maintain backward listing and/or lateral head and neck position in sitting side panels may be indicated for more aggressive supportSling back insertPt requires no postural support, no neuro deficits. Not intended for longterm usePlanar back insertPatient requires mild to moderate trunk support due to tone, strength, or deformity related postural concernsCurved back insertClinical indications: -requires moderate trunk support due to tone -strength or deformity related postural concernsParallel BarsProvide max stability and security or patient during beginning stages of ambulation or standing. Bar height allows 20-25 deg of elbow flex with hands 4-6inches in front of body Pt must progress out of parallel bars ASAPWalkerSignificant base of support, offers good stability. Should allow for 20-25 deg of elbow flexion. Three-point gait patternAxillary CrutchesAll levels of WB, but require higher coordination Fit: Crutches 6 in in front and 2 in lateral to pt Height: no greater than 3 finger widths from axilla Handgrip: allows for 20-25 deg of elbow flexion Two-point, three point, four point, swing to, swing throughLoftstrand CrutchesAll levels of WB, but require highest level of coordination for proper use. Less stable than axillary, not used often with geriatrics Fit: 20-25 deg of elbow flexion while holding handgrip with crutches 6in in front and 2 in lateral -Selected over axillary when pt has injury to axillary nerves and blood vessels Two point, three point, four point, swing to, swing throughCaneMin stability and support. Straight cane provides least support, should not be utilized with PWB. Small base and large base quad canes have larger BOS, can better liit WB on uninvolved LE. 20-25 deg of elbow flexion while grasping handgripNon-weight Bearing (NWB)Patient is unable to place any weight through involved extremity, and not permitted to touch ground or any surface. AD is requiredToe-touch Weight bearing (TTWB)Patient is unable to place any weight through involved extremity, but may place toes on the ground to assist with balance. AD requiredPartial Weight Bearing (PWB)Patient allowed to put some weight through involved extremity, expressed as a % of total weight. AD requiredWeight bearing as tolerated (WBAT)Patient determines amount of WB based on comfort, AD may not be required.Full Weight bearingPatient can place full weight on involved extremity. Assistive device is not required, but may be used to assist with balance.Guarding during ambulationStand to affected side and behind patient, avoid grasping armTwo point gait patternRequires bilateral ambulation aids. "Left crutch and right foot, right crutch and left foot."Three point gait patternOne injured LE with decreased WB. AD advances, followed by injured LE then uninjured LEFour point gait patternPatient does not move LE simultaneously with device. AD advances first, then opposite LE. May be used with coordination, balance, or strength deficits.Swing-to gaitpatient with bilateral trunk and or LE weakness uses crutches or a walker and advances LEs at the same time only to point of AD.Swing Through Gaitboth crutches are advanced then the legs swing past the crutchesNasogastric Tube (NG Tube)Feeding tube goes through the nose, pharynx, ad into the stomach. Used for short term liquid feeding, med admin, or remove gas from stomach. Tube in nostril/back of throat can inhibit cough and be irritatingPeripherally Inserted Central Catheter (PICC line)Inserted into peripheral vein and advanced to superior vena cava. Can stay in for weeks and deliver proteins, electrolytes, carbs, vitamins and minerals when pt is unable to use a feeding tube. Used for: -chemo drug admin -Antibiotic therapy -Parenteral Nutrition -Drugs that can't be injected peripherally Pts: -critically ill -Cancer -Require frequent blood drawsGastric Tube (G tube)Tube inserted through abdomen to stomach Used for long term feeding in presence of difficulty with swallowing, or to avoid risk of aspirationJejunostomy Tube (J-tube)Tube inserted through endoscopy into jejunum via abdominal wall Used for long term feeding for patients unable to receive food by mouthIntravenous System (IV)Sterile fluid source, pump, clamp, and catheter to insert into a vein Used to infuse fluids, electrolytes, nutrients, and meds Most commonly inserted into superficial veins (basilic, cephalic, antecubital) Permits nutrients to be introduced when GI tract is not able to digest or absorb foodArterial linemonitoring device consisting of a catheter that is inserted into an artery and attached to an electronic monitoring system. used to measure blood pressure or obtain blood samples. considered more accurate than traditional measures of blood pressure and does not require repeated needle punctures Used for: -Critically ill -HTN crisis -Uncontrolled HTN -Post MICentral Venous Pressure Catheter-used for measuring pressures in right atrium or SVC -indwelling venous catheter + pressure manometer -evaluates right ventricular function, right atrial filling pressure, and circulating blood volume -reduces need for repeated venipunctureHickman Catheter-inserted through cephalic or internal jugular vein -threaded into SVC and R atrium -used for long-term administration of substances into venous system (chemotherapeutic agents, total parenteral nutrition, and antibiotics)Intracranial pressure monitormeasures the pressure exerted against the skull using pressure sensing devices placed inside the skull Used for closed head injury, cerebral hemorrhage, overproduction of CSF or brain tumorPulmonary artery catheter (Swan-Ganz)Soft, flexible catheter inserted through vein into pulmonary artery to provide continuous measures of PA pressure. -Can also diagnose RHF -PA HTN -Heart function post-MI -CardiomyopathyNasal cannulaA device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils. Can deliver 6 L per minuteOronasal mask-consists of facepiece designed to cover nose and mouth with small vent holes to expel exhaled air along with a breathing tube and connector -used most for oxygen therapy -can be used to administer medications, mucolytic detergents, or humidit, by use of an accessory nebulizer -delivers 6-15 L/minOxygen Tenta canopy that surrounds the patient, providing oxygen, humidification, and a cool environment to help control body temperatureTracheostomy Maska device designed to be placed over a stoma or tracheostomy tube to provide supplemental oxygenBalanced suspensionRealigns fractures of the femur; uses pulley to create balanced suspension by countertraction to the top of the thigh splint. Thomas splint (positioned under anterior thigh) with Pearson attachment (supports leg from knee down) frequently used. Requires prolonged immobilization and increases incidence of secondary complications (contractures, skin breakdown)External Fixationa fracture treatment procedure in which pins are placed through the soft tissues and bone so that an external appliance can be used to hold the pieces of bone firmly in place during healing Allows for stability and earlier mobilityInternal Fixationa fracture treatment in which a plate or pins are placed directly into the bone to hold the broken pieces in placeExternal catheterApplied over shaft of penis, held in place by padded strap or adhesive tapeFoley catheterindwelling catheter inserted through the urethra and into the bladder that includes a collection system allowing urine to be drained into a bag; the catheter can remain in place for an extended periodSuprapubic Cathetercatheter inserted into the bladder through a small abdominal incision above the pubic area, performed under general anesthesiaOstomy device- provides a method for collection of waste from a surgically produced opening in the abdomen. -The removal of the waste occurs through a stoma extending into the small intestine. - The waste is collected in a plastic bag or pouch covering the stoma.Title I of the ADAEmployment. - Prohibits discrim. in all aspects of employment - Reasonable accommodationsTitle II of the ADAPublic Services. - No discrim. persons w/disabil. to participate in or benefit from svcs, programs, activ. of public entities: transporation, public edu., employment, recreation, social svcs, hc, courts, voting, etc.Title III of ADAPublic Accommodations and Services operated by public entities. - Places of accommodation (hospitals, hc providers' offices, schools, etc.) may not discrim. against persons w/disabil.Title IV of ADATelecommunications. - All televisions must have closed captioning - Relay svcs 24 hr/day, 7 days/wkTitle V of ADAMiscellaneous: includes insurance issues, congressional inclusion and amendments to Rehab Act of 1973ADA Ramp guidelines-12 inches of horizontal run for every inch of vertical rise -1 foot/1 inch. Example: If ramp rises 21 inches, must be at least 21 feet long -equivalent to 8.3% grade -Max rise for run is 30 inches (max run is 30 ft) -Ramp must be 36 inches wide -Level landing at top and bottom -If changing direction, landing area must be 5 ft by 5 ft (60 in by 60 in)ADA Doorway width RequirementsMinimum 32 inch widthADA Threshold Height RequirementsLess than 3/4 inch for sliding Less than 1/2 inch for other doorsADA carpet surface max. pile1/2 inchADA Hallway Clearance width36 inch widthADA Wheelchair Turning Radius (U-turn)60 inch width 78 inch lengthADA bathroom sink requirementsBetween 29 inches and 40 inches from floor to bottom of mirror 17 inch minimum depth under sink to back wallADA Bathroom toilet requirements17-19 inches from floor to top of toiletADA Parking space Requirements8 foot width 20 foot length 2% of spaces must be accessibleHeat TransferConduction Convection Conversion Evaporation RadiationConductionDirect contact between two materials at different temps--high heat transfers to low heat. Ex: Hot pack, cold packConvectionAir or water moving in constant motion over body causes gain or loss of heat. Ex: Whirlpool, fluidotherapyConversionNonthermal energy like mechanical or electrical is absorbed into tissue and transformed into heat. Ex: UltrasoundEvaporationLiquid absorbs energy and changes into vapor. Ex: Vapocoolant sprayRadiationDirect transfer of heat from radiation energy source. Ex: Laser, UV light, infrared lampCold Pack applicationdo not apply direct to skin -wetting towel will conduct better -check skin after 5 minutes Application time of 20 min, extend to 30 for spasticity reduction 5-10 min for ice massageMoist Hot PacksCan heat tissues 1-3 cm deep. If goal is to heat deeper tissues (knee joint capsule, muscle belly of quads), use a deep heat modality (diathermy, continuous ultrasound) Tissue temp should be elevated to 104-113 degrees F 6-8 Terry Towels to ensure adequate insulation from hot pack Check patient's subjective temp response and skin temp at 5 and 10 min checkpoints Pt should not lay on moist heat pack, have them lay prone Total treatment time no longer than 20 minContraindications to ThermotherapySensation, Circulation, Mentation!!! -Areas with lack of intact thermal sensation -Vascular insufficiency, vascular disease -Liniment or heat rub applied recently -Patient's subjective response to modality is unreliable (altered mentation) -Hemorrhage (recent or potential) -Malignancy -Acute inflammation or infectionIndications for UltrasoundCalcium deposits Chronic inflammation Delayed soft tissue healing Dermal ulcers Joint contracture Muscle spasm Myofascial trigger points Pain plantar warts Scar tissueEffective Radiating Area (ERA)Area of transducer that transmits ultrasound energyUltrasound intensityPower (Watts)/ERA (Cm2) Watts/Cm2 Ranges from 0.5-2.0 W/Cm2 Acute conditions: Decreased intensity (0.5-1.25 W/cm2) Subacute: 0.75-1.5 W/cm2 Chronic: 1.5-2.0 W/Cm2Beam Nonuniformity Ratio (BNR)Low BNR = less likely to experience hot spots and discomfort High BNR = need to move transducer more quickly. Between 2:1 to 8:1, but most devices are 5:1 to 6:1Ultrasound FrequencyHigh frequency is absorbed more rapidly and affects superficial tissues (3.3 MHz reaches 1-2 cm below skin) Low Frequency is absorbed deeper and is used for deeper tissues (1 MHz reaches 3-5 cm below skin)3.3 MHz UltrasoundShallow regions -Superficial tendonitis -Finger joints1 MHz UltrasoundDeep regions -Capsule -Deep muscle -Arthritis in larger jointsUltrasound Duty CycleThe fraction of time the US is on over one pulse period time on/time on+time off100% Ultrasound Duty CycleContinuous thermal ultrasound -Increase blood flow -Deform scar tissue -Heat contractile tissue Typically chronic conditions50% Ultrasound Duty CyclePulsed, non-thermal ultrasound -Tissue healing -Improving fluid dynamics -Pain modulation Acute to subacute conditions20% Ultrasound Duty CyclePulsed Non-thermal ultrasound -Improving fluid dynamics and resolving swelling Acute conditionsStatic lumbar tractionUsed if patient's symptoms are exaggerated by movement.Intermittent lumbar tractionJoint mobilization forthose who cannot tolerate static traction. Max force during hold period, then min force (50% of max) is used during hold. Little evidence to guide.Lumbar traction force-Force of 25% of patient's BW is needed to overcome friction force -50% is required to separate vertebrae -Maximum of 30 lbs for first trial to assess pt response -In acute phase, keep duration to 15 for intermittent and 10 for sustained -Max duration is 30 minSupine lumbar traction (Flexed position of spine)Greater separation of posterior structures (facet joints, intervertebral foramen) Useful for spinal stenosisProne lumbar traction (Extended position of spine)Greater separation of anterior structures (disk spaces) Beneficial for posterolateral disk herniationsCervical Spine Degrees of flexion for Traction0-5 degrees flexion: Upper Cervical Spine 10-20 degrees flexion: Midcervical spine 25-35 degrees flexion: Lower cervical spineLong stretch bandages- Can apply 60-70 mmHG - Most often used for patients who are immobile because it provides little working pressure High resting pressure Low working pressureShort stretch bandagesLow resting pressure High working pressure Effective when patient is active, used during exercise. Pt must have functional calf muscle and gait patternt o benefit in LE. Not effective on flaccid/inactive limbMulti-Layered BandagesModerate to high resting pressure -several bandages with elastic and inelastic layers -providing protection, absorption, compression Most commonly used for venous stasis ulcersSemirigid BandagesTreated gauze applied to distal extremity, usually applied wet and dries hard. Used to treat venous stasis ulcers. Unna boot is example, made of zinc oxide impregnated gauze 35-40 mmHgDirect CurrentElectric current flowing from Anode (positive) to Cathode (negative electrode) continuously -Polarity is constant 1 mA/sq inch 40-80 mA*minBiphasic Current (acute pain)Pulse duration: Short, 50 usec Pulse Frequency: High, 100 pps Amplitude: SensoryE-Stim FrequencyNumber of pulses through each channel per second. High frequency causes more rapid fiber recruitmentBiphasic Current (Chronic Pain)Pulse Duration: Long, greater than 250 usec Pulse Frequency: Low, 1-10 pps Amplitude: Max sensoryBiphasic Current (Muscle Re-ed)Pulse Duration: Long, greater than 250 usec *Longer pulse duration needed to depolarize motor nerves* Pulse Frequency: Mod High, 50 pps Amplitude: Motoric, 1/3 ratio with 1.5 sec RampBiphasic Current (Edema Control)Pulse Duration: 50 usec acute, 200 Subacute, 250 chronic Pulse Frequency: 100 pps acute, 1-10 subacute, 50 pps chronic Amplitude: Sensory for acute, motoric sub-acute, and motoric 1/1 with 1.5 sec ramp for chronicRussian Stim (Chronic Pain)Pulse Duration: 10 ms (long) Pulse Frequency: 1-10 pps (Low) Amplitude: Max sensoryRussian Stim (Muscle Re-ed)10 ms PD 50 PPS Frequency (high) Motoric amplitude, 1/3 ratio with 1.5 sec ramp timeHigh voltage pulsed stimulationMuscle contractions, pain controlInterferential currentTwo alternating biphasic waveforms, producing an alternating higher/lower amplitude at their intersection. Comfy for patients, low amps to skin and higher amps to deeper tissues -Uses: pain relief, increased circulation, muscle stimulationAcute Pain IFC80-120 pps, sensory intensityChronic pain IFCFixed PD 1-10 pps Max sensoryAcute pain E-stim parametersLow pulse duration (50ish) High Pulse frequency (100-120 pps) Sensory amplitudeChronic pain E-stim parametersHigher pulse duration (250ms-1ms) Lower pulse frequency (1-10pps) Max sensory amplitudeMuscle re-education E-stimHigh pulse duration Medium pulse frequency (50 pps) Motoric with timeon/off ratio and rampNeuromuscular Electrical Stimulation (NMES)Used to facilitate skeletal muscle activity. Therapist aligns electrodes over muscle belly in parallel, separated by minimum of two inches. PPS: 35-50 Duty Cycle: 1/5 on/off ratio (10 seconds, on, 50 seconds off) Ramp: 1-4 seconds Treatment: 10-20 contractionsFunctional Electrical Stimulation (FES)NMES during a functional activity -Reducing shoulder subluxation (posterior delt and supraspinatus, 3 sec ramp up/down) -Foot drop during gait (Tibialis anterior + peroneals to prevent inversion sprain, 0-1 ramp up/down) -Impaired hand/finger function -Exercise to maintain mobilityTranscutaneous Electrical Stimulation (TENS)Increases sensory stimulation at site, blocking pain transmission (gate control, endogenous opioid)Conventional TENSShort Duration (50-100 usec) High Frequency (30-150 pps) Sensory amplitude (Low, no muscular contraction) Brief pain relief, only when current is generated (gate theory) Used to relieve pain during ADLsAcupunture-Like TENSLong Duration (100-300usec) Low Frequency (2-4 pps) Moderate Amplitude (Motoric) Several hours of pain relief (endogenous opioids) after 25-45 minute treatment Do not use during ADLsBrief Intense TENSLong Duration (150-500 usec) High Frequency (60-200 pps) Moderate Amplitude (paresthesia or motor response) Intended to minimize pain during painful activities (painful manualtherapy, dressing changes, debridement) via endogenous opioid pathway 15 min treatment timeNoxious TENS*Amplitude*: highest tolerated stimulus *Pulse freq*: high or low *Pulse duration*: long (250 usec up to 1sec) *Tx time*: 30-60sec for each point *Used for*: trigger pointsIontophoresisIntroducing ions into body through the skin using continuous direct current. Positively charged ions are carried into tissue from positive anode, negatively charged ions carried into body from negative cathode. "Active" Electrode carries the ion solutionIontophoresis Dosage-40-80 mA-min -Amplitudes range from 1.0-4.0 mA -Current amplitude x time -4.0 mA over 10 min = 40 mA-min -Lower amplitude and longer duration = less burns or irritation -Decrease likelihood of burns by decreasing current density, increasing size of cathode, and increasing space between electrodes.Acidic Reaction to IontophoresisHydrochloric acid forming under anode (positive electrode)Alkaline Reaction to IontophoresisSodium Hydroxideforming under cathode (negative electrode)Acetic Acid-iontophoresisNegative Used for calcific deposits, myositis ossificansCalcium Chloride-iontophoresisNegative Used for scar tissue, keloids, muscle spasmsCopper Sulfate-iontophoresisPositive Used for fungal infectionDexamethasone-iontophoresisNegative Used for inflammationIodine-iontophoresisNegative Used for Scars and adhesive capsulitisLidocaine-iontophoresisPositive Used for Analgesia and inflammationMagnesium Sulfate-iontophoresisPositive Used for Muscle Spasms and ischemiaSalicylates(Negative) Used for muscle/joint pain, plantar wartsZinc Oxide - iontophoresisPositive Used for healing, dermal ulcers, and woundsElectromyographya diagnostic test that measures the electrical activity within muscle fibers in response to nerve stimulationEMG of normal, relaxed muscleElectrical silence. Spontaneous potentials are abnormal and ay indicate nerve/muscle damageEMG Fibrillation potentialsLower motor neuron diseaseEMG positive sharp waveDenerved muscle disorders at rest (primary muscle disease like muscular dystrophy)EMG fasciculations-Indicative of irritation or degeneration of anteiro hor cell -Nerve root compression -Muscle spasmsEMG repetitive DischargeMyopathies, lesion of anterior horn cells and peripheral nervesEMG Polyphasic potentials (Voluntary)Myopathies, muscle or peripheral nerve involvementAirborne Precautions-Private room, monitored negative air pressure -6 to 12 air changes in room per hour -Room door closed with patient remaining in room -Mask and gloves Examples: Measles, Tuberculosis, Varicella (Chicken pox)Droplet PrecautionsInfectious agent transmission through mucous membranes of nose and mouth, contact with conjunctivae, through coughing, sneezing, laughing, or talking. -Requires close contact (infectious agents don't suspend in air past three feet) -Private room, may sharewith pt that has active infect of same microorganism -3 ft at least between pt and any contact (staff, visitor) -Room door can remain open -Wear a mask when working within 3 feet of patient -Limit transport outside room, pt must wear mask Examples: Bacterial--Haemophilus Influenzae (meningitis, pneumonia, sepsis), Neisseria Meningitidis, diptheria, mycoplasma pneumonia, pertussis, streptococcal A Viral--Adenovirus, influenza, mumps, rubella, Parvovirus B19Contact PrecautionsSkin-to-skin, contaminated intermediate object in patient's environment -Private room, may share with other pt with same microorganism -Gloves must change post direct contact with infectious material, and gloves come off prior to leaving room -Gown if substantial close contact with patient, remove gown prior to leaving room -Dedicate non-critical pt care equip to 1 patient, do not share between patients Examples: -GI, RR, skin/wound infections, drug-resistant bacteria, C-diff, E-coli, Hep A (incontinence), diphtheria, herpes, impetigo, scabies, zoster, EbolaAutonomic Dysreflexia: Recognition and ResponseComplete spinal cord injury above T6 when exposed to noxious stimuli (tight clothes, full bladder). Sxs: HTN, bradycardia, sweating, HA, nausea, red blotchy skin Pt in upright position (sitting/semirecumbent), then identify and remove noxious stimuliAllergic Reaction: ResponseFirst: Remove source of allergic reaction Then: check airway to assess if compromised and begin CPR if necessaryBurn: ResponseRemove source of burn, dilute if chemical, brush off if powder. Don't use cold water if large area bc of hypothermia If electrical, assess HR and RR, monitor for cardiac arrest Don't remove clothing if part of burnFracture: ResponseAssess peripheral pulses and sensation distal to injury to determine extent of injury to nerves/blood vessels Support site with firm object to stabilize Avoid movementHeat Illness: ResponsePlace patient in shaded or covered area, monitor vital signs Remove outer clothing and use ice bag or cold compress on forehead, neck, or groin. Administer water or electrolytes.Heart Attack: ResponseIf unresponsive, call EMS and locate AED. Initiate CPR until AED arrives. 5 cycles of CPR, then AED.Hypothermia/Frostbite: ResponseAssess verbal and motor responses. Warm the patient, starting with core, using towels, blankets, or skin-to-skin. If patient drops below 95 deg F, call EMS If frostbite, submerge area in warm water or warm uing body heat. Do not use massage, may increase tissue damageHypoglycemia: ResponsePale, moist skin, rapid HR, shallow breathing, HA, altered vision, confusion, seizure, LOC. Administer sugar (orange juice). If not conscious, intravenous glucose injection by medical professionalHyperglycemia: ResponseThirst, frequent urination, glucose in urine. Can progress to ketoacidosis (fruity breath, deep labored breathing, nausea and vomiting) Call EMS if ketoacidosis, pt will need to be injected with insulinLaceration: ResponseDirect pressure over site until bleeding ceases. If arterial bleeding, intermittent pressure to artery just proximal to site of injury Excessive blood flow = elevate above heart, sparingly use a tourniquet. Call EMS if blood is spurting or does not stop after 10 min of steady pressureObstructed Airway: ResponseCheck mouth for foreign object, then position behind patient to give forceful, inward/upward thrust on abdomen using closed fists until object is dislodged. If LOC, place in supine and perform rescue breathing and abdominal thrusts, using a finger to sweep mouthPulmonary Embolism: ResponseSOB, cough, chest pain worsening with deep breathing, lightheadedness, rapid/irregular heart rate, fever, diaphoresis, clammy skin, leg pain/swelling Call EMSSeizures: ResponsePlace patient in safe location and position without constraining movements. Monitor RR, ensure airway stays open. Turn pt on left side if vomiting occursShock: ResponsePresents with moist, cool skin, diaphoresis (excessive sweating), shallow/irregular breathing, low body temp, weakness, syncope Remove source of shock, monitor BP, HR, and RR. CPr if necessary. Place pt in supine with feet elevated above level of head, assuming no injury to head, spine, trunk or legs.Stroke: ResponseDrooping or numbness on one side of face. numbness or weakness of one arm, altered vision, headache, dizziness, lack of coordination, confusion, LOC Call EMS immediately, noting time initial sxs appeared. If symptoms go away after a few minutes, insist that patient seeks care for their TIACPR compression rate100-120 bpmCPR Compression to ventilation ratio30:2Misc PT responsibilties1. Reporting drug tolerance or adverse effects to physician immediately if placing pt at risk for harm 2. Students are an extension of PT and when under direct supervision, can perform all functions of PT 3. Are responsible for acting in best interests of patients and minimizing risk of pt harm and pt inconvenienceMisc PTA responsibilities1. Shall not determine appropriate electrical modality parameters 2. Should report suspected cases of abuse involving children or vulnerable adults to supervising therapist AND to appropriate authority 3. Modify interventions only when within POC set up by PT 4. PTAs and SPTAs can train pts with an AD once pt has been assessed and correct AD identified by PTPICO QuestionPatient, Intervention, Comparison, OutcomeLevels of Evidence-Systematic Review: best option -Randomized Control Trials: double blind -Cohort studies: longitudinal, not randomized or controlled, writing down observations, retrospective -Case Control: Individuals w/ disease are compared to invidiuals without -Cross-sectional: Observations are only made at one point in time, all subjects tested at same time -case study: one patient results -expert opinions: least valuableContinuous DataData that can take on any value, covers a range of values without gaps or interruptions. ROM, meters, kg, timeDiscrete dataNumerical data values that can be COUNTED. No inbetween -Patients diagnosed with cancer -Number of visits to clinicDichotomous DataDiscrete data limited to only two values Example: Male and female, smoker and non-smokerQualitative DataCategorical data. Represents categories distinguished by non-numeric characteristic (eye color, blood type, hand dominance)Quantitative DataNumbers that represent counts or measurementsNominal Measurement ScaleClassification scale. Values are mutually exclusive, each person can only be assigned one category like: Race, gender, types of schools, hair colors (e.g., public, private, parochial)Ordinal Measurement Scalebeing of a specified position or order in a numbered series. "Ranking scale" Levels of assistance, pain, joint laxity grades, manual muscle test gradesInterval Scalea scale of measurement in which the intervals between numbers on the scale are all equal in size. No true zero point Temperature (F or C)Ratio scaleIntervals between values are equal, there is a true zero point ROM (degrees), distance walked (m), time to complete activity(s)ReliabilityConsistency, reproducibility, or repeatability of a measurementAlternate forms reliability (parallel forms)Assesses consistency or agreement of measurements obtained with different forms of a test (Each SAT is considered an equivalent measure)Internal ConsistencyA measure of reliability; the degree to which a test yields similar scores across its different parts. Does the functional assessment scale include only items that relate to patient's physical function?Intrarater Reliabilitythe stability of repeated measures by the same examinerInterrater reliabilitythe amount of agreement in the observations of different raters who witness the same behaviorTest-retest Reliabilitya method for determining the reliability of a test by comparing a test taker's scores on the same test taken on separate occasionsValidityThe degree to which a useful or meaningful interpretation can be inferred from a measurementFace validityThe degree to which a measurement appears to test what it is supposed to. Important to patients who may not be compliant with repeated testing if they don't see how its measurements relate to their problemContent Validitythe extent to which a test samples the behavior that is of interest. Does the test measure all aspects of the thing being tested?Construct ValidityThe degree to which a test actually measures what it claims to measureCriterion-related ValidityValidity of a measurement established by comparing it to the gold-standardConcurrent ValidityA form of criterion-related validity where a measurement is compared to the gold standard at the same time.Predictive Validitya form of criterion-related in which validity is measured by how predictive it is of a future event. (use of GPA as admission criteria based on presumed ability to predict future academic success)Prescriptive ValidityForm of criterion-related validity in which the measurement suggests the form of treatment a person needs. Validity is judged on how accurate that prediction is.Alternate hypothesisA statement that is accepted if the sample data provide sufficient evidence that the null hypothesis is false.Null hypothesisthe hypothesis that there is no significant difference between specified populations, any observed difference being due to sampling or experimental error.Independent variableThe experimental factor that is manipulated; the variable whose effect is being studied.Dependent variableThe outcome factor; the variable that may change in response to manipulations of the independent variable.p valueProbability that a statistical result could happen by chance. If p value is smaller than alpha, null hypothesis is rejected (P< 0.05). If p value is larger than alpha, null hypothesis is not rejectedAlpha levelProbability of rejecting the null hypothesis when it is true Often 0.05 or 0.01.Type I error (alpha)Stating that there is an effect when none exists (accepting an experimental hypothesis when the null is true)Type II Error (Beta)Stating there is not an effect when one exists (failure to reject null hypothesis when it's false)Effect SizeMeasure of magnitude of the difference between two treatments, or the magnitude of relatioship between two variable. Larger ES=statistically significantEffect size indexMean of treatment - mean of control group/standard deviation of one group Less than 0.1 = trivial effect 0.1-0.3 = small effect 0.3-0.5 = Moderate effect Greater than 0.5 = Large effectMinimal Clinically Important Difference (MCID)Smallest difference in a patient's condition that the patient or clinician considers worthwhile and would warrant a change in patient's management.Minimal Detectable DifferenceMinimum change in patient's condition beyond threshold of measurement error. Smallest chnge that would be statistically significant.MeanArithmetic average - sum of all values divided by number of valuesMedianthe middle score in a distribution; half the scores are above it and half are below itModeValue that occurs most frequentlyNormal DistributionA function that represents the distribution of variables as a symmetrical bell-shaped graph. Mean, median, and mode are the same -68% of values fall in one Std. deviation (+-1) 34% each way -95% of values fall in two std. deviations (+-2) 13.6% -99% of values fall in three standard deviations (+-3) another 2.14% wayCoefficient of VariationA measure of relative variability computed by dividing the standard deviation by the mean and multiplying by 100. CV = sd/mean x 100PercentilesValue below which a certain percent of observations will fall. 20th percentile is the value or score below which 20% of scores will fallRangeDifference between maximum and minimum valuesStandard DeviationMeasurement of spread or dispersion of data. Valid in normal distributionParametric StatisticsAssumes that samples come from normally distributed populationsAnalysis of Variance (ANOVA)Inferential statistical procedure used to compare two or more populations by analyzing variancesVarianceDegree of difference in a data set. As it increases, power decreases.One-way ANOVAcompares multiple groups on a single independent variableTwo way ANOVACompares two or more groups of data with two or more independent variablesRegression AnalysisExamines relationship between between dependent variable and one or more independent variablesPearson product moment correlation (r)Measures the magnitude of the linear relationship between two variables on the inverval scale. Positive r = values increase or decrease together Negative r = values increase or decrease away from each other 0 = no relationshipT testComparing two means when population is not normally distributedSensitivityPercentage of people who test positive for a disease among a group of people who have the disease If someone tests negative to a sensitive test, you can rule them out. SnOUTSpecificityPercentage of people who test negative for a specific disease among a group of people who do not have the disease. If someone tests positive to a specific test, you can rule them in. SpINPositive Predictive Valueability of a diagnostic test to correctly determine the proportion of patients with the disease from all the patients with positive test resultsNegative Predictive ValueThe probability that a person with a negative test result is truly disease freeRelative Riskratio of incidence/prevalence of a disease in an exposed group to the incidence/prevalence of a disease in an unexposed group RR of 1 = Equally likely in both groups RR more than 1 = Exposure means more risk RR less than 1 = Exposure means less riskOdds RatioA measure of the odds of an event happening in one group compared to the odds of the same event happening in another group OR of 1 = Exposure does not increase risk of outcome OR more than 1: Greater odds of association between exposure and outcome OR less than 1 = Lower odds of association between exposure and outcomeNumber Needed to Treat (NNT)Numbe of patients that need to be treated to prevent one bad outcome or result in one additional good outcome. Ideal NNT is 1, everyone improves. Higher NNT = less effective treatmentPowerChance or percentage that a researcher will find a significant result in a sample if it exists. Usually set to 0.8 Low = low chance of finding significant result when one is present (Type II error)Beta valueProbability of accepting a false null hypothesis.Sample sizethe number of times a measurement is replicated in data collection. Directly proportional to power.X ray Radiographic ImagingIonizing electromagnetic radiation passes through tissues -Best Initial Study for MSK -Best initial assessment for joint, spine, and cardiopulmonary diseaseComputerized Tomography (CT)Ionizing electromagnetic radiation at different angles to produce cross-sectional slices -Subtle or complex fractures -Central Spinal Stenosis -First imaging choice in serious trauma involving multiple injuries to bone/soft tissueBone Scintigraphy (Bone scan)Nuclear imaging test using ionizing radiation and a radioactive nucleotide to assess for bone disease -Bone tumors -Skeletal Metastasis -Stress FracturesMagnetic Resonance ImagingNuclear magnetic resonance to visualize tissues. Does NOT use ionizing radiation -Rotator Cuff tears and muscular disorders -Labral and meniscal abnormalities -Disc herniations -Neurologic conditions (entrapment, compression) -Bone marrow variations (bone marrow, tumor, avascular necrosis)TrapeziusSpinal accessory nerve XI and branches of C3, C4Levator scapDorsal scapular nerve C5 and branches of C3 and C4Rhomboids major and minorDorsal scapular nerve C5Serratus anteriorLong thoracic nerve C5-C7Pec minorMedial pectoral nerve C8-T1SubclaviusNerve fibers from C5 and C6DeltoidAxillary nerve C5, C6Pectoralis majorUpper: lateral pec nerve C5-C7 Lower: medial pec nerve C8, T1Latissimus dorsiThoracodorsal C6-C8Teres majorLower subscap nerve C5, C6CoracobrachialisMusculocutaneous nerve C5-C7SubscapularisUpper and lower subscap nerve C5, C6SupraspinatusSuprascapular nerve C5InfraspinatusSuprascapular nerve C5, C6Teres minorAxillary nerve C5, C6Biceps brachiiMusculocutaneous nerve C5, C6BrachialisMusculocutaneous nerve C5, C6BrachioradialisRadial nerve C5, C6Pronator TeresMedian nerve C6, C7Pronator QuadratusMedian nerve C6, C7Triceps brachiiRadial nerve C7, C8SupinatorRadial nerve C6AnconeusRadial nerve C7, C8Flexor carpi radialisMedian nerve C6, C7Palmaris longusMedian nerve C6, C7Flexor carpi ulnarisUlnar nerve C8, T1Flexor digitorum superficialisMedian nerve C7, C8, T1Flexor digitorum profundusMedian nerve C8, T1 to 2nd and 3rd fingers; ulnar nerve C8, T1 to 4th and 5th fingersFlexor pollicis longusMedian nerve palmar interosseous branch C8, T1Extensor carpi ulnarisRadial nerve C6, C7, C8Extensor carpi radialis brevisRadial nerve C6, C7Extensor carpi radialis longusRadial nerve C6, C7Extensor digitorumRadial nerve C6, C7, C8Extensor indicisRadial nerve C6, C7, C8Extensor digiti minimiRadial nerve C6, C7, C8Extensor pollicis longusRadial nerve C6, C7, C8Extensor pollicis brevisRadial nerve C6, C7Abductor pollicis longusRadial nerve C6, C7IlliacusLumbar nerve and femoral nerve L2-L4Psoas major and minorLumbar nerve and femoral nerve L2-L4Rectus femorisFemoral nerve L2-L4SartoriusFemoral nerve L2, L3PectineusFemoral nerve L2-L4Adductor brevisObturator nerve L3, L4Adductor longusObturator nerve L3, L4Adductor magnusAnterior: obturator nerve L2-L4 Posterior: sciatic nerve L4, L5, S1-S3GracilisObturator nerve L2-L4SemitendinosusSciatic nerve-tibial division L5, S1, S2SemimembranosusSciatic nerve-tibial division L5, S1, S2Biceps femorisLong head: sciatic nerve-- tibial devision S1-S3 Short head: sciatic nerve-- peroneal division L5, S1, S2Gluteus maximusInferior gluteal nerve L5, S1, S2Gluteus mediusSuperior gluteal nerve L4, L5, S1Gluteus minimusSuperior gluteal nerve L4, L5, S1Tensor fasciae lataeSuperior gluteal nerve L4, L5, S1PiriformisFirst and second sacral nerves S1, S2Gemellus superiorSacral nerve L5, S1, S2Gemellus inferiorBranches from sacral plexus L4, L5, S1, S2Obturator internusBranches from sacral plexus L4, L5, S1, S2Obturator externusObturator nerve L3, L4Quadratus femorisBranches from sacral plexus L4, L5, S1Vastus intermediusFemoral nerve L2-L4Vastus lateralisFemoral nerve L2-L4Vastus medialisFemoral nerve L2-L4PopliteusTibial nerve L5, S1GastrocnemiusTibial nerve S1, S2SoleusTibial nerve S1, S2Tibialis posteriorTibial nerve L5, S1Flexor digitorum longusTibial nerve L5, S1Flexor hallicus longusTibial nerve L5, S1, S2Peroneus longusSuperficial peroneal nerve L4, L5, S1Peroneus brevisSuperficial peroneal nerve L4, L5, S1Peroneus tertiusDeep peroneal nerve L4, L5, S1Extensor digitorum longusDeep peroneal nerve L4, L5, S1Extensor hallucis longusDeep peroneal nerve L4, L5, S1Tibialis anteriorDeep peroneal nerve L4, L5, S1Flexor digitorum brevisMedial plantar nerve L4, L5Abductor digiti minimiLateral plantar nerve S1, S2Abductor hallucisMedial plantar nerve L4, L5Quadratus planaeLateral plantar nerve S1, S2Lumbricals1st lumbricals: medial plantar nerve L4, L5 2nd, 3rd, 4th lumbricals: lateral plantar nerve S1, S2Adductor hallucisLateral plantar nerve S1, S2Flexor hallucis brevisMedial plantar nerve L4, L5, S1Flexor digiti minimi brevisLateral plantar nerve S2, S3Plantar interosseiLateral plantar nerve S1, S2Dorsal interosseiLateral plantar nerve S1, S2Extensor digitorum brevis (incl. extensor hallucis brevis)Deep peroneal nerve L5, S1Rectus capitis anteriorC1-C3Rectus capitis lateralisC1-C3Rectus capitis posterior majorPosterior rami of C1Rectus capitis posterior minorPosterior rami of C1Longus capitisC1-C3Obliquus capitis superiorPosterior rami of CqObliquus capitis inferiorPosterior rami of C1Semispinalis capitisPosterior primary divisions on spinal nervesSternocleidomastoidSpinal accessory Cr11, C2, C3Splenius cervicisPosterior lateral branches of cervical nerves four through eight C4-C8Splenius capitisPosterior lateral branches of cervical nerves four through eight C4-C8Erector spinae: IliocostalisPosterior branches of the spinal nervesErector spinae: LongissimusPosterior branches of the spinal nervesErector spinae: SpinalisPosterior branches of the spinal nervesQuadratus lumborumBranches of T12, L1 nervesRectus abdominisIntercostal nerves T7-T12External oblique abdominalIntercostal nerves T8-T12, iliohypogastric nerve T12, L1, and ilioinguinal nerve L1Internal oblique abdominalIntercostal nerves T8-T12, iliohypogastric nerve T12, L1, and ilioinguinal nerve L1Transversus abdominisIntercostal nerves T7-T12, iliohypogastric nerve T12, L1, and ilioinguinal nerve L1Opponens pollicisMedian nerve C6, C7Abductor pollicis brevisMedian nerve C6, C7Flexor pollicis brevisSuperficial head: median nerve C6, C7 Deep head: ulnar nerve C8, T1Adductor pollicisUlnar nerve C8, T1Palmar interosseiUlnar nerve C8, T1Dorsal interossei (hand)Ulnar nerve, palmar branch C8, T1Lumbricals (hand)1st and 2nd: median nerve C6, C7 3rd and 4th: ulnar nerve C8, T1Opponens digiti minimiUlnar nerve C8, T1Abductor digiti minimi (hand)Ulnar nerve C8, T1Flexor digiti minimi brevis (hand)Ulnar nerve C8, T1Palmaris brevisUlnar nerve C8, T1Lumbar Plexus (FL)QL PsoasObturator Nerve (FL)Adductors (except for Pectineus and long tendinous portion of Add Magn) Obturator externusTibial Portion of Sciatic Nerve (FL)Hamstrings (except for the short head of Biceps Fem) Long tendinous portion of Add MagnTibial Nerve (FL)All posterior calf muscles All muscles on plantar side of footCommon Peroneal Nerve (EX)Short head of Biceps femurs Tib.ant., Ext.dig.long., Ext.hal.long Ext.dig.brev., Ext.hal.brev. Peroneus l. & b.Sacral Plexus (FL)Piriformis Obturator internus Gemelli sup.&inf Quad. femoris Levator aniGluteal Nerves (EX)Gluteals (maj, med, min) Tensor fasciae lataeFemoral Nerve (EX)Iliacus Pectineus Sartorius QuadricepsRadial Nerve (EX)Triceps brachii Anconeus Ext.carpi rad. br. & long. Brachioradialis Ext.dig., Ext.dig.min., Ext.carpi uln. Supinator Abd.poll.long& br Ext.poll.long., Ext. indicesAxillary Nerve (EX)Deltoid Teres MinorSubscapular Nerve (EX)Subscapularis Latissimus Dorsi & Teres MajorUlnar Nerve (FL)Fl.carpi uln. Fl. prof. dig.Median Nerve (FL)Fl. digit. superf. Fl. carpi radialis Palmaris longusMusculocutaneous Nerve (FL)Biceps br. Brachialis Coracobrach. Pronator Quad. Fl. dig. Prof., Fl. Poll. LongRoots of Sacral plexusThe sacral plexus begins as the anterior fibres of the spinal nerves S1, S2, S3, and S4. They are joined by the 4th and 5th lumbar roots, which combine to form the lumbosacral trunklumbar plexus

Flickr Creative Commons Images

Some images used in this set are licensed under the Creative Commons through
Click to see the original works with their full license.