Susan O sullivan Raymond Siegelman National Phy

so or interosseous nerve) occurs within radial tunnel (radial tunnel syndrome) f. Ulnar collateral ligament injuries. as result of overhead activities and (1) Occurs as result of repetitive valgus stress- throwing. es to medial elbow with overhead throwing. (b) Clinical signs include lateral elbow pain (2) Clinical signs include pain along medial that can be confused with lateral epi- elbow at distal insertion of ligament. In condylitis, pain over supinator muscle some cases paresthesias are reported in and paresthesias in a radial nerve distri- ulnar nerve distribution with positive bution. Tinel's sign may be positive. Tinel's sign. (4) Diagnostic tests utilized: electrodiagnostic (3) Diagnostic tests utilized: MR!. tests. (4) Clinical examination including mediallig- (5) Clinical examination helps to identify this ament instability test helps to identify this condition. condition. (6) Medications. (5) Medications. (a) Acetaminophen for pain. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (b) NSAIDS for pain and/or inflammation. (c) Neurontin for neuropathic pain. (6) Phy ical therapy goals, outcomes, and (7) Physical therapy goals, outcomes, and interventions. interventions. (a) Initial intervention includes rest and (a) Early intervention includes rest, avoid- pain management. ing exacerbating activities, use of (b) After resolution of pain and inflamma- NSAIDs, modalities and soft tion, strengthening exercises that focus tis ue/massage techniques to reduce on elbow flexors are initiated. Taping inflammation and pain. can also be used for protection during (b) Protective padding, and night splints to return to activities. maintain slackened position of involved nerves. g. Nerve entrapments. (c) With reduction in pain and paresthe- (1) Ulnar nerve entrapment. sias, rehabilitation program should (a) Various cau es which include direct focus on strengthening/endurance/ trauma at cubital tunnel, traction due to coordination exercise of involved mus- laxity at medial a pect of elbow, com- cles to achieve muscle balance pression due to a thickened retinacu- between agonists and antagonists, nor- lum or hypertrophy of flexor carpi mal flexibility of shortened structures, ulnaris muscle, recurrent subluxation and normalization of strength/ or dislocation and DID that affects the endurance/coordination. cubital tunnel. (d) Intervention should also include func- (b) Clinical findings include medial elbow tional training, patient education, and pain, and paresthesias in ulnar distribu- self-management techniques. tion, and a positive Tinel's sign. h. Elbow dislocations. (2) Median nerve entrapment. (1) Posterior dislocations account for most dis- (a) Occurs within pronator teres muscle locations occurring at elbow. and under uperficial head of flexor (a) Posterior dislocations are defined by digitorum superficialis with repetitive po ition of olecranon relative to the gripping activities required in occupa- humerus. tions (e.g., electricians) and with (b) Posterolateral dislocations are most leisure time activities (e.g,. tennis). common and occur as the result of (b) Clinical signs include an aching pain elbow hyperexten ion from a fallon with weakness of forearm muscles, the outstretched upper extremity. positive Tinel's sign with paresthesias (c) Posterior dislocations frequently cause in median nerve distribution. (3) Radial nerve entrapment. (a) Entrapment of distal branches (posteri-

avulsion fractures of medial epi- Musculoskeletal Physical Therapy 51 condyle secondary to traction pull of medial collateral ligament. sion causes atrophy and weakne s of thenar (2) Anterior and radial head dislocations muscles and lateral two lumbrical . account for only 1 to 2 percent of all elbow (6) Medications. dislocations. (a) Acetaminophen for pain. (3) With a complete dislocation ulnar collater- (b) NSAIDS for pain and/or inflammation. al ligament will rupture with possible rup- (7) Physical therapy goals, outcomes, and ture of anterior capsule, lateral collateral interventions. ligament, brachialis muscle, and/or wrist (a) Biomechanical faults cau ed by joint flexor and extensor muscles. (4) Clinical sign include rapid swelling, restrictions should be corrected with evere pain at the elbow and a deformity joint mobilization to the specific with olecranon pushed posteriorly. restrictions identified during the exam- (5) Diagnostic tests utilized: plain film imaging. ination. (6) Medications. (b) Soft tissue/massage techniques, modal- (a) Acetaminophen for pain. ities, flexibility exercises, and function- (b) NSAIDS for pain and/or inflammation. al exercises including strengthening, (7) Phy ical therapy goal , outcomes, and endurance, and coordination. interventions. b. DeQuervain's tenosynovitis. (a) Initial intervention includes reduction (1) Inflammation of extensor pollicis brevis of the dislocation. and abductor pollici longus tendons at first (b) If elbow is stable, there is an initial dorsal compartment. phase of immobilization followed by (2) Results from repetitive microtrauma or as a rehabilitation focusing on regaining complication of swelling during pregnancy. flexibility within limits of stability, and (3) Diagnostic tests utilized: MRI, but usually strengthening. not necessary to make diagnosis. (c) If elbow is not stable, surgery is indi- (4) Clinical signs include: pain at snuff box, cated. swelling, decreased grip and pinch 3. Wrist and hand condition. strength, positive Finkelstein's test (which a. Carpal tunnel syndrome (repetitive stress syn- places tendons on a stretch). drome). (5) Medications. (1) Compression of the median nerve at the (a) Acetaminophen for pain. carpal tunnel of the wrist as the result of (b) NSAIDS for pain and/or inflammation. inflammation of the flexor tendons and/or (6) Physical therapy goals, outcomes, and median nerve. interventions. (2) Commonly occurs as result of repetitive (a) Biomechanical faults caused by joint wrist motion or gripping, with pregnancy, restrictions should be corrected with diabetes, and rheumatoid arthritis. joint mobilization to the pecific (3) Must rule out potential of cervical spine restrictions identified during the exam- dysfunction, thoracic outlet syndrome, or ination. peripheral nerve entrapment that is mim- (b) Soft tissue/massage techniques, modal- icking this condition. ities, flexibility exercises, and function- (4) Diagno tic tests utilized: electrodiagno tic al exercises including strengthening, testing. endurance, and coordination. (5) Common clinical findings include exacer- c. Colles' Fracture. bation of burning, tingling, pins and nee- (I) Most common wrist fracture re ulting from dles, and numbness into median nerve dis- a fall onto an outstretched UE. These frac- tribution at night, and a positive Tinel's sign tures are immobilized between 5 to 8 and/or Phalen's Test. Long-term compres- weeks. Complication of median nerve com- pression can occur with excessive edema. (2) Characteristic \"dinner fork\" deformity of wrist and hand results from dorsal or poste-

52 (5) Physical therapy goals, outcomes, and interventions. rior displacement of distal fragment of (a) Early intervention includes mainte- radius with a radial shift of wrist and hand. nance of flexibility of distal and proxi- (3) Diagnostic tests utilized: plain film imaging. mal joints while UE is casted. Later (4) Complications may include loss of motion, intervention emphasizes strengthening, decreased grip strength, CRPS, and carpal stretching, and joint and soft tissue tunnel syndrome. mobilizations to regain full functional (5) Medications. use of wri t and hand. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. f. Dupuytren's contracture (Figure 1-3). (6) Physical therapy goals, outcomes, and (1) Observed as banding on palm and digit interventions. flexion contractures resulting from contrac- (a) Early physical therapy intervention ture of palmar fascia which adheres to skin. (2) Affects men more often than women. that focuses on normalizing flexibility (3) Contracture usually affect the metacar- is paramount to functional recovery of pophalangeal (MCP) and proximal inter- wrist and hand. phalangeal (PIP) joints of fourth and fifth (b) Biomechanical faults caused by joint digits in non-diabetic individuals and restrictions should be corrected with affects third and fourth digits most often in joint mobilization to the specific individuals with diabetes. restrictions identified during the exam- (4) Medications. ination. (a) Acetaminophen for pain. (c) Soft ti sue/massage techniques, modali- (b) NSAlDS for pain and/or inflammation. ties, flexibility exercises, and functional (5) Physical therapy goals, outcomes, and exercises including strengthening, interventions. endurance, and coordination. (a) Phy ical therapy intervention includes d. Smith' fracture. flexibility exercise to prevent further (1) Similar to Colles' fracture except distal contracture and splint fabrication/ fragment of radius dislocates in a volar application. direction causing a characteristic \"garden (b) Once contracture i under control pro- spade deformity\". mote restoration of normal hand func- (2) Diagnostic tests utilized: plain film imaging. tion through functional exercises. (3) Medications. (c) Physical therapy intervention follow- (a) Acetaminophen for pain. ing surgery includes wound manage- (b) NSAlDS for pain and/or inflammation. ment, edema control and progression (4) Physical therapy goals, outcomes, and of functional exercise. interventions. (a) Intervention is similar to Colles' frac- g. Boutonniere deformity (Figure 1-4). ture. (1) Results from rupture of central tendinous e. Scaphoid fracture. slip of extensor hood. (1) Results from a fall onto outstretched DE in (2) Observed deformity is extension of MCP a younger person. Most commonly frac- and distal interphalangeal (DIP) with flex- tured carpal. ion of PIP. (2) Diagnostic tests utilized: plain film imaging. (3) Commonly occurs following trauma or in (3) Complications include a high incidence of rheumatoid arthritis with degeneration of avascular necrosis of the proximal frag- the central extensor tendon. ment of the scaphoid secondary to poor (4) Medications. vascular supply. Carpals are immobilized (a) Acetaminophen for pain. between 4 to 8 weeks. (b) NSAIDS for pain and/or inflammation. (4) Medications. (5) Physical therapy goals, outcomes, and (a) Acetaminophen for pain. interventions. (b) NSAIDS for pain and/or inflammation.

(a) Physical therapy intervention includes Musculoskeletal Physical Therapy 53 edema management, flexibility exer- cises of involved and uninvolved ing, but may not be necessary. joints, splinting or taping, and func- (5) Medications. tional strengthening/endurance/coordi- nation exercises. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. h. Swan neck deformity (Figure 1-5). (6) Physical therapy goals, outcomes, and (1) Re ult from contracture of intrinsic mus- interventions. cle with dorsal subluxation of lateral (a) Physical therapy intervention include exten or tendons. (2) Observed deforrrUty is flexion of MCP and edema management, flexibility exer- DIP with extension of PIP. cises of involved and uninvolved (3) Commonly occurs following trauma or joints, splinting or taping, and func- with rheumatoid arthritis following degen- tional strengthening/endurance/coordi- eration of lateral extensor tendons. nation exercise . (4) Diagnostic tests utilized: plain film imag- i. Ape hand deformity (Figure 1-6). (1) Observed as thenar muscle wasting with Figure 1-3 Dupuytren's Contracture first digit moving dorsally until it is in line with second digit. (Adapted from Magee, OJ. Orthopedic Physical (2) Results from median nerve dysfunction. (3) Diagnostic tests utilized: electrodiagnostic Assessment, ed 2,WB Saunders, Philadelphia, 1992) testing. (4) Medications. Figure 1-4 Boutonniere Deformity (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (From Magee, OJ. Orthopedic Physical Assessment, (5) Physical therapy goals, outcomes, and interventions. ed 2,WB Saunders, Philadelphia, 1992, with permission) (a) Physical therapy intervention includes edema management, flexibility exer- cises of involved and uninvolved joints, splinting or taping, and func- tional strengthening/endurance/coordi- nation exercises. J. Mallet finger (Figure 1-7). (1) Rupture or avulsion of extensor tendon at its insertion into distal phalanx of digit. (2) Observed deformity is flexion of DIP joint. (3) Usually occurs from trauma forcing distal phalanx into a flexed position. (4) Diagnostic tests utilized: possibly MR!. (5) Medications. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (6) Physical therapy goals, outcomes, and interventions. (a) Physical therapy intervention includes edema management, flexibility exer- cises of involved and uninvolved joints, splinting or taping, and func- tional strengthening/endurance/coordi- nation exercise . k. Gamekeeper's thumb. (1) A sprain/rupture of ulnar collateral liga-

54 joints, splinting or taping, and func- ment of MCP joint of first ctigit. tional trengthening/endurance/coordi- nation exercises. (2) Results in medial instability of thumb. 1. Boxer's fracture. (3) Frequently occurs during a fall while skiing (1) Fracture of neck of fifth metacarpal. (2) Frequently sustained during a fight or from when increasing forces are placed on thumb punching a wall in anger or frustration. through ski pole. Immobilized for 6 weeks. (3) Casted for 2-4 weeks. (4) Diagnostic tests utilized: possibly MR!. (4) Diagnostic tests utilized: plain film imag- (5) Medications. ing. (a) Acetaminophen for pain. (5) Medications. (b) NSAIDS for pain and/or inflammation. (a) Acetaminophen for pain. (6) Physical therapy goals, outcomes, and (b) NSAIDS for pain and/or inflammation. interventions. (6) Physical therapy goals, outcomes, and (a) Physical therapy intervention includes interventions. (a) Physical therapy intervention includes edema management, flexibility exer- edema management, flexibility exer- cises of involved and uninvolved cise initially at uninvolved joints fol- lowed by involved joints after suffi- Figure 1-5 \"Swan Neck\" Deformity cient healing has occurred. (From Magee, OJ. Orthopedic Physical Assessment, (b) Initiation of functional strengthening! ed 2,WB Saunders, Philadelphia, 1992, with permission) endurance/coordination occurs when flexibility is restored. Figure 1-6 \"Ape Hand\" Deformity D. Lower Extremity Conditions (From Magee, OJ. Orthopedic Physical Assessment, 1. Hip conditions. ed 2,WB Saunders, Philadelphia, 1992, with permission) a. Avascular necrosis (AVN) of the hip (os teo necrosis ). Figure 1-7 Mallet Finger (1) Multiple etiologies resulting in an impaired (From Magee, OJ. Orthopedic Physical Assessment, blood supply to the femoral head. ed 2,WB Saunders, Philadelphia, 1992, with permission) (2) Hip ROM is decreased in flexion, internal rotation, and abduction. (3) Diagnostic tests utilized: plain film imag- ing, bone scans, CT and/or MRI may be utilized. (4) Symptoms include pain in the groin and/or thigh, and tenderness with palpation at the hip joint. (5) Coxalgic gait. (6) Medications. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (c) Corticosteroids contraindicated since they may be causative factor. Patient taking steroids for orne other condi· tion should have dose decreased. (7) Physical therapy goals, outcomes, and interventions. (a) Joint/bone protection strategies. (b) Maintain/improve joint mechanics and connective tissue functions.

(c) Implementation of aerobic capacity Musculoskeletal Physical Therapy SS /endurance conditioning or recondi- tioning such as aquatic programs. (7) With chronic conditions, patient may demonstrate a Trendelenburg gait. (d) Post- urgical intervention includes regaining functional flexibility, (8) Diagno tic te ts utilized: plain film imag- improving strength/endurance/coordi- ing show a positive displacement of upper nation, and gait training. femoral epiphysis. b. Legg-Calve-Perthe's disease (osteochondrosis). (9) Medications. (1) Age of onset between 2-13 years with aver- (a) Acetarrunophen for pain. age age of onset occurring at six years. (b) NSAIDS for pain and/or inflammation. (2) Males have a four times greater incidence than females. (IO)Physical therapy goals, outcomes, and (3) Characteristic psoatic limp due to weak- interventions. nes of psoas major; affected LE moves in (a) Joint/bone protection strategies. external rotation, flexion and adduction. (b) Maintain/improve joint mechanic and (4) Gradual onset of \"aching\" pain at hip, thigh connective tissue functions. and knee. (c) Implementation of aerobic capacity/ (5) AROM limited in abduction and extension. endurance conditiomng or recondition- (6) Diagnostic tests utilized: MRI is imaging ing such as aquatic programs. technique of choice. Positive bony crescent (d) Post- urgical intervention includes sign (collapse of subchondral bone at regaining functional flexibility, femoral necklhead). improving strength/endurance/coordi- (7) Medications. nation, and gait training. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. d. Femoral anteversion and antetorsion. (8) Physical therapy goals, outcomes, and (1) Excessive femoral antever ion or antetor- interventions. sion (30 degrees or greater) leads to squint- (a) Joint/bone protection strategies. ing patellae and toeing in. (b) Maintain/improve joint mechanics and (2) With an angle less than 0 degrees (retrover- connective tissue functions. sion), femoral neck is rotated backward in (c) Implementation of aerobic capacity/ relation to femoral condyles. endurance conditioning or recondition- (3) Diagnostic tests utilized: plain film imaging. ing such as aquatic programs. (4) Clinical examination including Craig's test (d) Post-surgical intervention includes helps to identify tills condition. regaining functional flexibility, (5) Physical therapy goals, outcomes, and improving strength/endurance/coordi- interventions. nation, and gait training. (a) Maintain/improve joint mechanics and connective tissue functions. c. Slipped capital femoral epiphysis. (1) Most common hip disorder observed in e. Coxa vara and coxa valga. adolescents and is of unknown etiology. (1) Angle of femoral neck with shaft of femur (2) On et in males: 10-17 years of age with the is less than 120 degrees, coxa vara results. average age of onset 13 years. (2) Angle of femoral neck with shaft of femur is (3) Onset in females: 8-15 year of age with greater than 135 degrees, coxa valga results. the average age of onset 11 years. (3) Coxa vara usually results from a defect in (4) Males have two times greater incidence ossification of head of femur. Coxa vara and than females. coxa valga may result from necrosis of (5) AROM is restricted in abduction, flexion, femoral head occurring with septic arthritis. and internal rotation. (4) Diagnostic tests utilized: plain film imaging. (6) Patient describes pain as vague at knee, (5) Physical therapy goals, outcomes, and thigh and rup. interventions. (a) Maintain/improve joint mechanics and connective tissue functions. f. Trochanteric bursitis. (1) An inflammation of deep trochanteric bursa

56 may be fabricated. h. Piriformis syndrome. from a direct blow, irritation by iliotibial band (ITB) and biomechanicalJgait abnor- (1) Piriformis muscle is an external rotator of malitie causing repetitive microtrauma. hip and can become overworked with (2) This condition is cornmon in patients with excessive pronation of foot, which causes rheumatoid arthritis. abnormal femoral internal rotation. (3) Diagno tic tests utilized: none. Considered a tonic muscle which is active (4) Diagnosis made by clinical examination. with motion of sacroiliac joint, particularly Differentiate from contractile condition by sacrum. comparing results of AROM, PROM, and resistive tests. (2) Tightness or spasm of piriformis muscle (5) Medications. can result in compression of sciatic nerve (a) Acetaminophen for pain. and/or sacroiliac dysfunction. (b) NSAIDS for pain and/or inflammation. (6) Physical therapy goals, outcomes, and (3) Diagnostic tests utilized: possibly electro- interventions. diagnostic tests for ciatic nerve. (a) Refer to intervention for general bursi- (4) Signs and symptoms include: tis/tendonitis/tendonosis (III.B.9-11). (a) Restriction in internal rotation. g. Iliotibial band tightness/friction disorder. (b) Pain with palpation of piriformis muscle. (c) Referral of pain to posterior thigh. (1) Etiology: tight iliotibial band, abnormal (d) Weakness in external rotation, positive gait patterns. piriformis test. (e) Uneven sacral base. (2) Results in inflammation of trochanteric bursa. (5) Perform lower extremity biomechanical examination to determine if abnormal bio- (3) Noble compression test is positive when mechanics are the cause. Must rule out friction is introduced over the lateral involvement of lumbar spine and/or femoral condyle during knee extension. sacroiliac joint. Ober's test will also demonstrate tightness in ITB. (6) Medications. (a) Acetaminophen for pain. (4) Medications. (b) NSAIDS for pain and/or inflammation. (a) Acetaminophen for pain. (c) Neurontin for neuropathic pain. (b) NSAIDS for pain and/or inflammation. (7) Physical therapy goals, outcomes, and (5) Physical therapy goals, outcomes, and interventions. (a) Reduction of pain utilizing modalities interventions. and manual therapy techniques such as (a) Reduction of pain and inflammation soft tissue/massage to piriformis muscle. (b) Joint oscillation to hip or pelvis to utilizing modalities, soft tissue tech- inhibit pain. niques, and manual therapy techniques (c) Correction of muscle imbalances and such as soft tissue/massage and joint biomechanical faults using strengthen- oscillations. ing, endurance, coordination, and flex- (b) Correction of muscle imbalances and ibility exercises to gain restoration of biomechanical faults using strengthen- normal function. ing, endurance, coordination, and flex- (d) Restore muscle balance and patient ibility (IT band, hamstrings, quadri- education regarding protection of the ceps, and hip flexors) exercises to gain sacroiliac joint (e.g., in truction not to restoration of normal function. step off a curb onto the dysfunctional (c) Biomechanical faults caused by joint lower extremity). restrictions should be corrected with (e) Correction of biomechanical faults joint mobilization to the specific may include orthoses or orthotic restrictions identified during the exam- devices for feet. ination. (d) Gait training, and patient education 2. Knee conditions. regarding the selection of running shoes and running surfaces. Orthoses

a. Ligament sprains. Musculoskeletal Physical Therapy 57 (1) Four major ligaments may be involved with knee prains (anterior cruciate, posterior utilizing modalities, soft tissue tech- cruciate, medial collateral, and lateral col- niques, and manual therapy techillques lateral). such as 0 cillations. (2) Injury to the ligaments may result in a sin- (c) Postoperatively, continuous passive gle plane or rotary instability. motion (CPM) devices may be used to (a) ACL laxity may result in single plane maintain promote flexibility of the anterior instability. joint. (b) PCL laxity may result in single plane (d) Correction of muscle imbalance and posterior instability. biomechanical faults using strengthen- (c) ACL and MCL laxity may result in ing, endurance, coordination, and flex- anteromedial rotary instability. ibility exercises to gain restoration of (d) ACL and LCL laxity may result in normal function. anterolateral rotary instability. (e) Biomechanical faults cau ed by joint (e) PCL and MCL laxity may result in restrictions should be corrected with posteromedial rotary instability. joint mobilization to the specific restrictions identified during the (0 PCL and LCL laxity may result in pos- examination. (0 Progression to functional training terolateral rotary instability. based on patient's occupation and/or (3) Classification of injury. recreational goals. b. Meillscal injuries. (a) First degree resulting in little or no (1) Result from a combination of forces to instability. include tibiofemoral joint flexion, com- pression, and rotation which places abnor- (b) Second degree resulting in miillmal to mal shear stresses on the meniscus. moderate instability. (2) Symptoms include lateral and/or medial joint pain, effusion, joint popping, knee (c) Third degree resulting in extreme giving way during walking, limitation in instability. flexibility of knee joint, and joint locking. (3) Diagnostic tests utilized: MRI typically (4) \"Unhappy triad\" includes injury to the done, but not always sensitive enough to medial collateral ligament, anterior cruci- confirm tear. ate ligament, and the medial meniscus (4) Clinical examination including the follow- resulting from a combination of valgum, ing special tests will be useful to make flexion, and external rotation forces applied diagnosis. to knee when the foot is planted. (a) McMurray test. (b) Apley test. (5) Diagnostic tests utilized: MRI. Difficult to (5) Medications. visualize complete ACL on MRI, so often (a) Acetaminophen for pain. read incorrectly as partially torn even if (b) NSAIDS for pain and/or inflammation. normal. (6) Physical therapy goals, outcomes, and interventions. (6) Refer to knee special tests that help to iden- (a) Reduction of pain and inflammation tify ligamentous instabilities of knee joint. utilizing modalities, soft tissue/mas- sage techniques to surrounding mus- (7) Recon truction frequently involves a com- cles, and manual therapy techniques bination of intra and extra-articular proce- such as joint 0 cillations to inhibit pain. dures. (b) Correction of muscle imbalances and biomechanical faults u ing strengthen- (8) Medications. ing, endurance, coordination, and flex- (a) Acetaminophen for pain. ibility exercises to gain restoration of (b) NSAIDS for pain and/or inflammation. (9) Physical therapy goals, outcomes, and interventions. (a) Physical therapy intervention is varied depending on whether the patient undergoes a surgical procedure as well as type of surgery that is performed. (b) Reduction of pain and inflammation

58 trauma or by congenital/developmental dysfunction. normal function. (b) May be interrelated with chondromala- (c) Biomechanical faults caused by joint cia patellae and/or patella tendonitis. (c) Common result is an abnormal restrictions should be corrected with patellofemoral tracking that leads to joint mobilization to the specific abnormal patellofemoral stress. restrictions identified during the exam- (d) Occasionally surgery is indicated. ination. (e) Diagnostic tests utilized: possibly MRI (d) Progression to functional training to rule out other dysfunctions. based on patient's occupation and/or (f) Medications. recreational goals. • Acetaminophen for pain. c. Patellofemoral conditions. • NSAIDS for pain and/or inflarnrna- (1) Abnormal patella positions. (a) Patella alta. tion. • Malalignment in which patella (g) Physical therapy goals, outcomes, and tracks superiorly in femoral inter- interventions. condylar notch. • Patellofemoral (McConnell) taping May result in chronic patellar sub- luxation. is helpful to inhibit pain during reha- Positive camel back sign (two bilitation. bumps over anterior knee region • Patella mobilization indicated with instead of typical one. Two bumps restrictions of patella glides e.g., if ince patella is riding high within patella is in a lateral glide position femoral condyles so there is a supe- and has decreased medial glide, per- rior bump and then tibial tuberosity form a medial glide joint mobiliza- forms second bump inferiorly). tion to the patella. (b) Patella baja. • Correction of muscle imbalance • Malalignment in which patella and biomechanical faults using tracks inferiorly in femoral inter- strengthening, endurance, coordina- condylar notch. tion, and flexibility exercise to gain • Results in restricted knee extension restoration of normal function. with abnormal cartilaginous wear- (3) Patellar tendonitis. ing resulting in DID. (a) May be related to overload and/or (c) Lateral patellar tracking. jumping related activities/sports. • Could result if there is an increase in (b) May also be interrelated to \"Q angle\" with a tendency for later- patellofemoral dysfunction. al subluxation or dislocation. (c) Diagnosis made by clinical examination. (d) Diagnostic tests utilized: plain film (d) Medications. imaging including \"sunrise\" view. • Acetaminophen for pain. (e) Physical therapy goals, outcomes, and • NSAIDS for pain and/or inflammation. interventions. • Corticosteroid injection or by mouth. • Regaining functional strength of (e) Physical therapy goals, outcomes, and structures surrounding knee, partic- interventions. ularly vastus medialis oblique • Refer to intervention for general bursi- (VMO) muscle, regain normal flexi- tisltendonitisltendonosis (lll.B.9.11). bility of ITB and hamstrings, d. Pes anserine bursitis. orthoses (if appropriate) and patellar (1) Typically caused by overuse or a contusion. bracing/taping. (2) Must be differentiated from tendonitis. (2) Patellofemoral pain syndrome (PFPS). (3) Diagnosis made by clinical examination. (a) Common dysfunction that may occur Differentiate from contractile condition by on its own or in conjunction with other comparing results of AROM, PROM, and entities. May have been caused by

resistive tests. Musculoskeletal Physical Therapy 59 (4) Medications. due to its anatomic design. (a) Acetaminophen for pain. (b) Numerous etiologic factors include (b) NSAIDS for pain and/or inflammation. (c) Corticosteroid injection or by mouth. trauma, shearing, impacting and avul- (5) Physical therapy goals, outcomes, and sion forces. interventions. (c) Common mechanism of injury is a fall (a) Refer to intervention for general bursi- with knee subjected to a shearing force. tis/tendonitis/tendonosis (III.B.9.11). (2) Tibial plateau. e. Osgood-Schlatter Uumper's knee). (a) Common mechanism of injury is a combination of valgum and compres- (1) Mechanical dysfunction resulting in trac- sion forces to knee when knee is in a tion apophysitis of the tibial tubercle at the flexed position. patellar tendon insertion. (b) Often occurs in conjunction with a medial collateral ligamentous injury. (2) Diagnostic tests utilized: plain film find- (3) Epiphyseal plate. ings demonstrate irregularities of the epi- (a) Mechanism of injury is frequently a physeal line. weight bearing torsional stress. (b) Presents more frequently in adoles- (3) Occasionally surgery is indicated. cents where an ACL injury would (4) Diagnosis made by clinical examination. occur in an adult. (5) Medications. (4) Patella. (a) Most common mechanism of injury is a (a) Acetaminophen for pain. direct blow to patella as result of a fall. (b) NSAIDS for pain and/or inflammation. (5) Diagnostic tests utilized: plain film imag- (6) Physical therapy goals, outcomes, and ing most likely, unless complex fracture, interventions. which would benefit from CT. (a) Modify activities to prevent excessive (6) Medications. (a) Acetaminophen for pain. stress to irritated site. (b) NSAIDS for pain and/or inflammation. f. Genu varum and valgum. (7) Physical therapy goals, outcomes, and interventions. (1) Normal tibiofemoral shaft angle is six (a) Physical therapy intervention empha- degrees of valgum. sizes return of function without pain. (b) Early flexibility is important in pre- (2) Genu varum is an excessive medial tibial venting capsular adhesions. torsion commonly referred to as 3. Conditions of the lower leg. \"bowlegs\". a. Anterior compartment syndrome (ACS). (1) Increased compartmental pressure resulting (3) Genu varum results in excessive medial in a local ischemic condition. patellar positioning and the pigeon-toed (2) Multiple etiologies; direct trauma, fracture, orientation of the feet. overuse and/or muscle hypertrophy. (3) Symptoms of chronic or exertional com- (4) Genu valgum is an excessive lateral tibial partment syndrome are produced by exer- torsion commonly referred to as \"knock cise or exertion and described as a deep knees\". cramping feeling. (4) Symptoms of acute ACS are produced by (5) Genu valgum results in excessive lateral sudden trauma causing swelling within the patellar positioning. compartment. (5) Diagnosis made by clinical examination. (6) Diagnostic tests utilized: plain film imag- (6) Acute ACS is considered a medical emer- ing. (7) Diagnosis made by clinical examination. (8) Physical therapy goals, outcomes, and interventions. (a) Intervention includes decreased load- ing of knee while maintaining strength and endurance. g. Fractures involving knee joint. (1) Femoral condyle. (a) Medial femoral most often involved

60 (1) Overuse injury resulting most often in microfracture of the tibia or fibula. gency and requires immediate surgical intervention with fasciotomy. (2) 49% of all stress fractures involve the tibia, b. Anterior tibial periostitis (shin splints). and 10% involve the fibula. (1) Musculotendinous overuse condition. (2) Three common etiologies include: (3) Three Common etiologies: abnormal bio- (a) Abnormal biomechanical alignment. mechanical alignment, poor conditioning, (b) Poor conditioning. and improper training methods. (c) Improper training methods. (3) Muscles involved include anterior tibialis (4) Diagnostic tests utilized: plain film imag- and extensor hallucis longus. ing and bone scan. (4) Pain elicited with palpation of lateral tibia and anterior compartment. (5) Medications. (5) Diagnosis made by clinical examination. (a) Acetaminophen for pain. (6) Medications. (b) NSAIDS for pain and/or inflammation. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (6) Physical therapy goals, outcomes, and (7) Physical therapy goals, outcomes, and interventions. interventions. (a) Correction of muscle imbalances and (a) Correction of muscle imbalances and biomechanical faults using strengthen- ing, endurance, and coordination biomechanical faults using strengthen- exercises. ing, endurance, and coordination exer- (b) Flexibility exercises for anterior com- cises. partment muscles as well as the triceps (b) Flexibility exercises for anterior com- surae to gain restoration of normal partment muscles as well as the triceps function. surae to gain restoration of normal function. 4. Foot and ankle conditions. c. Medial tibial stress syndrome. a. Ligament sprains. (1) Overuse injury of the posterior tibialis (1) 95% of all ankle sprains involve laterallig- and/or the medial soleus resulting in aments. periosteal inflammation at the muscular (2) With lateral sprains, foot is plantar flexed attachments. and inverted at time of injury. (2) Etiology is thought to be excessive prona- (3) The most common grading system is as fol- tion. lows: (3) Pain elicited with palpation of the distal (a) Grade I: no loss of function with mini- posteromedial border of the tibia. mal tearing of the anterior talofibular (4) Diagnosis made by clinical examination. ligament. (5) Medications. (b) Grade II: some loss of function with par- (a) Acetaminophen for pain. tial disruption of the anterior talofibular (b) NSAIDS for pain and/or inflammation. and calcaneofibular ligaments. (6) Physical therapy goals, outcomes, and (c) Grade ill: complete loss of function interventions. with complete tearing of the anterior (a) Correction of muscle imbalances and talofibular and calcaneofibular liga- biomechanical faults using strengthen- ments with partial tear of the posterior ing, endurance, and coordination exer- talofibular ligament. cises. (4) Diagnostic tests utilized: MRI if necessary. (b) Flexibility exercises for anterior com- (5) Instability is evaluated using anterior draw- partment muscles as well as the triceps er and talar tilt special tests. surae to gain restoration of normal (6) Medications. function. (a) Acetaminophen for pain. d. Stress fractures. (b) NSAIDS for pain and/or inflammation. (7) Physical therapy goals, outcomes, and interventions. (a) Physical therapy intervention is varied

depending on whether the patient Musculoskeletal Physical Therapy 61 undergoes a surgical procedure as well as type of surgery that is performed. (b) Functional training and restoration of (b) Reduction of pain and inflammation muscle imbalances using exercise to utilizing modalities, soft tissue tech- normalize strength, endurance, coordi- niques, and manual therapy techniques nation, and flexibility. such as oscillations. (c) Correction of muscle imbalances and (c) Early PROM is important in preventing biomechanical faults using strengthen- capsular adhesions. ing, endurance, coordination, and flex- ibility exercises to gain restoration of d. Tarsal tunnel syndrome. normal function. (1) Entrapment of the posterior tibial nerve or (d) Biomechanical faults caused by joint one of it branches within the tarsal tunnel. restriction should be corrected with (2) Over/excessive pronation, overuse prob- joint mobilization to the specific lems resulting in tendonitis of the long restrictions identified during the exam- flexor and posterior tibialis tendon, and ination. trauma may compromise space in the tarsal (e) Progression to functional training tunnel. based on patient's occupation and/or (3) Symptoms include; pain, numbness and recreational goals. paresthesias along the medial ankle to the b. Achilles tendonitis/tendonosis. plantar surface of the foot. (1) Differentiate whether an inflammatory ten- (4) Diagnostic tests utilized: electrodiagnostic donitis or a chronic tendonosis. tests. (2) Clinical examination including Thompson (5) Positive Tinel sign at the tarsal tunnel. test helps to identify this condition. (6) Medications. (3) Medications. (a) Acetaminophen for pain. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (b) NSAIDS for pain and/or inflammation. (c) Neurontin for neuropathic pain. (c) Corticosteroid injection or by mouth. (7) Physical therapy goals, outcomes, and (4) Physical therapy goals, outcomes, and interventions. interventions. (a) Intervention includes the use of (a) Refer to intervention for general bursi- orthoses to maintain neutral alignment tis/tendonitis/tendonosis (ill.B.9.11). of the foot. c. Fractures of foot and ankle. (1) Unimalleolar involves the medial or lateral e. Flexor hallucis tendonopathy. malleolus. (1) Identified as a tendonitis in the acute stage (2) Bimalleolar involves the medial and lateral or can present as a chronic tendonosis. malleoli. Commonly seen in ballet performers. (3) Trimalleolar involves the medial and later- (2) Medication . al malleoli, and the posterior tubercle of the (a) Acetaminophen for pain. distal tibia. (b) NSAIDS for pain and/or inflammation. (4) Diagnostic tests utilized: plain film imag- (c) Corticosteroid injection or by mouth. ing. (3) Physical therapy goals, outcomes, and (5) Medication . interventions. (a) Acetaminophen for pain. (a) Refer to intervention for general bursi- (b) NSAIDS for pain and/or inflammation. tis/tendonitis/tendonosis (ill.B.9.11). (6) Physical therapy goals, outcomes, and interventions. f. Pes cavus (hollow foot). (a) Phy ical therapy intervention empha- (1) Numerous etiologie to include genetic sizes return of function without pain. predisposition, neurologic disorders result- ing in muscle imbalances, and contracture of soft tissues. (2) Deformity observed includes an increa ed height of longitudinal arches, dropping of anterior arch, metatarsal heads are lower than hindfoot, plantar flexion and splaying

62 joints. Supination is observed at mid- tarsal joints. of forefoot, and claw toes. (4) Diagnosis made by clinical examination (3) Function is limited due to altered including thorough biomechanical lower quarter exam. arthrokinematics resulting in limited ability (5) Physical therapy goals, outcomes, and to absorb forces through foot. interventions. (4) Diagnosis made by clinical examination (a) Manipulation followed by casting or including thorough biomechanical lower splinting for postural condition. quarter exam. (b) Talipes equinovarus requires surgical (5) Physical therapy goals, outcomes, and intervention to correct deformity fol- interventions. lowed by casting or splinting. (a) Intervention includes patient education i. Equinus. (1) Etiology can include congenital bone emphasizing limitation of high impact deformity, neurological disorders such as sports (i.e., long distance running and cerebral palsy, contracture of gastrocne- ballet), use of proper footwear and fit- mius and/or soleus muscles, trauma, or ting for orthoses. inflammatory disea e. g. Pes planus (flat foot). (2) Deformity observed: plantar flexed foot. (I) Etiologies include genetic predisposition, (3) Compensation secondary to limited dorsi- muscle weakness, ligamentous laxity, flexion includes subtalar or midtarsal paralysis, excessive pronation, trauma or pronation. disease (e.g., rheumatoid arthritis). (4) Diagnosis made by clinical examination (2) Normal in infant and toddler feet. including thorough biomechanical lower (3) Deformity observed may include a reduc- quarter exam. tion in height of medial longitudinal arch. (5) Physical therapy goals, outcomes, and (4) Decreased ability of foot to provide a rigid interventions. lever for push off during gait as result of (a) Physical therapy intervention includes altered arthrokinematics. flexibility exercise of shortened struc- (5) Diagnosis made by clinical examination tures within foot, joint mobilization to including thorough biomechanical lower joint restrictions identified in examina- quarter exam. tion, strengthening to intrinsic and (6) Physical therapy goals, outcomes, and extrinsic foot muscles, and orthotic interventions. management. (a) Intervention emphasizes patient educa- J. Hallux valgus. tion, use of proper footwear and orthotic (1) Etiology is varied to include biomechanical fitting. malalignment (excessive pronation), liga- h. Talipes equinovarus (club foot). mentous laxity, heredity, weak muscles, (I) Two types: po tural and talipes equino- and footwear that is too tight. varus. (2) Deformity observed: a medial deviation of (2) Etiology. head of first metatarsal from midline of (a) Postural which results from intrauter- body, metatarsal and base of proximal first ine malposition. phalanx moves medially, distal phalanx (b) Talipes equinovarus which is an abnormal then moves laterally. development of the head and neck of the (3) Normal metatarsophalangeal angle is 8°_ talus as the result of heredity or neuromus- 20°. cular disorders e.g., myelomeningocele. (4) Diagnosis made by clinical examination (3) Deformity observed. including thorough biomechanical lower (a) Plantarflexed, adducted and inverted quarter exam. foot (postural). (5) Physical therapy goals, outcomes, and (b) Talipes equinovarus has three compo- nents: plantarflexion at talocrural joint, inver ion at subtalar, talocalcaneal, talonavicular and calcaneocuboid

interventions. Musculoskeletal Physical Therapy 63 (a) Early orthotic fitting and patient educa- (4) Diagnosis made by clinical examination tion. including thorough biomechanical lower (b) Later management requires surgery quarter exam. followed by flexibility exercises to (5) Physical therapy goals, outcomes, and re tore normal function, strengthening interventions. exercises and possible joint mobiliza- (a) Intervention includes trengthening, tion to identified restrictions. and regaining proper alignment of foot k. Metatarsalgia. (i.e., through use of orthoses). (I) Etiologies. (a) Mechanical: tight triceps surae group m. Charcot-Marie-Tooth and/or achilles tendon, collapse of (I) Peroneal muscular atrophy that affects transverse arch, short first ray, prona- motor and sensory nerves. tion of forefoot. (2) May begin in childhood or adulthood. (b) Structural changes in transverse arch (3) Initially affects muscles in lower leg and possibly leading to vascular and/or foot, but eventually progresses to muscles neural compromise in tissues of fore- of hands and forearm. foot. (4) Slowly progressive disorder that has vary- (c) Changes in footwear. ing degrees of involvement depending on (2) Complaint frequently heard is pain at first degree of genetic dominance. and second metatarsal heads after long (5) Diagnostic tests utilized: electrodiagnostic periods of weight bearing. tests. (3) Diagnosis made by clinical examination (6) Diagnosis made by clinical examination including thorough biomechanical lower including thorough biomechanical lower quarter exam. quarter exam. (4) Medications. (7) Medications. (a) Acetaminophen for pain. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (b) NSAIDS for pain and/or inflammation. (c) Neurontin for neuropathic pain. (c) Neurontin for neuropathic pain. (5) Phy ical therapy goals, outcomes, and (8) Physical therapy goals, outcomes, and interventions. interventions. (a) Intervention includes correction of bio- (a) No specific treatment to prevent since mechanical abnormality (improving it is an inherited disorder. flexibility of triceps surae), modalities (b) Physical therapy intervention centers to decrease pain. on preventing contracture /skin break- (b) Prescription and/or creation of down and maximizing patient' func- orthoses. tional capacity to perform activities. (c) Patient education regarding selection (c) Patient education and training regard- of footwear. ing braces and ambulatory assistive 1. Metatarsus adductus. devices. (1) Etiology: congenital, muscle imbalance, or neuromuscular diseases such as polio. n. Plantar fasciitis. (2) Two types: rigid and flexible. (1) Etiology usually mechanical. (3) Deformity observed. (a) Chronic irritation of plantar fascia (a) Rigid results in a medial subluxation of from excessive pronation. tarsometatarsal joints. Hindfoot is (b) Limited ROM of first MTP and slightly in valgus with navicular lateral talocrural joint to head of talus. (c) Tight triceps surae. (b) Flexible is observed as adduction of all (d) Acute injury from excessive loading of five metatarsals at the tarsometatarsal foot joints. (e) Rigid cavus foot. (2) Results in microtears at attachment of plan- tar fascia. (3) Diagnostic tests utilized: none.

64 (c) Due to increased mobility of hindfoot, fewer mu culoskeletal problems devel- (4) Diagnosis made by clinical examination op from this deformity than occurs including thorough biomechanical lower with rearfoot varus. quarter exam. Differentiated from tarsal tunnel syndrome by a negative Tinel sign. (d) Diagnosi made by clinical examina- tion including thorough biomechanical (5) Medications. lower quarter exam. (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. (e) Physical therapy goals, outcomes, and (c) Corticosteroid injection or by mouth. intervention . Regaining proper mechanical alignment (6) Physical therapy goals, outcomes, and • Improving flexibility of shortened interventions. soft tissues. (a) Physical therapy intervention includes • Orthotic fitting and patient educa- regaining proper mechanical alignment. tion regarding selection of footwear. (b) Modalities to reduce pain and inflam- mation. (3) Forefoot varus. (c) Flexibility of the plantar fascia for the (a) Etiology: congenital abnormal devia- pes cavus foot. tion of head and neck of talus. (d) Careful flexibility exercises for triceps (b) Deformity observed: inver ion of fore- surae. foot when subtalar joint is in neutral. (e) Joint mobilization to identified restric- (c) Diagnosis made by clinical examina- tions. tion including thorough biomechanical (f) Night splints. lower quarter exam. (g) Strengthening of invertors of foot. (d) Physical therapy goal, outcomes, and (h) Patient education regarding selection interventions. of footwear, and orthotic fitting. • Regaining proper mechanical align- ment. o. Forefoot/rearfoot deformities. • Improving flexibility of shortened (l) Rearfoot varus (subtalar varus, calcaneal soft tissues. varus). • Orthotic fitting and patient educa- (a) Etiology: abnormal mechanical align- tion regarding selection of footwear. ment of tibia, shortened rearfoot soft tissues, or malunion of calcaneus. (4) Forefoot valgus. (b) Deformity observed: rigid inversion of (a) Etiology: congenital abnormal devel- calcaneus when subtalar joint is in neu- opment of head and neck of talus. tral position. (b) Deformity observed: eversion of fore- (c) Diagnosis made by clinical examina- foot when the subtalar joint is in neutral. tion including thorough biomechanical (c) Diagnosis made by clinical examina- lower quarter exam. tion including thorough biomechanical (d) Physical therapy goals, outcomes, and lower quarter exam. interventions. (d) Physical therapy goals, outcomes, and • Regaining proper mechanical align- interventions. ment. • Regaining proper mechanical align- • Improving flexibility of shortened ment. soft tissues. • Improving flexibility of shortened • Orthotic fitting and patient educa- soft tissues. tion regarding selection of footwear. • Orthotic fitting and patient educa- (2) Rearfoot valgus. tion regarding selection of footwear. (a) Etiology: abnormal mechanical align- ment of the knee (genu valgum), or tib- E. Spinal Conditions ial valgus. 1. Muscle strain. (b) Deformity observed: eversion of calca- a. May be related to sudden trauma, chronic or neus with a neutral subtalar joint. sustained overload, or abnormal muscle biome-

chanics secondary to faulty function (abnormal Musculoskeletal Physical Therapy 65 joint or muscle biomechanics). b. Commonly will resolve without intervention, mobilization to the specific restrictions but if trauma is too great or if related to chron- identified during the examination. ic etiology will benefit from intervention. (2) Exerci e should focus on dynamic stabi- c. Diagnosis made by clinical examination by lization of trunk with particular emphasis comparing results of flexibility (AROM/ on abdominals and trunk extension with PROM), resistive tests, and palpation. multifidus muscle working from a fully d. Medications. flexed position of trunk up to neutral, but (I) Acetaminophen for pain. not into trunk extension. (2) NSAIDS for pain and/or inflammation. (3) Avoid extension and/or other positions that (3) Corticosteroid injection or by mouth. add stress to defect (i.e., extension, ipsilat- (4) Mu cle relaxants e.g., as Flexoril or vali- eral sidebending, and contralateral rota- tion). um. (4) Patient education regarding the elimination (5) Trigger point injections. of positions of extension and postural reed- e. Physical therapy goals, outcomes, and inter- ucation. ventions. (5) Braces such as Boston brace and TLSO (I) Biomechanical faults caused by JOint have traditionally been used, but frequency is decreasing. restrictions should be corrected with joint (6) Spinal manipulation may be contraindicat- mobilization. ed for this condition particularly at the level (2) Patient education regarding the elimination of of defect. harmful positions and postural reeducation. 3. Spinal or intervertebral stenosis. (3) Spinal manipulation for pain inhibition is a. Etiology: congenital narrow spinal canal or generally indicated for this condition. intervertebral foramen coupled with hypertro- 2. Spondylolysis/spondylolisthesis. phy of the spinal lamina and ligamentum a. Etiology: thought to be congenitally defective flavum or facets as the result of age-related par interarticularis. degenerative processes or disease. b. Spondylolysis is a fracture of the pars interar- b. Results in vascular and/or neural compromise. ticularis with positive \"scotty dog\" sign on c. Signs and symptoms (Table 1-8). oblique radiographic view of spine. (1) Bilateral pain and paresthesia in back, but- c. Spondylolisthesis is the actual anterior or pos- tocks, thighs, calves and feet. terior slippage of one vertebra on another fol- (2) Pain is decreased in spinal flexion, increased lowing bilateral fracture of pars interarticularis. in extension. d. Spondylolisthesis can be graded according to (3) Pain increases with walking. amount of slippage from I (25 % slippage) to 4 (4) Pain relieved with prolonged rest. (100% slippage). d. Diagnostic tests utilized: imaging including e. Diagnostic te ts utilized: plain film (oblique to plain films, MRI and/or CT scan. Occasionally see fracture and lateral views to see slippage). myelography is helpful. f. Clinical examination including stork test helps e. Clinical examination including bicycle (van to identify this condition. Gelderen) test helps to identify this condition and g. Medications. differentiate it from intermittent claudication. (I) Acetaminophen for pain. f. Medications. (2) NSAIDS for pain and/or inflammation. (1) Acetaminophen for pain. (3) Corticosteroid injection or by mouth. (2) NSAIDS for pain and/or inflammation. (4) Muscle relaxants. (3) Corticosteroid injection or by mouth. (5) Trigger point injections. (4) Muscle relaxants. h. Physical therapy goals, outcomes, and inter- (5) Trigger point injections. ventions. g. Physical therapy goals, outcomes, and inter- (1) Biomechanical faults caused by JOint ventions. restrictions should be corrected with joint (1) Biomechanical faults cau ed by joint

66 traindicated for this condition. (c) Patient education regarding proper restrictions should be corrected with joint mobilization to the specific restrictions body mechanic , position to avoid, identified during the examination. limiting repetitive bending and twist- (2) Perform flexion biased exercise and exer- ing movements, limiting upper extrem- cises that promotes dynamic stability ity overhead and sitting activities, and throughout the trunk and pelvis. carrying heavy loads. (3) Avoid extension and/or other positions that b. Posterolateral bulge/herniation. narrow the spinal canal or intervertebral (1) Most commonly observed disc disorder of foramen (i.e., exten ion, ipsilateral lumbar spine due to three structural defi- sidebending, and ipsilateral rotation). ciencies: (4) Manual and/or mechanical traction. (a) Posterior disc is narrower in height (a) Traction. than anterior disc. (b) Posterior longitudinal ligament is not Cervical spine pOSItIOning is at 15 as strong and only centrally located in degrees of flexion to provide the lumbar spine. optimum intervertebral foraminal (c) Posterior lamellae of annulus are thinner. opening. (2) Etiology: overstretching and/or tearing of • Contraindications include joint annular rings, vertebral endplate and/or lig- hypermobility, pregnancy, rheuma- amentous structures from high compressive toid arthriti , Down syndrome, or forces or repetitive microtrauma. any other systemic disease which (3) Results in loss of strength, radicular pain, affects ligamentous integrity. paresthesia and inability to perform activi- 4. Disc conditions. ties of daily living (Table 1-8). a. Internal disc disruption. (4) Diagnostic tests utilized: MR!. (1) Internal structure of disc annulus is disrupt- (5) Clinical examination helps to identify this ed, however, external structures remain condition. normal. Most common in lumbar region. (6) Medications. (2) Symptoms include constant deep achey (a) Acetaminophen for pain. pain, increased pain with movement, no (b) NSAIDS for pain and/or inflammation. objective neurologic findings although (c) Muscle relaxants. patient may have referred pain into lower (d) Trigger point injection. extremity. (e) Corticosteroid injection or by mouth. (3) Regular CT or myelogram will not demon- (7) Physical therapy goals, outcomes, and strate any abnormal findings. Can be diag- interventions. nosed by CT discogram or an MRI. (a) Exercise program to promote dynamic (4) Clinical examination helps to identify this stability throughout trunk and pelvis a condition. well as to provide optimal stimulus for (5) Medications. regeneration of disc. (a) Acetaminophen for pain. (b) Positional gapping for 10 minutes to (b) NSAIDS for pain and/or inflammation. increase space within region of space (c) Muscle relaxants. occupying lesion e.g., ifleft posterolat- (d) Trigger point injections. eral lumbar herniation present: (e) Corticosteroid injection or by mouth. • Have patient sidelying on right ide (6) Physical therapy goals, outcomes, and interventions. with pillow under right trunk (a) Biomechanical faults caused by joint (accentuating trunk side bending restrictions should be corrected with right). joint mobilization to the specific • Flex both hips and knees. re trictions identified during the exam- • Rotate trunk to left (or pelvi to ination. right). (b) Spinal manipulation may be con-

• Patient can be taught to perform this Musculoskeletal Physical Therapy 67 at home. above. (c) Spinal manipulation may be con- d. Anterior bulgelherniation is very rare due to traindicated for this condition, particu- larly at the level of the herniation. structural integrity of anterior intervertebral disc. (d) Patient education regarding proper 5. Facet joint conditions. body mechanics, positions to avoid, a. Degenerative joint disease (DID). limiting repetitive bending and twist- (1) Etiology: DID is part of normal aging ing movements, limiting upper extrem- ity overhead and sitting activities, and process because of weight bearing proper- carrying heavy loads. ties of facets and intervertebral joints. (2) Results in bone hypertrophy, capsular (e) Manual and/or mechanical traction. fibrosis, hyper or hypomobility of joint, • Traction: cervical spine positioning and proliferation of synovium. is at 15 degrees of flexion to provide (3) Symptoms include reduction in mobility of the optimum intervertebral forami- the spine, pain, and possible impingement nal opening. of associated nerve root resulting in loss of • Contraindications include joint strength and paresthesias (Table 1-8). hypermobility, pregnancy, rheuma- (4) Diagnostic tests utilized: plain film imaging. toid arthritis, Down syndrome, or (5) Clinical examination including lumbar any other systemic disease which quadrant test helps to identify this condition. affects ligamentous integrity. (6) Medications. • Efficacy of traction for intervention (a) Acetaminophen for pain. of disc conditions is currently under (b) NSAIDS for pain and/or inflammation. scrutiny. (c) Muscle relaxants. (d) Trigger point injection. c. Central posterior bulgelhemiation. (e) Corticosteroid injection or by mouth. (1) More commonly observed in the cervical (7) Physical therapy goals, outcomes, and pine but can be seen in the lumbar spine. interventions. (2) Etiology: overstretching and/or tearing of (a) Exercise program to promote dynamic annular rings, vertebral endplate and/or lig- amentous structures (posterior longitudinal tability throughout trunk and pelvis as ligament) from high compressive forces well as to provide optimal stimulus for and/or long term postural malalignment. regeneration of facet cartilage and/or (3) Re ults in loss of strength, radicular pain, capsule. paresthesia, inability to perform activities (b) Biomechanical faults caused by joint of daily living and possible compression of restrictions should be corrected with the spinal cord with central nervous system joint mobilization to the specific restric- symptoms e.g., hyperreflexia, and a posi- tions identified during the examination. tive Babinski reflex (Table 1-8). (c) Spinal manipulation may be useful for (4) Diagnostic tests utilized: MR!. this condition. (5) Clinical examination helps to identify this b. Facet extrapment (acute locked back). condition. (1) Caused by abnormal movement of fibro- (6) Medications. adipose meniscoid in facet during exten- (a) Acetaminophen for pain. sion (from flexion). Meni coid does not (b) NSAIDS for pain and/or inflammation. properly re-enter joint cavity and bunches (c) Muscle relaxants. up becoming a space occupying lesion, (d) Trigger point injections. which distends capsule, causing pain. (e) Corticosteroid injection or by mouth. (2) Flexion is most comfortable for patient and (7) Physical therapy goals, outcomes, and extension increases pain. interventions. (3) Clinical examination including lumbar • Refer to posterolateral intervention quadrant test helps to identify this condition. (4) Medications.

68 for this condition. (2) Correction of muscle imbalances and bio- (a) Acetaminophen for pain. (b) NSAIDS for pain and/or inflammation. mechanical faults using strengthening, (c) Muscle relaxants. endurance, coordination, and flexibility (d) Trigger point injections. exercises to gain restoration of normal (e) Corticosteroid injection or by mouth. function. (5) Physical therapy goals, outcomes, and (3) Biomechanical faults caused by joint interventions. restrictions should be corrected with joint (a) Positional facet joint gapping and/or mobilization to the specific restrictions identified during the examination. manipulation are appropriate treatments. (4) Progression to functional training based on 6. Acceleration/deceleration injuries of cervical patient' occupation and/or recreational goals. spine. (5) Patient education regarding the elimination of a. Formerly known as \"whiplash\". harmful positions and postural reeducation. b. Occurs when excess shear and tensile forces (6) Manual and/or mechanical traction. (a) Traction. are exerted on cervical structures. c. Structures injured may include facets/articular • Cervical spine positioning i at l5 degrees of flexion to provide the opti- processes, facet joint capsules, ligaments, disc, mum intervertebral foraminal opening. anterior/posterior muscles, fracture to odontoid process and spinous processes, TMJ, sympa- • Contraindication include joint thetic chain ganglia, spinal and cranial nerves. hypermobility, pregnancy, rheuma- d. Signs and symptoms. toid arthritis, Down Syndrome, or (1) Early include headaches, neck pain, limited any other systemic disea e which affects ligamentous integrity. flexibility, reversal of lower cervical lordosis and decrease in upper cervical kyphosis, 7. Hypermobile spinal segments. vertigo, change in vision and hearing, irri- a. an abnormal increase in ROM at a joint due to tability to noise and light, dysesthesias of insufficient soft tissue control (i.e., ligamen- face and bilateral upper extremities, nausea, tous, discal, mu cle, or a combination of all difficulty swallowing and emotional lability. three). (2) Late include chronic head and neck pain, b. Diagnostic tests utilized: plain film imaging, limitation in flexibility, TMJ dysfunction, particularly dynamic flexion/extension views. limited tolerance to ADL's, disequilibrium, c. Clinical examination helps to identify this anxiety, and depression. condition. e. Common clinical findings include postural d. Medications. changes, excessive muscle guarding with soft (1) Acetaminophen for pain. tissue fibrosis, segmental hypermobility, and (2) NSAIDS for pain and/or inflammation. gradual development of restricted segmental (3) Muscle relaxants. motion cranial and caudal to the injury (seg- (4) Trigger point injections. mental hypomobility). (5) Sclerosing injections. f. Diagnostic tests utilized: plain film imaging, (6) Corticosteroid injection or by mouth. CT, and/or MRI. e. Physical therapy goals, outcomes, and inter- g. Clinical examination helps to identify this con- ventions. dition. (1) Pain reduction modalities to reduce irri- h. Medications. tability of structures. (1) Acetaminophen for pain. (2) Passive ROM within a normal range of (2) NSAIDS for pain and/or inflammation. movement. (3) Muscle relaxants. (3) Passive stabilization with cor ets, splints, (4) Trigger point injections. casts, tape, and collars. (5) Corticosteroid injection or by mouth. (4) Increase strength/endurance/coordination i. Physical therapy goals, outcomes, and inter- ventions. (1) Spinal manipulation is generally indicated

especially in the multifidus, abdominals, Musculoskeletal Physical Therapy 69 extensor and gluteals which control posture. (5) Regain muscle balance. mobilization to the specific restrictions (6) Patient education regarding postural reedu- identified during the examination. cation, limiting excessive overloading, lim- (4) Patient education regarding the elimination of iting sustained activities, and limiting end harmful positions and postural reeducation. range postures. (5) Sacroiliac belts may be useful in some 8. Sacroiliac joint (SIJ) conditions. patients. a. Cau e and specific pathology is unknown. 9. Repetitive/cumulative trauma to back. Since this i a joint, it is assumed that it can a. Disorders of the nerves, soft tissues, and bones become inflamed, develop degenerative precipitated or aggravated by repeated exer- changes, develop abnormal movement pat- tions or movements of the back occurring most terns, etc. often in the workplace. b. Anatomically and functionally SIJ is closely b. Repetitive trauma disorders account for 48% of related to lumbar spine, so a thorough exami- all reported occupational diseases. nation of both regions is indicated if a patient c. Diagnosis is difficult with up to 85% of back presents with pain in either. pain nondiagnosed. c. Diagnostic tests utilized: plain film imaging d. Typically causes one of the conditions previ- and possibly MRI. Occasionally double blind ously listed above: muscle, disc, and/or joint injections may be used to assist in making the impairment. diagnosis (I st injection is provocative in nature e. Vocational factors which contribute to back and 2nd injection is analgesic. If increased pain include; physically heavy static work pos- \"same\" pain with 1st injection and decreased tures, lifting, frequent bending and twisting, pain following 2nd injection joint is deter- and repetitive work and vibration. mined to be pathologic). f. Chronic disability may be reduced by enroll- d. Clinical examination including the following ment in a work conditioning program which special tests will be useful to make diagnosis. includes patient education, aerobic exercises, (l) Gillet's test. general strengthening and functional stability (2) Ipsilateral anterior rotation test. exercises that promote endurance for work (3) Gaenslen's test. related activities. (4) Long sitting (supine to sit) test. g. Clinical examination helps to identify this (5) Goldthwait's test. condition. e. Medications. h. Intervention should be focused on prevention, (I) Acetaminophen for pain. consisting of education. If this phenomenon (2) NSAIDS for pain and/or inflammation. leads to a condition listed above, follow the spe- (3) Muscle relaxants. cific intervention associated with that condition. (4) Trigger point injections. 10. Other conditions affecting the spine (Figure 1-8). (5) Corticosteroid injection or by mouth. a. Bone tumors. f. Physical therapy goals, outcomes, and inter- (I) May be primary or metastatic. ventions. (a) Primary tumors include multiple (1) Spinal manipulation such as SIJ gapping is generally indicated for this condition to myeloma (which is most common pri- inhibit pain, reduce muscle guarding, and mary tumor of bone), Ewing's sarco- restore normal joint motion. ma, malignant lymphoma, chondrosar- (2) Correction of muscle imbalances through- coma, osteosarcoma, and chondromas. out pelvis using strengthening, endurance, (b) Metastatic bone cancer ha primary coordination, and flexibility exercises to sites in lung, prostate, breast, kidney, gain restoration of normal function. and thyroid. (3) Biomechanical faults caused by joint (c) Patient history should always include restrictions hould be corrected with joint questions about a prior episode of cancer. (d) Signs and symptoms include pain which is unvarying and progressive, is not relieved with rest or analgesics, and is

70 cervical dysfunction. c. Dysfunctions fall into three diagnostic categories. more pronounced at night (Table 1-8). (e) Diagnostic tests utilized: plain film (1) DJD such as OA or RA in the TMJ (refer to OA and RA for causes, characteristic find- imaging, CT, and/or MRI as well as ings, diagnostic methods, medical and laboratory tests. physical therapy intervention). b. Vi ceral tumors. (1) Esophageal cancer symptomatology may (2) Myofascial pain, is most common form of include pain radiating to the back, pain with temporomandibular dy function (TMD), swallowing, dysphagia and weight loss. which is discomfort or pain in muscles that (2) Pancreatic cancer symptomatology control jaw function as well as neck and includes a deep gnawing pain that may shoulder muscles. (refer to MPS for causes, radiate from the chest to the back. characteristic findings, diagnostic method , (3) Diagnostic tests utilized: plain film imaging, medical and physical therapy intervention). CT, and/or MRI as well as laboratory tests. c. Gastrointestinal conditions. (3) Internal derangement of joint, meaning a (1) Acute pancreatitis may manifest itself as dislocated jaw, displaced articular disc, or midepigastric pain which radiates through injury to condyle. to back. (a) Loss of functional mobility may result (2) Cholecystitis may present with abrupt severe from increased activity in mu cles of abdominal pain and right upper quadrant mastication as result of stres and anxiety. tenderness, nausea, vomiting, and fever. (b) Causes. (3) Diagnostic tests utilized: plain film imaging, • Trauma: leading to joint edema; CT, and/or MRI as well as laboratory tests. capsulitis; hypomobility/hypermo- . d. Cardiovascular and pulmonary conditions. bility; or abnormal function of liga- (1) Heart and lung disorders can refer pain to ments, capsule and/or muscles. chest, back, neck, jaw and upper extremity. • Congenital anatomic anomalies: (2) Abdominal aortic aneurysm (AAA) usually change in shape of palate. appears as nonspecific lumbar pain. • Abnormal function such as repeat- (3) Diagnostic tests utilized: plain film imaging, edly chewing ice/hard candy, para CT, and/or MRI as well as laboratory tests. normal breathing (mouth breather), (4) Will be identified as pain during examina- forward head posture. tion of abdominal region. (c) Diagnostic tests utilized: plain film e. Urologic and gynecologic conditions. imaging and/or MRI if necessary. (1) Kidney, bladder, ovary, and uterus disorders (d) Clinical examination helps to identify can refer pain to the trunk, pelvis, and thighs. this condition. (2) Diagnostic tests utilized: plain film imaging, (e) Medications. CT, and/or MRI as well as laboratory tests. • Acetaminophen for pain. f. (Figure 1-6). • NSAIDS for pain and/or inflammation. 11. Temporomandibular joint conditions. • Muscle relaxants. a. Common signs and symptoms include joint noise • Trigger point injections. (i.e., clicking, popping and/or crepitation), joint • Corticosteroid injection or by mouth. locking, limited flexibility of jaw, lateral devia- (f) Physical therapy goals, outcomes, and tion of mandible during depression or elevation of interventions. mandible, decreased strength/endurance of mus- • Postural reeducation regarding cles of mastication, tinnitus, headaches, forward regaining the normal anterior-poste- head posture, and pain with movement rior curves and left-right symmetry of mandible. of the spine. b. Cervical spine must be thoroughly examined • Modalities for reduction of pain and due to close biomechanical and functional rela- inflammation. tionships between TMJ and cervical region. • Biofeedback to minimize effects of Many patients with TMJ have a component of stress and/or anxiety.

Joint mobilization if restnctIOn in Musculoskeletal Physical Therapy 71 TMJ is pre ent. Primary glide is inferior, which gaps joint, stretches It is critical to normalize the cervical the capsule and allows relocation of spine posture prior to the patient anteriorly displaced disc. receiving any permanent dental pro- o Flexibility and muscle strengthening cedures and/or appliances. exercises (e.g., Rocobado's jaw F. Orthopaedic Surgical Repairs opening while maintaining the 1. Surgical repairs of upper extremity. tongue in contact with the palate, and a. Rotator cuff tears. isometric mandibular exercises). (1) Usually degenerative and occur over time o Patient education (e.g., foods to with impingement of supraspinatus tendon avoid, and maintaining proper pos- between greater tuberosity and acromion. tural alignment). (2) Signs and symptoms include: o Night splints may be prescribed by (a) Significant reduction of AROM into the dentist to maintain resting jaw abduction. position. (b) No reduction of PROM. o Educate patient regarding resting (c) Drop arm test is positive. position of tongue on hard palate. (d) Poor scapulothoracic and glenohumeral rhythm. (3) Diagnostic te ts utilized: arthrogram tradition- Left eye Upper molars Upper molars Right eye TIp of tongue Left lower molars Right lower molars Side of tongue Pharynx and larynx Right diaphragm Heart\" Heart (central portion) Central portion Central portion of Pleura Pleura of left diaphragm Liver right diaphragm Gallbladder and Diaphragmatic duodenum pericardium Heart Appendix Heart Left lung and pleura - Right kidney (C3-T12) anp renal peMs Bladder trigone Uterine cervix Pancreas Heart Bladder fundus Spleen Rectum and trigone region of bladder \"The pain of coronary insufficiency can involve any aspect of the anterior chest but is more common in the substemal region. Figure 1-8: Pain referred from viscera (From Rothstein, J et al:The Rehabilitation Specialist's Handbook, 2nd edition, FA Davis, Philadelphia PA, 1998, P 484-485, with permission)

72 providing collagen remodeling which preserves free tendon gliding. ally had been the \"gold standard\" test. MRI • Early intervention consists of wound may be done, but may not be as sensitive. management, edema control, and (4) Physical therapy goals, outcomes, and passive exercises. interventions. • Active extension exercises are initi- (a) Rehabilitation is initiated following a ated first followed by flexion. • Resi tive and functional exercises period of immobilization with surgical are introduced when full AROM is intervention. achieved. (b) Physical therapy intervention empha- (c) Proximal repairs are immobilized with sizes return of normal strength! the wrist and digital joints in extension endurance/coordination of muscles, for 4 weeks. joint mechanics, flexibility (AROMI (d) Physical therapy goals, outcomes, and PROM), and scapulothoracic and gleno- interventions. humeral rhythm with overhead function. Early A/PROM in flexion with b. Tendon injuries and repairs of the hand. metacarpophalangeal joint in exten- (1) Flexor tendon repairs. sion. At 6 weeks, full AROM is ini- (a) First 3-4 weeks, distal extremity is tiated into flexion and extension. immobilized with a protective splint 2. Surgical repairs of lower extremity. with wrist and digits flexed. Rubber a. Total hip replacement/arthroplasty (THR) band traction is applied to maintain (1) This information may vary depending on interphalangeal joints in 30 to 50 surgical procedure and/or MD prefer- degrees of passive flexion. ence/protocol. Must be familiar with post- (b) Physical therapy goals, outcomes, and operative protocol for each patient relative interventions. to procedure and/or MD. • Patient can perform resisted exten- (2) Cemented versus non-cemented. (a) Cemented hips can tolerate full weight sion and passive flexion within con- bearing irnmeiliately following surgery. straints of splint. AROM to toler- (b) Cement may crack with aging causing ance is initiated at 4 weeks. a loosening of prosthesis. Non-cement- • Goal is to manage all soft tissues ed technique is more stressful on bones through wound-healing phases by during the surgical procedure. providing collagen remodeling (c) Non-cemented procedures are typical- which preserves free tendon gliding. ly used with younger and/or more • Early intervention consists of wound active individuals. Cemented tech- management, edema control, and nique may be better for individuals pa sive exercises. with fragile bones or for those who • Active extension exercises are initi- will benefit from immediate ability to ated first followed by flexion. weight bear e.g., those with dementia • Resistive and functional exercises or significant debilitation. are introduced when full AROM is (3) Bed positioning with a wedge to prevent achieved. adduction. (2) Extensor tendon repairs. (4) Patient should avoid the po ition of hip (a) Distal repairs are immobilized such flexion greater than 90 degrees with adduc- that the distal interphalangeal joints are tion and internal rotation. Partial weight in neutral for 6 to 8 weeks. bearing to tolerance is initiated on the sec- (b) Physical therapy goals, outcomes, and ond post surgery day using crutches or a interventions. walker with typical urgical procedures. • AROM is initiated at 6 weeks with (5) Physical therapy goal , outcomes, and proximal interphalangeal joints in neutral. • Goal is to manage all soft tissues through wound-healing phases by

interventions. Musculoskeletal Physical Therapy 73 (a) Physical therapy intervention focus on fracture healing. Weight bearing 1-7 bed mobility, transitional movements, weeks is 25%; 50% by week 8; 75% by ambulation, and return to premorbid week 10; and 100% weight bearing activities of daily living. without an assistive device by week 12. b. Open reduction internal fixation (ORIP) fol- (e) Avoidance of forceful mobilization and lowing femoral fracture. PROM into flexion greater than 90 (1) Patient will typically be non-weight bearing degrees is important due to the for 1-2 weeks using crutches or a walker. mechanical restraints of the prosthesis. Thereafter, the patient will be partial-weight bearing as tolerated. (0 Biomechanical faults caused by joint (2) Physical therapy goals, outcomes, and interventions. restrictions should be corrected with (a) Physical therapy intervention focus on joint mobilization to the specific bed mobility, transitional movements, restrictions identified during the ambulation, and return to premorbid examination. activities of daily living. d. Ligamentous repairs of knee. c. Total knee replacements/arthroplasty (TKR). (1) Six phases of rehabilitation are followed (1) TKR surgery is typically performed as with ACL and PCL reconstructive surgery. a result of severe DJD of the knee joint (2) Anterior cruciate ligament reconstruction. which has led to pain and impaired (a) Immediately following surgery, a con- function. tinuous passive motion unit (CPM) is (2) Physical therapy goals, outcomes, and utilized with PROM from 0-70 degrees interventions. of flexion. (a) Goals of early rehabilitation (1-3 (b) Motion is increased to 0-120 degrees weeks) include muscle reeducation, by the sixth week. soft tissue mobilization, lymphedema (c) Reconstruction is usually protected reduction, initiation of PROM (e.g. a with a hinged brace set at 20 to 70 continuous passive motion [CPM] degrees of flexion initially. machine is used in the hospital follow- (d) Patient is non-weight bearing for ing surgery), AROM and reduction of approximately one week. postsurgical swelling. (e) Weight bearing progresses as tolerated (b) Goals of the second phase of rehabili- to full weight bearing. tation include regaining endurance, coordination, and strength of the mus- (0 Patient is weaned from brace between cles surrounding the knee. Also func- tional activities to include progressive the 2nd to 4th weeks. ambulation stair climbing and transi- (3) Posterior cruciate ligament reconstruction. tional training based on healing and the type of prosthesis used. (a) Generally similar to ACL repair except (c) Goals and outcomes of the last phase patient is often initially in hinged brace of rehabilitation include returning the at 0° during ambulation. patient to premorbid activities of daily living. Functional and endurance train- (4) Physical therapy goals, outcomes, and ing and proprioceptive exercises are interventions following ACL and PCL sur- introduced during this phase. gical repairs. (d) The weight bearing status of patients (a) Six phases of rehabilitation are as fol- with a cemented prosthesis is at the lows: (1) preoperative, (2) maximum level of the patient's tolerance. Patients protection, (3) controlled motion, (4) with cementless prostheses are pro- moderate protection, (5) minimum gressed according to the time frame for protection, and (6) return to activity. (b) Specific interventions. • Soft tissue/massage techniques to quadriceps and hamstring muscles to reduce muscle guarding. • Joint oscillations to inhibit joint pain and muscle guarding. • Correction of muscle imbalances

74 (c) Physical therapy goal, outcomes, and interventions. and biomechanical faults using • Soft tissue/massage techniques to strengthening, endurance, coordina- quadriceps and hamstring mu cles tion, and flexibility exercises to gain to reduce muscle guarding. restoration of normal function. • Joint 0 cillation to inhibit joint pain • Biomechanical faults caused by and muscle guarding. joint restrictions should be corrected • Correction of muscle imbalances with joint mobilization to the specif- and biomechanical faults using ic restrictions identified during the strengthening, endurance, coordina- examination. tion, and flexibility exercises to gain • Progression to functional training restoration of normal function. based on patient's occupation and/or • Biomechanical faults caused by recreational goals. joint restrictions should be corrected e. Lateral retinacular release. with joint mobilization to the specif- (1) Typically performed as a result of ic restrictions identified during the patellofemoral pain syndrome (PFPS). examination. Purpose of procedure is to restore normal • Progression to functional training tracking of the patella during contraction of based on patient's occupation and/or the quadriceps muscle. recreational goals. (2) Physical therapy goals, outcomes, and interventions. 3. Surgical repairs of spine. (a) Intervention should emphasize closed a. Rehabilitation varies according to the type of kinetic chain exercises to strengthen surgery performed. quadriceps muscles and regain dynam- b. A back protection program and early mobiliza- ic balance of all structures (contractile tion exercises should be initiated prior to surgery. and non-contractile) surrounding knee. c. Patients should avoid prolonged sitting, heavy (b) Normalize the flexibility of the ham- lifting, and long car trips for approximately strings, triceps surae, and ITB will help three months. restore mechanical alignment. d. Repetitive bending with twisting should always (c) Mobilization of patella is important to be avoided. maintain nutrition and decrease the e. With micro-di cectomies, rehabilitation time is likelihood of adhesions. decreased becau e the fibers of the annulus f. Meniscal arthroscopy. fibrosus are not damaged. (1) Partial meniscectomy. f. With laminectomy/discectomy, early move- (a) Partial-weight bearing as tolerated ment and activation of paraspinal musculature when full knee extension is obtained. (especially multifidus) is necessary. (b) Physical therapy goals, outcomes, and g. Multilevel vertebra fusion: interventions. (1) Typically requires 6 weeks of trunk immo- • Initial goals focus on edema/effu- bility with bracing. sion control. (2) Once brace is removed and movement is • AROM is urged post surgical day one. allowed, important to regain as much nor- mal/functional movement as possible while • Isotonic and isokinetic strengthen- restoring functional activation of muscles. ing by day three. (3) With combined anterior/posterior surgical approach, bracing is seldom used. • Jogging on the ball of the foot or h. With Harrington rod placement for idiopathic toes is recommended to decrease the scoliosis, rehabilitation goals focus on early loading of the knee joint. mobilization in bed and effective coughing. (1) The patient can begin ambulation between (2) Repairs. the 4th to 7th day post-op. (a) Patient will be non-weight bearing for 3 to 6 weeks. (b) Rehabilitation of the joint begins with- in 7 to 10 days of procedure.

(2) The patient should avoid heavy lifting and Musculoskeletal Physical Therapy 75 excessive twisting and bending. 2. Subacute phase. i. Physical therapy goals, outcomes, and inter- a. Avoidance of continued irritation and repetitive ventions following surgical interventions. trauma. (1) Soft tissue/massage techniques to paraspinal (I) Modify activities at home/work/recreational. muscles to reduce muscle guarding. (2) Modify use of equipment or type of equip- (2) Joint oscillations to inhibit joint pain and ment at home/work/recreational. mu cle guarding. (3) Correct biomechanical faults such as leg (3) Correction of muscle imbalances using length discrepancy, abnormal foot biome- strengthening, endurance, coordination, chanics, abnormal throwing motion, etc. and flexibility exercises to gain restoration b. Joint mobilization. of normal function. Make sure that multi- c. Continued therapeutic exercise including flexi- fidus function is restored. bility/endurance/coordination exerci e. (4) Must develop dynamic stabilization for d. Postural reeducation. muscles of trunk and pelvis during all func- e. Biomechanical education. tional activities. (5) Biomechanical faults caused by joint 3. Functional restoration phase. restrictions should be corrected with joint a. Maintain or return to optimum level of patient mobilization to the specific restrictions function. identified during the examination. b. Normalize flexibility of joints and related soft (6) Progression to functional training based on tissues. patient's occupation and/or recreational goals. c. Restore loading capacity of connective tissues to normal strength. IV. Interventions for Patients/Clients with d. Functional strengthening exercises. e. Functional stabilization of the involved Musculoskeletal Conditions joint/region. A. Interventions for Patients/Clients with Acute B. Interventions for Patients/Clients with a Chronic Conditions Condition 1. Acute pha e. l. Determine possible causative factors. a. Immobilization: with limited (1-2 days) bedrest. a. Abnormal remodeling of injured tissues. Use of braces, slings, corsets, cervical collars, b. Chronic low-grade inflammation due to repeti- assistive devices, and taping. tive stresses of tissues. b. Control inflammatory response (RICE). 2. Reduce stresses to tissues. (I) Physical agents: ice and electric stimulation. a. Identify/eliminate the magnitude of loading. (2) Compression and elevation to reduce and b. Identify/eliminate direction of forces. prevent effusion and swelling. c. Identify and eliminate any biomechanical bar- (3) NSAIDs. riers that are preventing healing e.g., a leg (4) Re t/relaxation to reduce pain. length discrepancy. (5) Soft tissue/massage techniques. d. Patient education regarding protection of joints c. Assisted movement of injured tissues. and associated soft tissues. d. Joint oscillations (grades I and II) for pain 3. Regain structural integrity. relief. a. Improving flexibility. e. Therapeutic exercise. b. Postural reeducation. (1) Do e of 40%-60% of I repetItIOn maxi- c. Increasing tissue's capacity to tolerate loading. mum (i.e. high repetition with low resist- d. Functional strengthening/endurance/coordina- ance) to stimulate regeneration of tissue tion exercises. and revascularization. 4. Resume optimal patient function and prevention of (2) Exercise should be non-traumatic meaning reoccurrence. no pain and/or increased edema as a result a. Patient education regarding causative factors in of the exercise. dysfunction. f. Educate patient/client on joint protection b. Work conditioning. strategies. C. Specific Interventions I. Soft tissue/myofascial techniques.

76 fibers. Other hand guides limb as patient a. These techniques aid in reduction of metabo- actively shortens muscle. Simul- lites from muscle, aid in reactivating a muscle taneously as muscle shortens gradu- which has not been functioning secondary to ally release tension of hand in con- guarding and ischemia, revascularization of tact with muscle. muscle, and decrease guarding in a muscle. I. Transverse friction massage. (1) Used to initiate an acute inflammatory b. Autonomic: stimulation of skin and superficial response for a tissue that is in metabolic fascia to facilitate a decrease in muscle tension. stasis such as a tendonosis. (2) Involved tendon is bri kly massaged in a c. Mechanical: movement of skin, fascia, and transverse fashion (perpendicular to the muscle causes histological and mechanical direction of the fibers. changes to occur in soft tissues to produce (3) Performed for 5-10 minutes and tends to be improved mobility and function. Examples very uncomfortable for the patient. include accupressure, and osteopathic mechan- J. Movement approaches require the patient to ical stretching techniques. actively participate in treatment. Examples include: d. Goals: decrease pain, edema, and muscle (I) Feldenkrais. spasm, increase metabolism and cutaneous (a) Facilitates development of normal temperature, stretch tight muscles and other movement patterns. soft tissues, improve circulation, strengthen (b) The practitioner uses skillful, support- weak muscles, and mobilize joint restrictions. ive, gentle hands to create a sense of safety, maintain supportive contact, e. Indications: patients with soft tissue and joint while introducing new movement pos- restriction that results in pain and limits ADLs. sibilities in small, easily available increments. f. Contraindications. (2) Muscle energy techniques. (I) Absolute: soft tissue breakdown, infection, (a) Include voluntary contraction in a pre- cellulitis, inflammation, and/or neoplasm. cisely controlled direction, at varying (2) Relative: hypermobility, and sensitivity. levels of intensity, against an applied counter force from the clinician. g. Traditional massage techniques such as (b) Purpose is to gain motion that is limit- effleurage and petrissage. ed by restrictions of the neuromuscular system. h. Functional massage. (c) Modification of PNF technique. (I) Three techniques used to assist in reactiva- (3) PNF hold-relax-contract technique. tion of a debilitated muscle and/or to (a) Antagonist of the shortened muscle is increase vascularity to a muscle. contracted to achieve reciprocal inhibi- (a) Soft tissue without motion. tion and increased range. • Traditional technique, however, (b) Refer to Chapter 2 (Neuromuscular hands do not slide over skin, instead Physical Therapy) for details. they stay in contact with skin while 2. Articulatory techniques. hands and skin move together over a. Joint oscillation. the muscle. (I) Inhibit pain and lor muscle guarding. • Direction of force is parallel to mus- (2) Lubricate joint surfaces. cle fibers and total stroke time (3) Provide nutrition to the joint structures. should be 5-7 seconds. (4) It is suggested by Maitland that grades ill (b) Soft tissue with passive pumping. and IV oscillations are beneficial to stretch • Place muscle in shortened position tight connective tissues. and with one hand place tension on (5) Grades of movement as described by muscle parallel to muscle fibers. • Other hand passively lengthens muscle and simultaneously gradual- ly release tension of hand in contact with muscle. (c) Soft tissue with active pumping. • Place muscle in lengthened position and with one hand place tension on muscle perpendicular to muscle

Maitland (Figure 1-9). Musculoskeletal Physical Therapy 77 (a) Five grades of joint play in neutral. Syndrome), arterial insufficiency, and • Grade I oscillations are small ampli- active inflammatory and/or infective tude at the beginning of the range of process. joint play. (b) Relative: arthrosis (DJD), metabolic bone disease (osteoporosis, Paget's dis- • Grade II oscillations are large ampli- ease, and tuberculosis), hypermobility, tude at the midrange of joint play. total joint replacement, pregnancy, spondylolisthesis, use of steroids, and • Grade III oscillations are large ampli- radicular symptoms. tude at the end range of joint play. b. Joint mobilization. (1) To stretch/lengthen/deform collagen to nor- • Grade IV oscillations are small malize arthrokinematic glide of joint struc- amplitude at the end range of joint tures. play. (2) Grades of translatoric glide as described by Kaltenborn (Figure 1-10). • Grade V is a manipulation of high (a) Grade I. velocity and low amplitude to the • \"Loosening\" translatoric glide. anatomical end point of a joint. • Movement is a very small amplitude Technically this is not an oscillation since it is a single movement rather traction force. than a repetitive movement. • Used to relieve pain and/or decom- (b) Indications for use of oscillation press a joint during joint glides per- grades per Maitland. formed within examination or inter- • Grades I and II used to improve joint vention. lubrication/nutrition as well as (b) Grade II. decrease pain and muscle guarding. • \"Tightening\" translatoric glide. • Grades III and IV used to stretch tight • Movement takes up slack in tissues muscles, capsules, and ligaments. surrounding joint. • Grade V u ed to regain normal joint • Used to alleviate pain, assess joint mechanics as well as decrease pain play, and/or reduce muscle guard- and muscle guarding. ing. (c) Grade III. (6) Contraindications. • \"Stretching\" translatoric glide. (a) Absolute: joint ankylosis, malignancy involving bone, diseases that affect the FIGURE 1-10 integrity of ligaments (RA, and Down MANUAL MOBILIZATION OF THE JOINTS FIGURE 1-9 - GRADES OF MOVEMENT .. ...-I..II III Grade 1 Grade\" Loosening Tightening .. IV .. v Slack Zone t Tight Zone End of Active End of Passive Limit of Joint Integrity Range Range RANGE OF JOINT PLAY Slack taken-up Figure 1.7 \"Grades of Movement\" (From Kaltenborn, F. Manual Mobilization of the Joints: Volume\" The Spine, 4 ed, OPTp, Minneapolis, MN, 2003 (Adapted from Grieve, GP. Mobilization of the Spine;A with permission) Primary Handbook of Clinical Method, ed 5, Churchill Livingstone, NY, 1991)

78 • More commonly performed by physical therapists. Movement stretches the tissues crossing joint. (c) Mid-range. • Used to assess end feel or to • Very gentle, short lever arm tech- increase movement (stretch tissue). niques. (3) Traction: manual, mechanical, and self or • Barrier is created in mid-range by autotraction. specific positioning of patient as (a) Vertebral bodies separating. well as creating tautness in sur- (b) Distraction and gliding of facet joints. rounding soft tissues. (c) Tensing of the ligamentous structures • More commonly performed by of the spinal segment. osteopathic practitioners. (d) Intervertebral foramen widening. (e) Spinal muscles stretching. (5) Contraindkations. (4) Contraindications. (a) Absolute: joint ankylosis, malignancy (a) Absolute: joint ankylosis, malignancy involving bone, diseases that affect the involving bone, diseases that affect the integrity of ligaments (RA, and Down integrity of ligaments (RA, and Down Syndrome), arterial insufficiency, and Syndrome), arterial insufficiency, and active inflammatory and/or infective active inflammatory and/or infective process. process. (b) Relative: arthrosis (DID), metabolic (b) Relative: arthrosis (DID), metabolic bone disease (osteoporosis, Paget's di - bone disease (osteoporosis, Paget's dis- ease, and tuberculosis), hypermobility, ease, and tuberculosis), hypermobility, total joint replacement, pregnancy, total joint replacement, pregnancy, spondylolisthesis, use of steroids, and spondylolisthesis, use of steroids, and radicular symptoms. radicular symptoms. c. Manipulation. 3. Neural tissue mobilization. (1) Inhibit pain and lor muscle guarding. a. Movement of neural structures to regain (2) Improve translatoric glide in ca es of joint normal mobility. dysfunction due to restriction. b. Tension tests for upper and lower extremities (3) Healthcare practitioners who commonly (i.e., dural stretch test). perform manipulative thrusts include phys- (1) Movement of soft tissues that may be ical therapists, osteopaths, chiropractors, restricting neural structures (e.g., cross fric- and medical doctors. tion massage for adhesions of the radial (4) Type of manipulations. nerve to the humerus at a fracture site). (a) Generalized. (2) Indications: used for patients who have • Fairly forceful long lever techniques some type of restriction in neural mobility that are intended to include as many anywhere along the course of the nerve. vertebral segments as possible. (3) Postural reeducation: to open up the inter- More commonly performed by chi- vertebral foramen, and decrease tension to ropractic practitioners. tissues. (b) Specific. (4) Contraindications: extreme pain and/or • Aimed at having an effect on either increase in abnormal neurological signs. a specific segment or only a few ver- tebral segments. 4. Therapeutic exercise for musculoskeletal conditions. • Uses minimal force with short lever a. Therapeutic exercise is indicated for the fol- arms. lowing reasons. • Often includes \"locking\" techniques (1) Decrease muscle guarding. based on biomechanics to ensure (2) Decrease pain. that a specific vertebral segment (3) Increa e vascularity of tissue. receives the manipulative thrust. (4) Promote regeneration and/or speed up recovery of connective ti sues such as car- tilage, tendons, ligament , capsule , inter-

vertebral discs, etc. Musculoskeletal Physical Therapy 79 (5) Mobilize restricted tissue to increase systems of the body as well thus improving flexibility. your state of health in many ways. (6) Increase endurance of muscle. E. Relevant Pharmacology (7) Increase coordination of muscle. 1. Nonsteroidal anti-inflammatory drugs (NSAIDs). (8) Increase strength of muscle. a. Most commonly prescribed medication for (9) Sensitize muscles to minimize joints going into pain relief for musculoskeletal dysfunction. b. Examples include: ibuprofen (Motrin), naprox- excessive range in cases of hypermobility. en odium (Aleve), salsalate (Disalcid), and (lO)Develop· dynamic stability and functional indomethacin (Indocin). c. Provide analgesic, anti-inflammatory, and movement patterns allowing for optimal antipyretic capabilities. function within the environment. d. Adverse side effects could include gastroin- b. Home exercise program for patients/clients testinal irritation, fluid retention, renal or liver with musculoskeletal conditions. problems, and prolonged bleeding. (1) Patient's home program will consist of e. Cox-2 inhibitors have decreased gastrointesti- exercises to reinforce clinical program. nal irritation, but rofecoxib (Vioxx) was with- (2) Necessary to perform enough repetitions to drawn for the market secondary to its relation- have the desired physiologic effect on ship with heart related conditions. Other Cox-2 appropriate tissues as well as develop coor- inhibitors such as Celebrex and Bextra are dination and endurance to promote dynamic being evaluated for their safety and possible stability within functional patterns. association with heart related conditions. c. Refer to Therapeutic Exercise Foundations 2. Muscle relaxants. chapter for more details. a. Commonly prescribed for skeletal muscle D. Manual Therapy Approaches in Rehabilitation spasm. 1. All approaches provide a philosophical basis, b. Examples include: cyclobenzaprine HCI subjective evaluation, objective examination, a (Flexeril), methocarbamol (Robaxin), and diagnosis and a plan of care. carisoprodol (Soma). 2. Approaches can be divided into two categories. c. Act on the central nervous system to reduce a. Physician generated. skeletal muscle tone by depressing the internun- (1) Mennell who believed the joint is the dys- cial neurons of the brain stem and spinal cord. functional unit. d. Adverse side effects could include drowsiness, (2) Osteopaths suggest any component of the lethargy, ataxia, and decreased alertness. omatic ystem is responsible for dysfunction. 3. Non-narcotic analgesics. (3) Cyriax who contends that dysfunction is a. Prescribed when NSAIDs are contraindicated. due to an interplay between contractile and b. Examples include: acetaminophen (Tylenol). noncontractile tissues. c. Act on the central nervous system to alter res- b. Physical therapist generated. ponse to pain, and have antipyretic capabilities. (I) McKenzie who feels that postural factors d. Adverse ide effects are negligible when taken precipitate discal dy function. Treatment in recommended doses. Excessive amounts of emphasizes the use of extension exercises. acetaminophen may lead to liver disease or (2) Maitland proposes that the subjective evalua- acute liver shutdown. tion should be integrated with objective meas- F. Psychosocial Considerations ures in determining the dysfunctional area. 1. Malingering (symptom magnification syndrome). (3) Kaltenborn believes that abnormal joint a. Defined as a behavioral response where dis- mobility and soft tissue changes account plays of symptoms control the life of the for dysfunction. patient, leading to functional disability. c. Chiropractic generated. b. There may be psychological advantages to (1) Focus is to restore normal joint function illness. through soft tissue and joint manipulation. (1) The patient may feel protected from the Chiropractors believe that restoration of nor- threatening world. mal biomechanical function affects other

80 (2) Uncertainty or fear about the future. (3) Social gain. (4) Reduces stressors. c. Therapist needs to recognize symptoms and respond to the patient. (1) Tests to evaluate malingering back pain may include the Hoover and Burn's Tests and Waddell's Signs. (a) Hoover Test involves the therapist's evaluation of the amount of pressure the patient's heels place on the thera- pist's hands when the patient is asked to raise one lower extremity while in a supine position. (b) Burn's Test requires the patient to kneel and bend over a chair to touch the floor. (c) Waddell's Signs evaluate tenderness, simulation tests, distraction tests, regional disturbances, and overreac- tion. Waddell's scores can be predictive of functional outcome. (2) Functional capacity evaluations are used to evaluate psycho ocial as well as physical components of disability. (3) Emphasize regaining functional outcomes, not pain reduction. 2. Secondary gain. a. Usually some type of financial gain for staying ill. (1) Workers compensation. (2) Larger settlement for injury claims. b. Frequently seen in clinics that manage industri- al injuries. c. May not want to return to work for various rea- sons associated with the work environment, e.g., stress, dislike coworkers, etc. The authors wish to acknowledge the contributions of Connie J. Seymour. PT, PhD. OCS to previous editions of this chapter.

CHAPTER 2 NEUROMUSCULAR PHYSICALTHERAPY Susan B. O'Sullivan I. Anatomy and Physiology of the Nervous sations from opposite side of body. (3) Temporal lobe. System (a) Primary auditory cortex: receives/ A. Brain processes auditory stimuli. I. Cerebral hemispheres (telencephalon). a. Convolution of gray matter composed of gyri (b) Associative auditory cortex: processes (cre t ) and sulci (fissures). auditory stimuli. (1) Lateral central fissure (Sylvian fissure) separates temporal lobe from frontal (c) Wernicke's area: language comprehen- and parietal lobes. (2) Longitudinal cerebral fissure separates SiOn. the two hemispheres. (3) Central sulcus separates frontal lobe (4) Occipital lobe. from the parietal lobe. (a) Primary visual cortex: receives/ b. Paired hemispheres, consisting of 6 lobes on processes visual stimuli. each side: frontal, parietal, temporal, occipital, (b) Visual association cortex: processes insular, limbic. visual stimuli. (I) Frontal lobe. (a) Precentral gyrus: primary motor cortex (5) Insula. for voluntary muscle activation. (a) Deep within lateral sulcus, associated (b) Prefrontal cortex: controls emotions, with visceral functions. judgments. (c) Broca' area: controls motor aspects of (6) Limbic system. speech. (a) Consists of the limbic lobe (cingulate, (2) Parietal lobe. parahippocampal, and subcallosal (a) Postcentral gyrus: primary sensory gyri), hippocampal formation, amyg- cortex for integration of sensation. daloid nucleus, hypothalamus, anterior (b) Receives fibers conveying touch, pro- nucleus of thalamu . prioceptive, pain and temperature sen- (b) Phylogenetically oldest part of the brain, concerned with instincts and emotions contributing to preservation of the individual. (c) Basic functions include feeding, aggres- sion, emotions, endocrine aspects of sexual response.

82 (3) Other nuclei: assist in integration of visceral and somatic functions. c. White matter: myelinated nerve fibers located centrally. b. Subthalamus: involved in control of several (1) Transverse (commissural) fibers: intercon- functional pathways for sensory, motor, and nect the two hemispheres, including the reticular function. corpus callosum (the largest), anterior com- missure, hippocampal commissure. c. Hypothalamus. (2) Projection fibers: connect cerebral hemi- (1) Integrates and controls the functions of the spheres with other portions of the brain and autonomic nervous system and the neu- spinal cord. roendocrine system. (3) Association fibers: connect different portions (2) Maintains body homeostasis: regulates of the cerebral hemispheres, allowing cortex body temperature, eating, water balance, to function as an integrated whole. anterior pituitary function/sexual behavior, and emotion. d. Basal ganglia. (1) Mas es of gray matter deep within the cere- d. Epithalamus. bral hemisphere , including the corpus (1) Habenular nuclei: integrate olfactory, vi - striatum (caudate nucleus and lenticular ceral and somatic afferent pathways. nuclei) amygdaloid nucleus, and claustrum. (2) Pineal gland: secretes hormones that influ- The lenticular nuclei is further subdivided ence the pituitary gland and several other into the putamen and globus pallidus. organs; influences circadian rhythm. (2) Forms an associated motor system (extrapyramidal system) with other nuclei 3. Brainstem. in the subthalamus and midbrain. a. Midbrain (mesencephalon). (3) Circuits of the basal ganglia (BG). (1) Connects pons to cerebrum; superior (a) Oculomotor circuit (caudate loop): orig- peduncle connects midbrain to cerebellum. inates in frontal and supplementary (2) Contains cerebral peduncles (two lateral motor eye fields; projects to caudate; halves), each divided into anterior part or functions with saccadic eye movements. basis (crus cerebri and substantia nigra) (b) Skeletomotor circuit (putamen loop): and a posterior part (tegmentum). originates in precentral motor and post- (3) Tegmentum contains all ascending tracts central somatosensory areas; projects to and some descending tracts; the red nucleus putamen; functions to scale amplitude receives fibers from the cerebellum, is the and velocity of movements; reinforces origin for the rubro pinal tract, important selected pattern, suppresses conflicting for coordination; contains cranial nerve patterns; preparatory for movement nuclei: oculomotor and trochlear. (i.e. motor set, anticipatory movement). (4) Substantia nigra is a large motor nucleus (c) Limbic circuit: originates in prefrontal connecting with the basal ganglia and cortex; and limbic areas of cortex; to BG; to it is important in motor control and muscle prefrontal cortex; functions to organize tone. behaviors (executive functions, prob- (5) Superior colliculus is an important relay lem solving, motivation) and for proce- station for vision and visual reflexes; the dural learning. inferior colliculus is an important relay sta- tion for hearing and auditory reflexes. 2. Diencephalon. (6) Periaqueductai gray contains endorphin-pro- a. Thalamus. ducing cells (important for the suppression (1) Sensory nuclei: integrate and relay sensory of pain) and descending autonomic tracts. information from body, face, retina, cochlea, b. Pons. and taste receptors to cerebral cortex and (1) Connects the medulla oblongata to the mid- subcortical regions; smell (olfaction) is the brain, allowing passage of important exception. ascending and descending tracts. (2) Motor nuclei: relay motor information from (2) Anterior basal part acts as bridge to cere- cerebellum and globus pallidus to precentral bellum (middle cerebellar peduncle). motor cortex. (3) Midline raphe nuclei project widely and are

important for modulating pain and control- Neuromuscular Physical Therapy 83 ling arousal. (4) Tegmentum contains several important cra- receives input from corticopontocerebellar nial nerve nuclei: abducens, trigeminal, tracts and olivocerebellar fibers; it is con- facial, vestibulocochlear. cerned with the smooth coordination of vol- c. Medulla oblongata. untary movements; ensures accurate force, (1) Connects spinal cord with pons. direction and extent of movement. Important (2) Contains relay nuclei of dorsal columns for motor learning, sequencing of move- (gracilis and cuneatus), fibers cross to give ments, and visually triggered movements. rise to medial lemniscus. May have a role in assisting cognitive func- (3) Inferior cerebellar peduncle relays dorsal tion, mental imagery. spinocerebellar tract to cerebellum. B. Spinal Cord (4) Corticospinal tracts cross (decussate) in 1. General structure. pyramids. a. Cylindrical mass of nerve tissue extending (5) Medial longitudinal fasciculus arises from from the foramen magnum in skull continuous vestibular nuclei and extends throughout with medulla to the lower border of first lum- brainstem and upper cervical spinal cord; bar vertebra in the conus medullaris. important for control of head movements and b. Divided into 30 segments: 8 cervical, 12 thoracic, gaze stabilization (vestibulo-ocular reflex). 5 lumbar, 5 sacral, a few coccygeal segments. (6) Olivary nuclear complex connects cerebel- 2. Central gray matter contains: 2 anterior (ventral) lum to brainstem and is important for vol- and 2 posterior (dorsal) horns united by gray com- untary movement control. missure with central canal. (7) Contains several important cranial nerve a. Anterior horns contain cell bodies that give rise nuclei: hypoglossal, dorsal nucleus of to efferent (motor) neurons: alpha motor neu- vagus, and vestibulocochlear. rons to effect muscles and gamma motor neu- (8) Contains important centers for vital functions: rons to muscle spindles. cardiac, respiratory, and vasomotor centers. b. Posterior horns contain afferent (sensory) neu- 4. Cerebellum. rons with cell bodies located in the dor al root a. Located behind dorsal pons and medulla in ganglia. po terior fossa. c. Two enlargements: cervical and lumbosacral for b. Structure. origins of nerves of upper and lower extremities. (1) Joined to brainstem by 3 pairs of pedun- d. Lateral hom is found in thoracic and upper cles: superior, middle, and inferior. lumbar segments for preganglionic fibers of the (2) Comprised of 2 hemispheres and midline autonomic nervous system. vermis; has cerebellar cortex, underlying 3. White matter: anterior (ventral), lateral, and poste- white matter, and 4 paired deep nuclei. rior (dorsal) white columns or funiculi. (3) Archicerebellum (flocculonodular lobe) a. Ascending fiber systems (sensory pathways). connects with vestibular system and is con- (1) Dorsal columns/medial lemniscal system: cerned with equilibrium and regulation of convey sensations of proprioception, vibra- muscle tone; helps coordinate vestibular- tion, and tactile discrimination; divided into ocular reflex. fasciculus cuneatus (upper extremity tracts, (4) Paleocerebellum (rostral cerebellum, ante- laterally located) and fasciculus gracilis rior lobe; also known as spinocerebellum) (lower extremity tracts, medially located); receives input from proprioceptive path- neurons ascend to medulla where fibers ways and is concerned with modifying cross (lemniscal decussation) to form medial muscle tone and synergistic actions of mus- lemniscus, ascend to thalamus and then to cles; it is important in maintenance of pos- somatosensory cortex. ture and voluntary movement control. (2) Spinothalamic tracts: convey sensations of (5) Neocerebellum (cerebellar hemisphere, pos- pain and temperature (lateral pinothalamic terior lobe; also know as pontocerebellum); tract), and crude touch (anterior spinothala- mic tract); tracts ascend 1 or 2 ipsilateral spinal cord segments (Lissauer's tract),

84 b. Divided into 2 divisions: sympathetic and parasympathetic; both have afferent and effer- synapse and cross in spinal cord to opposite ent nerve fibers; preganglionic and postgan- side and ascend in ventrolateral spinothala- glionic fibers. mic system. (1) Sympathetic (thoracolumbar) division: pre- (3) Spinocerebellar tracts: convey propriocep- pares body for fight or flight, emergency tion information from muscle spindles, responses; raises heart rate and blood pres- Golgi tendon organs, touch and pressure sure, constricts peripheral blood vessels receptors to cerebellum for control of vol- and redistributes blood; inhibits peristalsis. untary movements; dorsal spinocerebellar (2) Parasympathetic (craniosacral) division: tract ascends to ipsilateral inferior cerebel- conserves and restores homeostasis; slows lar peduncle while ventrospinocerebellar heart rate and reduces blood pressure, tract ascends to contralateral and ipsilateral increases peristalsis and glandular activity. superior cerebellar peduncle. (4) Spinoreticular tracts: convey deep and c. Autonomic plexuses: cardiac, pulmonary, celiac chronic pain to reticular formation of brain- (solar), hypogastric, pelvic. stem via diffuse, polysynaptic pathways. b. Descending fiber systems (motor pathways). d. Modulated by brain centers. (1) Corticospinal tracts: arise from primary (1) Descending autonomic system: arises from motor cortex, descend in brainstem, cross in control centers in hypothalamus and lower medulla (pyramidal decussation), via lateral brainstem (cardiac, respiratory, vasomotor) corticospinal tract to ventral gray matter and projects to preganglionic ANS seg- (anterior hom cells); 10% of fibers do not ments in thoracolumbar (sympathetic) and cross and travel in anterior corticospinal tract craniosacral (parasympathetic) segments. to cervical and upper thoracic segments; (2) Cranial nerves: visceral afferent sensations important for voluntary motor control. via glossopharyngeal and vagus nerves; (2) Vestibulospinal tracts: arise from vestibular efferent outflow via oculomotor, facial, nucleus and descend to spinal cord in later- glossopharyngeal and vagu nerves. al (uncrossed) and medial (both crossed and uncrossed) vestibulospinal tracts; C. CNS Support Structures important for control of muscle tone, anti- 1. Bony structure. gravity muscles and postural reflexes. a. Skull (cranium): rigid bony chamber that con- (3) Rubrospinal tracts: arise in contralateral red tains the brain and facial skeleton, with an nucleus and descend in Lateral white columns opening (foramen magnum) at its base. to spinal gray; assist in motor function. 2. Meninges: three membranes that envelop the brain. (4) Reticulospinal system: arises in the reticu- a. Dura mater: outer, tough, fibrous membrane lar formation of the brainstem and attached to inner surface of cranium; forms falx descends (both crossed and uncrossed) in and tentorium. both ventral and lateral columns, termi- b. Arachnoid: delicate, vascular membrane. nates both on dorsal gray (modifies trans- c. Subarachnoid space: formed by arachnoid and mission of sensation, especially pain) and pia mater, contains cerebrospinal fluid and cis- on ventral gray (influences gamma motor terns, major arteries. neurons and spinal reflexes). d. Pia mater: thin, vascular membrane that covers the (5) Tectospinal tract: arises from superior col- brain surface; forms tela choroidea of ventricles. liculus (midbrain) and descends to ventral 3. Ventricles: four cavities or ventricle that are filled gray; assists in head turning responses in with cerebrospinal fluid and communicate with response to visual stimuli. each other and with the spinal cord canal. 4. Autonomic Nervous System (ANS). a. Lateral ventricles: large, irregularly shaped a. Concerned with innervation of involuntary with anterior (frontal), posterior (occipital) and structures: smooth muscle, heart, glands; helps inferior (temporal) horns; communicates with maintain homeostasis (constant internal body third ventricle through foramen of Monro. environment). b. Third ventricle: located posterior and deep between the two thalami; cerebral aqueduct

communicates third with fourth ventricle. Neuromuscular Physical Therapy 85 c. Fourth ventricle: pyramid-shaped cavity locat- (3) Interneurons are short relay neurons. ed in pons and medulla; foramina (openings) of (4) Axon bundles are called tracts or fasciculi; Luschka and Magendie communicate fourth with subarachnoid space. in spinal cord, collections of tracts are 4. Cerebrospinal fluid: provides mechanical support called columns, or funiculi. (cushions brain), controls brain excitability by reg- c. Neuroglia: support cells that do not transmit ulating ionic composition, aids in exchange of signals; important for myelin and neuron pro- nutrients and waste products. duction; maintenance of K+ levels and re- a. Produced in choroid plexuses in ventricles. uptake of neurotransmitters following neural b. Normal pressure: 70-180 mmJH20. transmission at synapses. c. Total volume: 125-150 cc. 2. Function: neuronal signaling. 5. Blood-brain barrier: the selective restrIction of a. Resting membrane potential: pOSItive on out- blood borne substances from entering the CNS; side, negative on inside (about -70 mY). associated with capillary endothelial cells. b. Action potential: increased permeability of 6. Blood supply: brain is 2% of body weight with a Na+ and influx into cell with outflow of K+ circulation of 18% of total blood volume. results in polarity changes (inside to about a. Carotid system: internal carotid arteries arise +35mV) and depolarization; generation of an off of common carotids and branch to form action potential is all-or-none. anterior and middle cerebral arteries; supplies a c. Conduction velocity is proportional to axon large area of brain and many deep structures. diameter; the largest myelinated fibers conduct b. Vertebrobasilar system: vertebral arteries arise the fastest. off of subclavian arteries and unite to form the c. Repolarization results from activation of K+ basilar artery; this vessel bifurcates into two pos- channels. terior cerebral arteries; supplies the brainstem, d. Myelinated axons: many axons are covered cerebellum, occipital lobe and parts of thalamus. with myelin with small gaps (nodes of Ranvier) c. Circle of Willis: formed by anterior communi- where myelin is absent; the action potential cating artery connecting the two anterior cere- jumps from one node to the next, termed salta- bral arteries and the posterior communicating tory conduction; myelin functions to increase artery connecting each posterior and middle speed of conduction and conserve energy. cerebral artery. e. Nerve fiber types. d. Venous drainage: includes cerebral veins, dural (1) A fibers: large, myelinated, fast conducting. venous sinuses. (a) Alpha - proprioception, somatic motor. D. Neurons (b) Beta - touch, pressure. 1. Structure. (c) Gamma - motor to muscle spindles. a. Neurons vary in size and complexity. (d) Delta - pain, temperature, touch. (1) Cell bodies (genetic center) with dendrites (2) B Fibers: small, myelinated, conduct less rapidly; preganglionic autonomic. (receptive surface area to receive informa- (3) C fibers: smallest, unmyelinated, slowest tion via synapses). conducting. (2) Axons conduct impulses away from the (a) Dorsal root: pain, reflex responses. cell body (one-way conduction). (b) Sympathetic: post-ganglionic sympa- (3) Synapses allow communication between neu- rons; chemical neurotransmitters are released thetics. (chemical synapses) or electrical signals pass E. Peripheral Nervous System directly from cell to cell (electrical synapses). b. Neuron groupings and types. 1. Peripheral nerves are referred to as lower motor (1) Nuclei are compact groups of nerve cell neurons (LMN); functional components may vary. bodies; in the peripheral nervous system a. Motor (efferent) fibers originate from motor these groups are called ganglia. nuclei (cranial nerves) or anterior horn cells (2) Projection neurons carry impulses to other (spinal nerves). parts of the CNS. b. Sensory (afferent) fibers originate in cells out- side of brainstem or spinal cord with sensory ganglia (cranial nerves) or dorsal root ganglia (spinal nerves).

86 vertebral body, with C8 exiting below C7 and above Tl. c. Autonomic nervous system fibers: sympathetic (2) In the thoracic, lumbar, and sacral seg- fibers at thoracolumbar spinal segments and ments, the roots exit below the correspon- parasympathetic fibers at craniosacral seg- ding vertebral body. ments. (3) Spinal cord ends at the level of Ll; in the lumbosacral region, the nerve roots 2. Cranial nerves: 12 pairs of cranial nerves, all descend almost vertically below the cord to nerves are distributed to head and neck except form the cauda equina (horse's tail). C.N. X which is distributed to thorax and abdomen e. After emerging from the intervertebral fora- (Table 2-1). men, each spinal nerve divide into a large a. C.N. I, II, VIII are pure sensory, carry special anterior ramus (supplying the mu c1es and skin senses of smell, vision, hearing and equilibri- of the anterolateral body wall and limbs) and a um. small posterior ramus (supplying the muscles b. C.N. ill, IV, VI are pure motor, controlling eye and skin of the back); each ramus contains movements and pupillary constriction. motor and sensory fibers. c. C.N. XI, XII are pure motor, innervating stern- f. The anterior rami join at the root of the limbs ocleidomastoid, trapezius, and tongue. to form nerve plexuses. The cervical and d. C.N. V, VII, IX, X are mixed: motor and senso- brachial plexuses are at the root of the upper ry; involved in chewing (V), facial expression limbs; the lumbar and sacral plexuses are at the (VII), wallowing (IX, X), vocal sounds (X); root of the lower limbs. sensations from head (V, VII, IX), alimentary (1) The cervical plexus arises from Cl through tract, heart, vessels, and lungs (IX,X), and taste C4 nerve roots. The brachial plexus arises (VII, IX, X). from C5 through T I nerve roots that split e. C.N. ill, VII, IX, X carry parasympathetic into anterior and posterior divisions, redis- fibers of ANS; involved in control of smooth tributing fibers into 3 cords (lateral, po te- muscles of inner eye (III), salivatory and rior, medial) and finally into the peripheral lacrimal glands (VII), parotid gland (IX), mus- nerves that supply the upper extremity. cles of heart, lung, and bowel (X). (2) The lumbar plexus arises from TI2 through fA nerve roots. The sacral plexus arises 3. Spinal nerves: 31 pairs of spinal nerves; spinal from fA through S3 nerve roots. Nerve nerves are divided into groups ( 8 cervical, 12 tho- fibers from both are redistributed into the racic, 5 lumbar, 5 sacral, coccygeal) and corre- peripheral nerves that supply the lower spond to vertebral segments; each has a ventral extremity. root and a dorsal root. (3) Refer to Table 1-6A, l-6B, and l-6C for a. Ventral (anterior) root: efferent (motor) fibers to specific cord segments, nerves, and mus- voluntary muscles (alpha motoneurons, gamma cles innervated. motoneurons), and to viscera, glands and F. Spinal Level Reflexes: involuntary responses to stim- smooth muscles (preganglionic ANS fibers). uli; basic, specific and predictable; dependent upon b. Dorsal (posterior) root: afferent (sensory) intact neural pathway (reflex arc); reflexes may be fibers from sensory receptors from skin, joints, monosynaptic or polysynaptic (involving interneu- and muscles; each dorsal root possesses a dor- rons); provides basis for unconscious motor function sal root ganglion (cell bodies of sensory neu- and basic defense mechanisms. rons); there is no dorsal root for Cl. 1. Stretch (myotatic) reflexes. c. The term dermatome refers to a specific seg- a. Stimulus: muscle stretch. mental skin area innervated by sensory spinal b. Reflex arc: afferent Ia fiber from muscle spin- axons; the term myotome refers to the skeletal dle to alpha motoneuron projecting back to muscles innervated by motor axons in a given muscle of origin (monosynaptic). spinal root. A motor unit consists of the alpha c. Functions for maintenance of muscle tone, sup- motoneuron and the muscle fibers it innervates. port agonist muscle contraction, and to provide d. Nerve roots exit from the vertebral column through the intervertebral foramina. (1) In the cervical spine numbered roots exit horizontally above the corresponding

Neuromuscular Physical Therapy 87 TABLE 2-1 - EXAMINATION OF CRANIAL NERVE INTEGRITY NERVE FUNCTION TEST POSSIBLE ABNORMAL FINDINGS I O~actory Smell Test sense of smell on each side: use common, non- Anosmia (inability to detect smells), seen with frontal lobe lesions II Optic Vision irritating odors; close off other nostril Blindness, myopia (impaired far vision); presbyopia (impaired near vision) II, III Optic and Pupillary reflexes Test visual acuity OCulomotor Extraocular movements central: Snellen eye chart; test each eye separately Visual field defects: (homonymous hemianopsia) III,IV, VI Oculomotor, by covering other eye; test at distance of 20 feet Trochlear, and Absence of pupillary constriction Abducens Visual fields: test peripheral vision by confrontation Anisocoria (unequal pupils); Homer's syndrome, CN III paralysis VTrigeminal Strabismus (eye deviates from normal conjugate position) Test pupillary reactions (constriction) by shining Impaired eye movements VII Facial light in eye; if abnormal, test near reaction VIII Vestibulocochlear Strabismus: eye pulled outward by CN 6; eye cannot look upward, (Acoustic) Examine pupillary size/shape downward, inward movements May see ptosis, pupillary dilation IX XGlossopharyngeal Test extraocular movements in each of six directions Eye cannot look down when eye is adducted and Vagus CN III: turns eye up, Observe position of eye Esotropia (eye pulled inward) down, in Eye cannot look out Elevates eyelid Test pursuit eye movement Loss of facial sensations, numbness with CN V lesion CN IV: turns adducted eye Test pursuit eye movement down Loss of corneal reflex ipsilaterally (blinking in response to corneal touch CN VI: turns eye out Observe position of eye Weakness, wasting of muscles of mastication Test pursuit eye movement Deviation of jaw when opened to ipsilateral side Sensory: face Test pain, light touch sensations: forehead, cheeks, Paralysis ipsilateral facial muscles: inability to close eye, Droop in comer of jaw (eyes closed) mouth, Difficulty with speech articulation; PNI CN? Bell's palsy; CNS facial Sensory: cornea Test corneal reflex: touch lightly with wisp of cotton paralysis stroke Motor: temporal and Palpate muscles; have patient clench teeth, hold Vertigo, dysequilibrium masseter muscles against resistance Gaze instability with head rotations Nystagmus (constant,involuntary cyclical movement of the eyeball) Facial expression Test motor function facial muscles: Raise eyebrows, Deafness, impaired hearing, tinn~us Vestibular function Frown, Show teeth, Smile Close eyes tightly Unilateral conductive loss: sound lateralized to impaired ear Cochlear function Puff out both cheeks Sensorineural loss: sound heard in good ear Phonation Test balance: vestibulospinal function Conductive loss: sound heard through bone = to or longer than air Swallowing Test eye-head coordination: vestibular ocular reflex Sensorineural loss: sound heard longer through air (VOR) Dysphonia: hoarseness denotes vocal cord paralysis; nasal quality denotes palatal weakness Test aUd~ory acuity Dysphagia Test for lateralization (Weber test): place vibrating tuning fork on top of head, mid-position; check if sound heard in one ear, or equally in both Compare air and bone conduction (Rinne test): place vibrating tuning fork on mastoid bone, then close to ear canal; sound heard longer through air than bone Usten to voice quality Examine for difficulty in swallowing XI Spinal Accessory Palatal, pharynx control Have patient say \"ah\"; observe motion of soft palate Paralysis: palate fails to elevate (lesion of CN Xl; (elevates) and position of uvula (remains midline) Gag reflex Asymmetrical elevation: unilateral paralysis Muscle function Stimulate back of throat lightly on each side Absent reflex: lesion of CN IX; possibly CN X Examine bulk, strength Atrophy, fasciculations, weakness (PNI): Trapezius muscle Inability to shrug ipsilateral shoulder; shoulder droops Sternocleidomastoid Shrug both shoulders upward against resistance Inability to tum head to oppos~e side Tum head to each side against resistance XII Hypoglossal Tongue movements Usten to patient's articulation Dysarthria (lesions of CN Xor CN XII) Examine resting pos~ion of tongue Atrophy or fasciculations of tongue Examine tongue movements (move side-to-side, Impaired movements, deviation to weak side on protrusion protrude)

88 II. Neurological Examination: History, Systems feedback about muscle length. Review, Tests and Measures d. Clinically, sensitivity of the stretch reflex and A. Patient Interview intactness of spinal cord segment are tested by applying stretch to the deep tendons (DTR). 1. Presenting symptoms: onset, progre ion, nature e. Reciprocal inhibition: via an inhibitory interneuron the same stretch stimulus inhibits of symptoms, insight into one' medical condition. the antagonist muscle. f. Reciprocal innervation: describes the responses a 2. Past medical history: other diagnoses, surgeries, stretch stimulus can have on agonist (autogenic facilitation), antagonist (reciprocal inhibition) as health factors. well as on synergistic muscles (facilitation). 2. Inverse stretch (myotatic) reflex. 3. Social hi tory: current living ituation, a. Stimulus: muscle contraction. b. Reflex arc: afferent Ib fiber from Golgi tendon family/social support, education level, employ- organ via inhibitory interneuron to muscle of origin (polysynaptic). ment, lifestyle, risk factors. c. Functions to provide agonist inhibition, diminution of force of agonist contraction, B. Examine Level of Consciousness stretch-protection reflex. 3. Gamma reflex loop. 1. Determine orientation to person, place, time (ori- a. Stretch reflex forms part of this loop. b. Allows muscle tension to come under control ented x 3). of descending pathways (reticulospinal, ve tibulospinal and others). 2. Determine response to stimuli. c. Descending pathways excite gamma motor neuron , causing contraction of muscle spin- a. Purposeful, nonpurposeful, no response. dle, and in turn increased stretch sensitivity and increased rate of firing from spindle afferents; b. Verbal, tactile, simple commands. impulses are then conveyed to alpha motor neurons. c. Painful stimuli: pinch, pinprick. 4. Flexor (withdrawal) reflex. a. Stimulus: cutaneous sensory stimuli. 3. Determine behavior: determine level of confusion b. Reflex arc: cutaneous receptors via interneu- rons to largely flexor muscles; multi-segmental delirium, stupor, coma. ' response involving groups of muscles (polysy- naptic). 4. Glasgow Coma Scale (GCS). c. Functions as a protective, withdrawal mecha- nism to remove body part from harmful stimuli. a. Relates consciousne s to three elements of 5. Crossed exten ion reflex. a. Stimulus: noxious stimuli and reciprocal action re ponse: eye opening, motor re ponse, and of antagonists; flexors of one side are excited causing extensors on same side to be inhibited; verbal response. opposite responses occur in opposite limb. b. Reflex arc: cutaneous and muscle receptors b. Scoring range from 3 to 15: severe brain injury diverging to many spinal cord motoneurons on same and opposite side (polysynaptic). (scores of 8 or less); moderate brain injury c. Function: coordinates reciprocallirnb activities such as gait. (scores 9-12); minor brain injury (scores 13-15). c. Coma: a state defined by no eye opening even to pain, failure to obey commands, and inabili- ty to speak with recognizable words. d. Unresponsive vigilance (vegetative) state: a state characterized by the return of sleep/wake cycles, normalization of vegetative functions (respiration, HR, BP, digestion), and lack of cognitive responsiveness (can be aroused but is unaware). C. Examine Cognitive Function 1. Memory. a. Immediate recall: name 3 items previously pre- sented after a brief interval, i.e., 5 minutes. b. Recent memory (short-term): recall of recent events i.e., What did you have for breakfast? c. Remote memory (long-term): recall of past events, i.e., Where were you born?, Where did you grow up? 2. Attention. a. Length of attention span: i.e., digit span reten- tion test, recall of up to 7 number in order pre- sented. b. Ability to attend to ta k without redirection

(sustained attention); determine time on task, Neuromuscular Physical Therapy 89 frequency of redirection. c. Ability to shift attention from one task to D. Examine Speech and Communication another (divided attention); assess ability of 1. Expressive function: assess fluency of speech, dual ta k control; assess also for perseveration speech production. (mental inertia): getting stuck on a task. a. Non-fluent aphasia (Broca's, motor aphasia, d. Ability to stay on task in presence of detractors expressive aphasia). (focused attention); assess impact of environ- (1) A central language disorder in which speech mental vs. internal detractors. is typically awkward, restricted, interrupt- e. Ability to follow commands: 1 or 2 step, multi- ed, and produced with effort. level commands. (2) The result of a lesion involving the third 3. Emotional responseslbehaviors. frontal convolution of the left hemisphere a. Safety, judgment: impulsivity and lack of inhi- (Broca's area). bition. b. Verbal apraxia: impairment of volitional artic- b. Affect, mood: irritability, agitation, depression ulatory control secondary to a cortical, domi- and withdrawal. nant hemisphere lesion. c. Frustration tolerance. c. Dysarthria: impairment of speech production, d. Self-centeredness (egocentricity). in the CNSIPNS mechanisms that control res- e. Insight into disability. piration, articulation, phonation and move- f. Ability to follow rules of social conduct. ments of jaw and tongue. g. Ability to tolerate criticism. 2. Receptive function: assess comprehension. 4. Higher level cognitive abilities. a. Fluent aphasia (Wernicke's aphasia, receptive a. Judgment, problem solving. aphasia). b. Abstract reasoning. (1) A central language disorder in which spon- c. Fund of general knowledge: current events, taneous speech is preserved and flows ability to learn new information, generalize smoothly while auditory comprehension is learning to new situations. impaired. d. Calculation: erial 7 test (count backward from b. The result of a lesion in the posterior first tem- 100 by 7). poral gyrus of the left hemisphere (Wernicke's e. Sequencing: ability to order components of area). cognitive or functional task; assess if cueing is 3. Global dysfunction (global aphasia): a severe necessary, frequency of cues. aphasia characterized by marked impairments in 5. Screening tool: the Mini-Mental Status Exam. both comprehension and production of language. a. Includes screening items for orientation, regis- 4. Determine effectiveness of non-verbal communi- tration, attention and calculation, recall, and cation. language. a. Ability to read, write. b. Maximum score is 30; scores between 21 to 24 b.Use of gestures, symbols, pictographs. indicate mild cognitive impairment, scores between 16 to 20 reflect moderate impairment, E. Examine Cranial Nerves and scores 15 and below indicate severe (Table 2-1). impairment. 6. Cognitive scale: Rancho Levels of Cognitive 1. C.N.! Olfactory: sense of smell. Function (LOCF). 2. C.N.II Optic: visual acuity. a. A ses e cognitive recovery from traumatic 3. C.N. III, IV, VI (Oculomotor, Trochlear, brain injury. b. Includes eight levels of behavior ranging from: Abducens). no response (I) to decreased response levels (II a. Examine for ptosis: drooping of the upper eyelid. & ill), confused levels (IV, V, VI), appropriate b. Test pursuit eye movements/note any devia- - automatic, purposeful levels (VII, Vill). c. Delineates emerging behaviors; patients may tion, asymmetries. plateau at any level. c. Test for accommodation, pupillary light reflex. 4. C.N. V Trigeminal. a. Test motor function: have patient clench jaw, hold against resistance. b. Test corneal reflex: touch cornea with cotton wisp; if absent or diminished indicates danger of corneal injuries.

90 blood pressure (SBP), 90mmHg diastolic blood pressure (DBP). c. Test sensory function of forehead, cheeks, c. Note changes in response to activity: normally dun. HR rises in direct proportion to intensity of exercise; SBP rises while DBP remains the 5. C.N. VII Facial. same or falls moderately (a widening of pulse a. Test motor function of muscles of facial pressure). expression: have patient wrinkle forehead, d. With increasing intracranial pressures, changes show teeth, close eyes tightly, puff cheeks. in both HR and BP occur late. b. Determine sense of taste: have patient identify 2. Determine respiratory rate (RR), depth, rhythm, sugar, salt or vinegar placed on front of tongue. and characteristics of the inspiratory and expirato- ry phases. 6. C.N. vm Vestibulocochlear. a. Cheyne-Stokes respiration: a period of apnea lasting 10-60 seconds followed by gradually a. Cochlear division. increasing depth and frequency of respirations; (1) Test auditory acuity. accompanies depression of frontal lobe and (2) Weber test (lateralization): strike tuning diencephalic dysfunction. fork and place handle on middle of fore- b. Hyperventilation: increased rate and depth of head; check for hearing perceived in mid- respirations; accompanies dysfunction of lower dle of head or in one ear only. midbrain and pons. (3) Rinne test (air versus bone conduction): c. Apneustic breathing: abnormal respiration strike tuning fork and place on mastoid marked by prolonged inspiration; accompanies process, then place near external ear canal; damage to upper pons. check hearing acuity. 3. Determine temperature: elevation may indicate infection, damage to hypothalamus or brainstem. b. Vestibular division. G. Examine for CNS Infection or Meningeal (1) Test balance, postural responses. Irritation (2) Test eye-head coordination and orientation; I. Signs are global not focal. Vestibular ocular reflex (VOR): check for 2. Nuchal rigidity: limitation and guarding of head gaze stability with head movements, degra- flexion resulting from spasm of posterior neck dation of visual acuity with head and body muscles. movements, smooth eye pursuit when a. Kernig's sign: in supine, flex thigh and knee tracking, nystagmus (constant, involuntary, fully to chest, then extend knee; causes spasm cyclical movements of the eye). of hamstring, resistance, and pain. b. Brudzinski's sign: in supine, flex head to chest 7. C.N. IX Glossopharyngeal: test sense of taste on causes flexion of both legs (drawing up). posterior 113 of tongue. 3. Irritability: photophobia, disorientation, restlessness. 4. Slowed mental function; persistent headache, 8. C.N. X Vagus (motor). increased in head down position; may progress to a. Determine phonation, articulation: have patient delirium, lethargy and coma. open mouth and say \"ah\"; observe movements 5. Altered vital signs: increased HR and RR, fever; of soft palate. fluctuating BP. b. Determine swallowing: examine ability to 6. Generalized weakness. effectively chew and coordinate tongue move- H. Examine for Increased Intracranial Pressure ments to propel bolus down esophagus. Secondary to Cerebral Edema and Brain c. Test gag reflex; disruption indicates danger of Herniation aspiration. 1. Altered level of consciousness: progressing from restlessness, confusion to decreasing level of con- 9. C.N. XI Spinal accessory: examine strength, size, sciousness, unresponsiveness and coma. tone of trapezius and sternocleidomastoid muscles. 2. Altered vital signs: increased BP; widening pulse pressure and slowing of pulse; irregular respira- 10. C.N. XII Hypoglossal: examine motor function of tongue: have patient protrude tongue, note direc- tion, any deviation of movement; examine strength of tongue movements. F. Examine Vital Signs 1. Determine heart rate (HR), blood pressure (BP). a. Note any irregularities in heart rhythm: bound- ing, thready (fine, barely perceptible). b. Note fall or excess rise in BP: hypertension- equal to or greater than 140mmHg systolic

tions including periods of apnea, Cheyne-Stokes Neuromuscular Physical Therapy 91 respirations; elevated temperature. 3. Headache. c. Apply stimulus in random, unpredictable 4. Vomiting: secondary to irritation of vagal nuclei, order; avoid summation. C.N.X. 5. Pupillary changes (C.N.ill signs): ipsilateral dila- d. To assess responses, always pose a choice (e.g., tion of pupil (unequal pupils), slowed reaction to hot or cold). light progressing to fixed, dilated pupils (a poor prognostic sign). e. Check for objective manifestations: withdraw- 6. Papilledema: edema of optic nerve, C.N. II, at al, wincing, blinking. entrance to eye. 7. Progressive impairment of motor function: weak- f. Consider skin condition (calluses, scars) for ness, hemiplegia, positive Babinski, decorticate or areas of desensitivity. decerebrate rigidity (see section on exarnination of muscle tone). g. Look for signs of repetitive trauma, skin lesions. 8. Seizure activity. 5. Test superficial sensations. I. Examine Autonomic Nervous System Function 1. Effect of sympathetic stimulation. a. Pain: test sharp/dull sensation in response to a. Overall: fight or flight, arousal reaction. sharp/dull stimuli with disposable safety pin or b. Increased HR, force of contraction. paper clip. c. Increased BP, RR. d. Dilated pupils. b. Temperature: test hot/cold sensation in e. Hyperalertness. response to hot/cold stimuli with test tubes f. Constriction of systernic arterioles: skin, filled with hot or cold water. abdominal. c. Touch: test touch/nontouch in response to g. Decreased peristalsis and tone. slight touch stimulus (cotton ball) or no touch. h. Sweating. 2. Effect of parasympathetic stimulation. 6. Test proprioceptive (deep) sensations. a. Overall: restoration of homeostasis, system a. Joint position sense: test ability to perceive joint position at rest in response to your positioning balance. the patient's limb (up or down, in or out). b. Slowed HR, decreased force of contraction. b. Movement sense (kinesthesia): test ability to c. Decreased BP, slower RR. perceive movement in response to your moving d. Constriction of pupils. the patient's limb; patient can duplicate move- e. Increased peristalsis. ment with opposite limb or give a verbal report. f. Dilation of systemic arterioles. c. Vibration sense (pallesthe ia): test propriocep- tive pathways by applying vibrating tuning fork J. Examine Sensory Function or pressure only (sham vibration) on bony areas. 1. Subjective: ask patient to describe (map out areas) 7. Test combined (cortical) sen ations: discrimina- where ensation does not feel normal; provide sen- tive sensory tests; use a sample of 2 or 3 from this sory clues. group. a. Stereognosis: test ability to identify familiar 2. Capitalize on topographical organization, use sen- objects by manipulation and touch. sory dermatome chart. b. Tactile localization: test ability to identify the location of a touch stimulus on the body by 3. Document key ensory systems: test superficial verbal report or pointing. and proprioceptive sensations first, then combined c. Two-point discrimination: test ability to recog- (cortical) sensations. nize 1 or 2 blunt points applied to the skin simultaneously; determine minimal distance on 4. Testing considerations. skin two points can still be distinguished, in a. Ensure patient comprehends instructions and millimeters. can communicate responses. d. Bilateral simultaneous stimulation: test ability b. Occlude vision: consider barrier method (use a to identify simultaneous touch on the two sides piece of paper to block vision) versus blind- of the body. folding the patient. e. Barognosis: test ability to identify different gra- dations of weight in similar size/shape objects. f. Graphesthesia: test ability to identify numbers. letters or symbols traced on skin. g. Recognition of texture: te t ability to identify

92 different sized objects, e.g., large block from group of blocks. different textures (e.g., cotton, wool, silk) c. Spatial relations: have patient duplicate a pat- rubbed on skin. tern, 2 or 3 blocks. 8. Evaluation and documentation. d. Position in space: have patient demonstrate dif- a. Determine if the patient can readily distinguish ferent limb position , e.g., put your arm over- one sensation from another. head, put your foot underneath the chair. b. Determine the sensory threshold, the lightest e. Topographical disorientation: check to see if stimulu perceived. patient can navigate a familiar route on own, c. Determine the degree and location of deficits e.g., travel from room to P.T. clinic. (dermatome mapping). f. Depth and di tance imperception: check to see d. Determine the patient's subjective feelings, if patient can judge depth and di tance, e.g., level of awareness of sensory losses. navigate stairs, sit down into chair accurately. e. Determine functional impact of sensory losses. g. Vertical disorientation: check to see if patient K. Examine Perceptual Function can accurately determine what is upright, e.g., 1. Suspect perceptual dysfunction if patient has diffi- hold a cane, ask patient when it is vertical; ask culty with functional mobility skills or activities of patient to determine if own body is vertical. daily living for reasons that cannot be accounted 5. Examine for agnosia. for by specific sensory, motor or comprehension a. Check for the inability to recognize familiar deficits. objects with one sensory modality, while a. Rule out specific sensory and motor loss, lan- retaining the ability to recognize the same guage impairment, hearing loss, visual distur- object with other sensory modalities. bances as cau e of loss of function. b. The subject doesn't recognize an object (clock) b. Rule out psychological/emotional and cogni- by sight but can recognize it by sound (ticking). tive factors. 6. Examine for apraxia. 2. Test for homonymous hemianopsia. a. Evaluate voluntary movement: apraxia is the a. Loss of 112 of visual field in each eye contralat- inability to perform voluntary learned move- eral to the side of a cerebral hemisphere lesion. ment in the absence of loss of sensation, b. Slowly bring 2 fingers from behind head into strength, coordination, attention, or compre- the patient's visual field while asking the hension. It represents a breakdown in the con- patient to gaze straight ahead, the patient ceptual and/or motor production ystems. indicates when and where the fingers first b. Ideomotor apraxia: patient cannot perform the appear. task upon command but can do the task when 3. Examine for body scheme/body image disorders. left on own. a. Body scheme disorder (somatognosia): have c. Ideational apraxia: patient cannot perform the patient identify body parts or their relationship task at all, either on command or on own. to each other. L. Examine Motor Function b. Visual spatial neglect (unilateral neglect): Refer to Tables 1-1,2-2 and 2-3. check to see if patient ignores one side of the 1. Determine muscle bulk, firmness. body and stimuli coming from that side. a. Check to see if there is atrophy. c. Right/left discrimination disorder: have patient (1) Determine if atrophy due to denervation, identify right and left sides of own and your body. d. Anosognosia: severe denial, neglect, lack of disuse, or primary atrophy. awareness of severity of condition; check to see (2) The presence of persistent fasciculations if patient demonstrates severe impairments in neglect and body scheme. suggests neurogenic injury. 4. Examine for spatial relations syndrome. (3) Examine by inspection, palpation, and girth a. Figure-ground discrimination: have patient pick out an object from an array of objects, measurement. e.g., brake from rest of wheelchair. b. Check muscle frrmnes , tenderne s, reactivity. b. Form constancy: have patient pick out an 2. Examine muscle tone. object from an array of similarly shaped but a. Use PROM to asse s muscle tretch reflexe and responsiveness to pas ive elongation.

Neuromuscular Physical Therapy 93 TABLE 2-2 - DIFFERENTIAL DIAGNOSIS: COMPARISON OF MAJOR TYPES OF CENTRAL NERVOUS SYSTEM DISORDERS LOCATION CEREBRAL CORTEX BASAL GANGLIA: CEREBELLUM SPINAL CORD OF LESION Disorder CORTICOSPINAL TRACTS SUBCORTICAL GRAY Cerebellar lesion: tumor, SCI: trauma, complete Sensation stroke incomplete Stroke Parkinsonism Not affected Impaired or absent below Tone Impaired or absent: depends Not affected Normal or may be Hypertonia/spasticity below Reflexes on lesion location: decreased the level of the lesion Strength contralateral sensory loss Increased uniform resistance: leadpipe rigidity Initial flaccidity: spinal shock Bulk Hypertonia/spasticity Involuntary velocity-dependent Rachet-Iike at wrist Normal or may be decreased Increased hyperreflexia Movements clasp-knife or forearm: cogwheel; Initial flaccidity: Independent of rate Normal or weak: asthenia Impaired or absent below the cerebral shock Normal or may be decreased level of the lesion: paraplegia Slowness of movement or tetraplegia Increased hyperreflexia Contralateral weakness or paralysis: hemiplegia Normal: acute; disuse Normal or disuse atrophy Normal Disuse atrophy atrophy: chronic Resting tremor None Spasms Spasms Voluntary Dyssynergic: abnormal Bradykinesia/akinesia Ataxia: intention tremor Intact: above level of lesion Movements timing, coactivation, slowness, lack of spontaneous dysdiadochokinesia, activation, fatigability and automatic movements dysmetria, dyssynergia Impaired below level of lesion Postural nystagmus Impaired or absent: depends Control Impaired or absent, depends Impaired: stooped on level of lesion Gait on lesion location Impaired: truncal ataxia, Impaired: shuffling, dysequilibrium Impaired: gait deficits due festinating gait to abnormal synergies, Impaired: ataxic gait deficits, spasticity, timing deficits wide-based, unsteady TABLE 2-3 - DIFFERENTIAL DIAGNOSIS: COMPARISON OF UPPER MOTOR NEURON (UMN) AND LOWER MOTOR NEURON (LMN) SYNDROMES Location of lesion, UMN LESION LMN LESION Structures involved Disorders Central nervous system Cranial nerve nuclei/nerves Cortex, brainstem, corticospinal tracts, spinal cord SC: anterior hom cell, spinal roots, peripheral nerve Stroke, traumatic brain injury, spinal cord injury Polio, Guillain-Barre, PNI, peripheral neuropathy, radiculopathy Tone Increased: hypertonia Decreased or absent: hypotonia, flaccidity Reflexes Velocity dependent Not velocity dependent Decreased or absent: hyporeflexia Involuntary Movements Increased: hyperreflexia, clonus Cutaneous reflexes decreased or absent Strength With denervation: fasciculations Exaggerated cutaneous and autonomic reflexes: + Babinski Limited distribution: segmental or focal pattern, Muscles bulk Root-innervated pattern Voluntary Movements Muscle spasms: flexor or extensor Neurogenic atrophy; rapid, focal, severe wasting Weakness or paralysis: ipsilateral (stroke) or bilateral (SCI) Weak or absent if nerve interrupted Corticospinal: contralateral if above decussation in medulla; Ipsilateral if below Distribution: never focal Variable, disuse atrophy Impaired or absent: dyssynergic patterns, obligatory synergies

94 (1) Flaccidity (absent tone), hypotonia increases the resistance (spasticity is veloc- (decreased tone): seen in segmental/lower ity dependent). (Table 2-4). Assess for motor neuron lesions: nerve roots and additional signs of spastic hypertonia: peripheral nerve injury; also seen initially (a) Clasp-knife response: marked resist- after suprasegmental/upper motor neuron lesions, i.e., brief period of spinal shock in ance to PROM suddenly gives way. spinal cord injuries, cerebral shock in (b) Clonus: maintained stretch stimulus stroke; there is decreased or no resistance to PROM. produces a cyclical, spasmodic con- traction; common in plantarflexors, (2) Spasticity (spastic hypertonia): seen in also seen in wrist flexors and jaw. suprasegmental/upper motor neuron (c) Hyperactive cutaneous reflexes, i.e., + lesions; there is increased resistance to Babinski response: dorsiflexion of PROM; check to see if increasing the speed great toe with fanning of other toes in response to stroking up the lateral side TABLE 2-4 - TYPICAL PATTERNS OF SPASTICITY IN UPPER MOTOR NEURON SYNDROME UPPER LIMBS ACTIONS MUSCLES AFFECTED Scapula Retraction, downward rotation Rhomboids Shoulder Adduction and internal rotation, depression Pectoralis major, Latissimus dorsi, Teres major, Subscapularis Elbow Flexion Biceps, Brachialis, Brachioradialis Forearm Pronation Pronator teres, Pronator quadratus Wrist Flexion, adduction F. carpi radialis Hand Finger flexion, clenched fist F. dig.profundus/sublimis, Add. pollicis brevis, F pollicis brevis Thumb adducted in palm LOWER LIMBS ACTIONS MUSCLES AFFECTED Pelvis Retraction (hip hiking) Quadratus lumborum Hip Adduction (scissoring) Add. longus/brevis Internal rotation Add. magnus, Gracilis Knee Extension Gluteus maximus Foot & ankle Extension Quadriceps Plantarflexion Gastroc-soleus Hip & knee Inversion Tibialis posterior (prolonged sitting posture) Equinovarus Trunk Toes claw Long toe flexors COG forward (MP ext., PIP flex, DIP ext) Ext. Hallucis longus (prolonged sitting posture) Toes curl Peroneus longus (PIP, DIP flex) Iliopsoas Flexion Rectus femoris, Pectineus Hamstrings Sacral sitting Rotators Lateral flexion with concavity rotation Internal/external obliques Rectus abdorninis, External obliques Excessive forward flexion Psoas minor Forward head The form and intensity of spasticity may vary greatly, depending upon the CNS lesion site and extent of damage. The degree of spasticity can fluctuate within each individual (Le. due to body position, level of excitation, sensory stimulation, and voluntary effort). Spasticity predominates in antigravity muscles (Le. the flexors of the upper extremity and the extensors of the lower extremity). If left untreated, spasticity can result in movement deficiencies, subsequent contractu res, degenerative joint changes, and deformity. Adapted from Mayer NH, Esquenazi A, Childers MK (1997). Common patterns of clinical motor dysfunction. Muscle and Nerve 6:S21.

of the sole of the foot; indicative of Neuromuscular Physical Therapy 95 corticospinal (pyramidal) tract disrup- tion. tone in automatic postural adjustments. (d) Hyperreflexia: increased deep tendon (1) Check stiffness of limbs and trunk in main- reflexes. (e) Some degree of muscle weakness is taining posture against gravity. usually present. (2) Check for abnormal movements: are move- (0 Modified Ashworth Scale: 6 grades are used for grading spasticity. ments restricted, performed with great effort, are there limitations in voluntary o no increase in muscle tone. movements? c. Evaluation and documentation. I slight increase in muscle tone, (1) Determine which body parts, joints have minimal resistance at end of ROM. abnormal tone. (2) Determine if asymmetries exist, UEs vs. I+ slight increase in muscle tone, min- LEs, axial (trunk) vs. appendicular (limbs), imal resistance through less than distal vs. proximal. half of ROM. (3) Describe the character of the resistance, i.e. uniform, clasp-knife, leadpipe, etc. 2 more marked increase in muscle (4) Describe the effects of tone on active tone, through most of ROM, affect- movement, upright posture. ed part easily moved. 3. Examine reflexes. a. Deep tendon reflexes (DTRs): may be indicat- 3 considerable increase in muscle ed in CNS or PNS lesions (i.e., nerve root tone, passive movement difficult. impingement, peripheral nerve injury. hypotonia or spastic hypertonia). 4 affected part(s) rigid in flexion or (1) Tap directly on tendon: stretch stimulus extension will produce contraction of agonist muscle with corresponding quick movement. (3) Rigidity: increased resistance to PROM (2) Reflexes commonly tested: jaw reflex, that is independent of the velocity of move- trigeminal C.N. V; biceps, C5-C6; triceps, ment. Rigidity seen in basal ganglialnigros- C7-C8; brachioradial , C5-C6; hamstrings, triatal disorders: increased resistance to L5-S3; quadriceps (knee jerk, patellar), L2- passive movement in both agonist and 4; achilles (ankle jerk), SI-2. antagonist muscle. Rigidity can be leadpipe (3) Scoring: scale ranges from 0 (absent (uniform throughout the range) or cog- reflex), 1+ (decreased response), 2+ (nor- wheel (interrupted by a series of jerks). mal response), 3+ (exaggerated), to 4+ Associated with Parkinson's disease, rest- (hyperactive). ing tremor, bradykinesia, etc.; strength and b. Superficial (cutaneous) reflexes: normally reflexes are not affected. occurring reflexes in response to noxious stim- ulus (light scratch) applied to skin. (4) Decerebrate rigidity/posturing: seen in (1) Plantar reflex (SI-2, tibial nerve): comatose patients with brainstem lesions between the superior colliculus and the plantarflexion of toes in response to vestibular nucleus; results in increased tone stroking lateral sole of foot from calca- and sustained posturing of all limbs; neus to base of fifth metatarsal and trunk/neck in rigid extension. medially across metatarsal heads (neu- rologically intact individual). (5) Decorticate rigidity/posturing: seen in (2) + Babinski response:abnormal plantar comatose patients with lesions above the reflex response with dorsiflexion of the superior colliculus; results in increased great toe and fanning (abduction) of tone and sustained posturing of upper limbs the four lesser toes; seen in patients in flexion and the lower limbs in extension. with corticospinal lesions. (3) In patients with hyper ensitive feet, (6) Opisthotonos: prolonged severe spasm of plantar responses can be also stimulat- muscles causing the head, back and heels to arch backwards; arms and hands are held rigidly flexed. Seen in severe meningitis tetanus, epilepsy, strychnine poisoning. b. Use AROM, active movement control to assess

96 (1) CVA: hemipareses or hemiplegia. (2) SCI: paraplegia or tetraplegia (quadriple- ed by proximal to distal stroking along the lateral foot (Chaddock) or tibial gia). crest (Oppenheim). (3) TBI: any level or degree po sible. (4) Abdominal reflexes (T6-Ll): lateral to d. Clinical issues with strength testing (standard medial scratching of skin (toward MMT) patients with CNS, UMN lesions. umbilicus) in each of four quadrants (I) Passive restraint: soft tissue changes produces deviation of the umbilicus toward the stimulus (neurologically restrict ability to move e.g., contractures. intact individual). Loss of abdominal (2) Active restraint: spastic muscles restrict reflexes is a sign of corticospinal lesions). ability to move. (5) Cremasteric reflex (Ll-L2): stroking (3) Abnormal synergistic activity, inappropri- of skin of the proximal and medial thigh produce elevation of the testicle ate coactivation of muscles. (neurologically intact individuals); lost (4) Recruitment problems: abnormal Type IT in spinal cord injury and corticospinal lesions. fiber recruitment. c. Primitive/spinal reflexes, tonic/brainstem reflex- (5) Abnormal reflex activity: re tricts ability to es (usually 1 or 2 in each category are sam- pled): may be indicated in CNS lesions (e.g., move. stroke, traumatic brain injury). (6) Isokinetic dynamometry: patients with UMN (1) See Pediatrics chapter for specifics of tests. (2) Reflexes that may be tested. syndrome (i.e. stroke) typically demonstrate (a) Primitive/spinal: flexor withdrawal, decreased torque development with increased crossed extension, traction, grasp. problems at higher speeds, decreased limb (b) Tonic/brainstem: asymmetrical tonic excursion, extended time to peak torque neck reflex (ATNR), symmetrical tonic development, extended time peak torque neck reflex (STNR), symmetrical tonic held, increased time interval between recip- labyrinthine (STLR), positive support, rocal contractions, and change on \"suppos- associated reactions. edly normal\" extremities. (3) Scoring: scale (Capute) ranges from: 0 e. Clinical issues with strength testing patients (absent), 1+ (tone change; no visible move- with PNS, LMN lesions: ment of extremities), 2+ (visible movement (1) With myopathies: see proximal weakne of extremities), 3+ (exaggerated, full move- of extremities. ment of extremities, to 4+ (obligatory and (2) With neuropathies: see distal weakness of sustained movement, lasting for more than extremities. 30 seconds). (3) Some conditions produce decremental d. Examine midbrain/cortical reactions: righting strength 10 ses, e.g., myasthenia gravis. reactions, (RR) protective extension (PE), 5. Examine aerobic capacity/endurance. equilibrium reactions (ER) (see section on a. Fatigue is the failure to generate the required or Balance assessment). expected force during sustained or repeated 4. Examine strength. contractions. a. Determine/document: relative strength/peak (1) Fatigue is protective: guard against over- power, ability to initiate/accelerate contraction, work and injury. control torque output at varying speeds. (2) Fatigue is task dependent. b. Methods: patient's self-report, manual muscle (3) Sources of fatigue. test (MMT), isokinetic dynamometry, observa- (a) CNS/central fatigue: seen in multiple scle- tion/functional assessment. rosis, amyotrophic lateral sclerosis, chronic c. Decreased strength: paresis (weakness) or fatigue syndrome. paralysis (loss of voluntary motion). (b) Neural/myoneural junction: seen in MS, post-polio syndrome, Guillain-Barre syn- drome, myasthenia gravis. (c) Muscle contractile failure: metabolic changes at the level of the mu cle, e.g., depleted Ca++ stores, seen in mu cular dystrophy.

b. Determine/document: euromuscular Physical Therapy 97 (1) Source of fatigue. (2) Frequency and severity of fatigue episodes. neck or shoulder muscles. (3) Threshold for fatigue: level of exercise that (2) Chorea: relatively quick twitches or \"danc- cannot be sustained indefinitely. (a) Onset is typically gradual not abrupt. ing\" movements. (b) Dependent upon the intensity and (3) Athetosis: slow, irregular, twisting, sinuous duration of activity attempted. (4) Factor that influence fatigue: e.g., health movements, occurring especially in upper tatu , environmental temperature, stress. extremities. (5) Level of functional performance: inde- (4) Tremor: continuous quivering movements; pendence, modified dependence, depend- rhythmic, oscillatory movement observed ence, level of assistance, assistive devices. at rest (resting tremor). (6) Episodes of exhau tion: limit of endurance (5) Myoclonus: single, quick jerk. beyond which no further performance is b. Cerebellar disorders: intention tremor occur- possible. ring when voluntary movement is attempted. (7) Overwork weakness or injury: prolonged c. Cortical disorders: epileptic seizures, tonic/ decrease in absolute strength and endurance clonic convulsive movements. due to excessive activity of partially dener- d. Determine/document: vated muscle. Common in post-polio syn- (1) Are movement extraneous and sponta- drome, Duchenne muscular dystrophy. neous, apparently unintended? (8) Test and Measures. (2) Part(s) of body involved, orientation in space. (a) Modified Fatigue Impact Scale (MFIS): (3) Frequency, amplitude, pattern. subjective scale that includes 3 sub- (4) Effect of triggering stimuli or changes in scales assessing the impact of fatigue environment. on physical, cognitive, and psychoso- (5) Methods: patient's self-report, observation! cial function. functional assessment, videotaped analysis. (b) Isokinetic dynamometry, EMG: can 8. Examine coordination. ob erve decrements in force production. a. Gross motor coordination: body posture, bal- ance, and extremity movements involving large 6. Examine voluntary movement control. muscle groups. a. Determine/document: (1) Quality (synergistic organization) of mus- TABLE 2-5 cle activation patterns. ABNORMAL SYNERGY PATTERNS OF (2) Are movement appropriate and timely in THE EXTREMITIES SEEN IN PATIENTS response to stimulus or command? (3) Able to easily vary type of contraction pat- FOLLOWING STROKE tern, i.e. isometric, concentric, eccentric? (4) Are movements ymmetrical? UPPER EXTREMITY (5) Adequate control of multiple body seg- ments, postural stabilization? Flexion synergy components: scapular retraction/elevation, (6) Assess for presence of abnormal synergy shoulder abduction, external rotation, elbow flexion', patterns: muscle synergistic patteros that forearm supination, wrist and finger flexion'. are highly stereotyped and obligatory. Commonly seen in UMN dysfunction (e.g., Extension synergy components: scapular protraction, CVA, TBI). (Table 2-5). shoulder adduction', and internal rotation, elbow extension, forearm pronation, wrist and finger flexion. 7. Examine for presence of involuntary movements. a. Extrapyramidal disorders, basal ganglia dys- LOWER EXTREMITY function. (1) Tics: spasmodic contractions of specific Flexion synergy components: hip flexion, abduction, extemal muscles, commonly involving face, head, rotation, knee flexion, ankle dorsiflexion and inversion. Extension synergy components: hip extension, adduction', internal rotation, knee extension', ankle plantarflexion' and inversion. The form and intensity of abnormal synergy patterns may vary greatly, depending upon the eNS lesion site, extent of damage, and stage of recovery. Synergies can fluctuate due to body position (presence of reflexes), degree of spasticity, level of excitation, sensory stimulation, and voluntary effort. Generally the strongest components are starred'.

98 to perform rapid alternating move- ments. (1) Upper extremity tests: unilateral (finger to (7) Scoring: 0 (unable), I (severe impairment), nose); rapid alternating movements 2 (moderate impairment), 3 (minimal (RAM), e.g., supination/pronation; bilater- impairment) to 4 (normal performance). al symmetrical (clapping, RAM), bilateral (8) Methods. asymmetrical movements (alternate touch (a) Patients self-report. knee/shoulder), bilateral unrelated move- (b) Observation/functional assessment. ments (knee pat/elbow extension). (c) Timed te t . (d) Videotaped analysis. (2) Lower extremity tests: unilateral (heel to 9. Examine balance: the control of relative positions shin, foot tapping); bilateral symmetrical of body parts by skeletal muscles, with respect to (foot tapping, alternate knee flexion/exten- gravity and to each other. sion); bilateral asymmetrical (alternate a. Sensory elements of balance. knee flexion/extension); bilateral unrelated (1) Visual system: check vi ual acuity, depth movements (knee flexion/extension and hip perception, visual field defects. abduction/adduction). (2) Somatosen ory: check proprioception, cutaneous sensation (touch, pressure), (3) Postural/trunk tests: whole body movements. lower extremities and trunk, especially feet b. Fine motor coordination: extremity movements and ankles. (3) Vestibular: check motor responses to posi- concerned with utilization of small muscle tional and movement testing. groups. (a) Move or position the body; observe (1) Thumb/finger opposition (unilateral, bilat- automatic adju tments that restore nor- mal alignment of the head position eral). (face vertical, mouth horizontal)(right- (2) Manual/finger dexterity: grasp and release. ing reactions). (3) Standardized tests and measures: Jebsen- (b) Alter the body's center of mass (COM) and/or ba e of support (BaS); observe Taylor Hand Function Test, Minnesota automatic postural adjustments that Rate of Manipulation Test, Purdue serve to maintain body posture and Pegboard. balance (keep COM within the BaS). c. Evaluation and documentation. (c) Alter the body's COM outside of the (1) Speed/rate control: does increasing the BaS; observe the automatic adjust- speed of performance affect quality of ments of the arms (protective reaching) motor performance? and/or legs (protective stepping) to (2) Control: are movements precise? are con- extend and support the body weight in tinuous and appropriate motor adjustments anticipation of a fall event. made if speed and direction are changed? (d) Testing considerations: can use a dis- can movement and distance be judged placing manual force against the COM following a moving target? does occluding (a perturbation or push) or displace the vision alter performance? BaS using a moveable surface (plat- (3) Steadiness: is there consistency over time? form, gymnastic ball, equilibrium can a position be maintained without sway- board). ing, tremors or extra movements? does (4) Tests of sensory interaction/organization. patient fatigue rapidly? Clinical Test for Sensory Interaction in (4) Response orientation: does correct movement Balance CTSm, e.g., foam and dome, occur in response to a specific stimulus? (Shumway-Cook and Horak) or modified (5) Reaction time: does movement occur in a Clinical Test of Sensory Interaction on reasonable amount of time? Balance (mCTSIB) using computerized force- (6) Descriptive comments/terms. (a) Dyssynergia: impaired ability to asso- ciate muscles together for complex movement. (b) Dysmetria: impaired ability to judge the distance or range of movement. (c) Dysdiadochokinesia: impaired ability

plate technology (e.g., NeuroComBasic Neuromuscular Physical Therapy 99 and Balance Master systems). (a) Examines 6 different sensory condi- back using a long axis of motion (lower extremity i relatively fixed). tions, progressing in difficulty: (b) Hip strategy: hip and lower trunk mus- Condition I: eyes open, fixed support cles maintain balance by shifting COM surface. using hip motions (flexion or exten- Condition 2: eyes closed, fixed sup- sion). port. (c) Stepping strategy: rapid steps are taken Condition 3: visual conflict (sway-ref- to realign COM within BaS. erenced vision using a moving sur- (5) Check static balance: ability to maintain a round screen or dome), fixed support. position and response to perturbation. Condition 4: eyes open, moving sup- (a) Sitting: holding a steady position, arm port surface (platform or dense foam). support, no arm support. Condition 5: eyes closed, moving sup- (b) Standing: double limb, single limb port surface. support. Condition 6: visual conflict, moving (c) Romberg test: standing with feet in nor- support surface. mal stance position, first with eyes open, (b) Evaluation and documentation. then with eyes closed; used to detect posterior column (sensory) ataxia. Record time standing posture is (d) Sharpened or Tandem Romberg: have maintained (30 ec.); record changes patient stand in a tandem heel-to-toe in the amount and direction of position, first with eyes open, then eyes po tural sway, cale of 1 (minimal closed; increases sensitivity of way) to 4 (fall). Romberg test. • Patients dependent on vision become (6) Check dynamic balance: response to unstable in conditions 2, 3, 5, 6. dynamic movement challenges. • Patients dependent on surface/ (a) Functional movement tasks: standing- somatosensory inputs become unsta- up and sitting-down, walking, turning. ble in conditions 4, 5, 6. (b) Navigation through obstacle course, • Patients with vestibular loss become dual-tasks (\"walkie-talkie\" test, walk unstable in conditions 5, 6. and carry items). • Patients with sensory selection (c) BaS challenges: sitting on Swiss ball, problems become unstable in condi- balance/wobble board or dyna disc; tions 3-6. standing on balance/wobble board, b. Musculoskeletal elements and Limits of dense foam, foam rollers. Stability (LOS). (d) Refer to Table 2-6 for an example of (I) Determine musculoskeletal strength and Functional Balance Grades. ROM, lower extremities and trunk. c. Standardized screening tests and measures for (2) Determine limits of stability (LOS): ability functional balance. Appropriate for those indi- to move their center of mass (COM) over viduals at risk for falls; individuals with signif- the BaS during self-initiated movements; icant dizziness and imbalance would be unable can document with forceplate analysis. to complete these tests. See Geriatric Physical (3) Determine center of alignment: location of Therapy, Chapter 8, section on Fall Prevention COM within the center of the BaS; center for discussion of these tests. of pressure documented using forceplate (I) Performance-Oriented Mobility Assessment, analysis. POMA (Tinetti). (4) Determine availability of postural syner- (2) Get up and Go Test; Timed GUG Test. gies (strategies) used to preserve balance. (3) Functional Reach, FR. (a) Ankle strategy: ankle muscles (dorsi- (4) The Berg Balance Scale. flexors and plantarflexors) maintain (5) Dynamic Gait Index. balance by shifting COM forward or (6) Falls Efficacy Scale.