Ther Ex exam 2
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. What would you like to do?
the ability to maintain equilibrium; maintain center of mass over the BOS
What is the difference between static and dynamic balance?
static is still dynamic is movement.
awareness of static posture is known as?
Kinesthesia is relative to ____________ and how does it happen?
joint motion; sensory receptor signals from muscle, tendon, and joints.
the overall function of joint receptors to deliver input concerning joint position movement, direction, speed and amplitude is known as?
limits of stability can also be described as?
limits of stability
the perimeter of the contact area between the body and its support surface and can be altered by foot placement?
The ground "pushing back" in an equal and opposite direction is also known as?
ground reaction force
What is it called when your body respones to external forces acting on the body?
reactive postural control
anticipated response to internally generated, destabilizing forces imposed on body movements are known as?
proactive postural control
T/F: if something interfers with sensory it will interfer with balance?
What allows an individual to appropriately "modify sensory and motor systems in response to changing task and environmental demands?
adaptive postural control
What roles does the nervous system play in balance?
- sensory processing regarding movement, and orientation through the vestibular, visual, and somatosensory.
- sensorimotor intergration for linking sensation to motor responses and for anticipatory and adaptive aspects of postural control.
- development of motor strategies for planning, programming, and executing balance responses
how does the musculoskeletal system play a role in balance?
postural alignment, flexibility, joint ROM and mobility, muscle recruitment and performance.
What are the contextual effects on balance?
- closed vs. open environment
- support surface
- amount of lighting
- effects of gravity and inertial forces on the body
- task characterisitics
how does your visual system help with balance?
- position of head relative to environment
- orientation of the head to maintain level gaze
- direction and speed of head movement
How does the somatosensory/propreoception system help with balance?
- muscle proprioceptos
- joint receptors
- skin mechanoreceptors
What does the vestibular system do for balance?
info regarding the movement of the head in relationship to gravity and inertial forces.
The seamless intergration of the information received from all three systems is what allows for the maintenance of balance. The intergration follows...?
- basal Nucli
- supplementary motor systems
What is the sensory level for condition 1?
eyes open, stable surface
what is the sensory level for condition2?
eyes closed, stable surface
what is the sensory level for condition 3?
visual conflict with moving surround, stable surface
what is the sensory level for condition 4?
eyes open, moving surface
what is the sensory level for condition 5?
eyes closed, moving surface
what is the sensory level for condition 6?
visual conflict with moving surround and moving platform.
What does the mechanoreceptors provide information for?
- joint placement
- velocity and amplitude of joint motion
which mechanoreceptor responds slowly to static joint position?
ruffini type 1
which mechanoreceptor adapts quickly to chages in joint position?
pacinian type 2
Which mechanoreceptor is active at all extemes of joint motion and is stimiulated with manipulation?
Which type of mechanoreceptor transmit info related to pain and inflammation?
free nerve endings- type 4
There are two different types of balance reflexes, what are they?
- vestibuoocular reflex- VOR
- vestibulospinal reflex -VSR
Which balance reflex allows for coordination of head and eye movements; allows for gaze stabilization and visual tracking?
Which balance reflex attempts to stabilize the bod and control movements; coordination of the trunk in upright movement?
There are 6 general types of motor stratigies for balance. Wht are they?
- change in support
The strategy that would most commonly be used for small disturbances would be?
the strategy that would most commonly be used for large and rapid disturbances; commonly associated with rotational perturbation of trunk?
the strategy that would most commonly be involved with quickly lowering the body by flexing the knees with secondary flexion at ankles and hips?
What common balance strategy would respond to fast and large postural perturbation; following a stumble?
What kind of strategy would you be using if you broke your fall with your hands?
change in support
Balance impairments can result from several different things. What are they?
- sensory input impairment
- sensorimotor intergration
- motor output & biomechanical output deficits
What is the major cause for morbidity, mortality, reduced functioning, and premature placement in nursing home?
You have an 80 y/o pt. in an acute care setting who has been on bed rest due to an upper respiratiory infection. You have orders from the Dr. to get this patient up today. You're reading their chart and you see that they have gait deficits that require use of an AD, they have arthritis in their hip, and they wear glasses. What would be your major concern with this patient?
Risk of falling
T/F: balances tests can also be used at balance exercises?
double leg stance, rhomberg & sharpened rhomberg, single leg stance and tandem walking are all examples of what?
balance test and exercises
KAT, physioball, BAPS, minitramp and UE prioprioceptive training are examples of?
specific balance task tools
What are some of the things you need to do and look out for when balance training with a patient?
- use a gait belt & guard appropriately with as many people as necessary
- use // bars and hand rails when available and necessary
- clear the area of any hazardous objects
- make sure the equipment is in good shape and works properly before you begin treatment
visual, vestibular, and proprioceptive factors contribute to what type of input for balance?
sensorimotor intergration, anticipatory balance control and reactive balance control are factors that contribute to what type of balance processing?
Postural alignment, muscle recruitment, strength, and endurance, joint mobility, flexibility, coordination and pain are what type of factors that contribute to balance?
motor and biomechanical
What are the variable that you can manipulate with balance training?
- environment- open vs. closed
- support surface- stable vs. unstable surface
- BOS- wide vs. narrow
- COM- low vs. high
What are the variables commonly used for beginning stages of balance training?
- closed environment
- stable surface
- all senses involved
- wide BOS
- low COM
How would you progress standing balance?
- wide BOS with double stance
- feet together (rhomberg)
- standing in tandem
- single leg stance/stork stance
- * with all of these you would include:
- eyes open vs. closes
- UE rotational exercises
- progess to unstable surface
How would you progress walking balance?
- gait in // bars
- forward and backward walking
- tandem walking
- stepping over obstacles
- up and down stairs
How would you prepare a patient for home and community ambulation?
- walking on uneven terrain
- lifting objects from high and low
- pushing and pulling doors
- car transfers
- carrying common objects
- anticipatory timing activities
- boarding an elevator
- getting on an escalator
What is the main thing you need to keep in mind before progressing balance training?
they do not have to master all activites at one level prior to including higher level activites- you mix and match between levels depending on what the patient can do.
T/F: the CNS takes 1000's of repetitions before it is "re-trained"
T/F: you want your goal of balance skills to progress to situations that are patient specific functions?
Some of the things that you should incorporate with balance training would include?
- aerobic conditioning
- coordination exercises
- postural exercises
- survial maneuver education
- fall prevention education
intermediate balance training levels would include what kind of activities?
- movement transitions: sit-to-stand
- standing: decreased BOS, eyes open and closed
- gait activities: narrow BOS, side stepping
advanced level balance activites would include?
- standing: open enviro., unstable, eyes open and closed
- gait: same as standing; tandem walking, side stepping
- elevation activities: step-up and down, lat. step-up's
- community activities: pushing/pulling doors, car transfers
What are some of the functional balance tests?
- berg balance scale
- functional reach test
What are some central vestibular issues that could interfer with balance?
- chronic alcoholism
what are some of the peripheral vestibular issues that could interfer with balance?
- BPPV- loose ear rocks; true spinning; flat to upright
- meneires disease
- chronic alcoholism
from heel contact/strike of the same foot again
the period of time during the gait cycle where both feet are in contact with the ground and supporting the body
the period of time where only one foot supports the body during the gait cycle
distance between one foot contact to the opposites foots contact (ave. for adult is 13-16 inchs)
what is the average stride for an adult?
What is the cadence/speed of the average adult?
What is the average width of the BOS for an adult?
What is the average degree of toe out for an adult?
opposite from the thorax; 4* forward on swing LE and 4*backward on stance LE is what?
increased cadence until no period of double support
distance covered per unit of time in meters; average 82 meters a minute/ 3mph
rate change in respect to time
acceleration & deceleration
what is heel strike in RLA?
what is foot flat in RLA?
what is heel off in RLA?
what is toe off in RLA?
what is acceleration in RLA?
what is decerleration in RLA?
what are the two primary stages of the gait cycle?
Weight acceptance, single LE support and swing LE advancement are what?
functional activity phases of the gait cycle
What is the necessary ROM for the hip?
what is the necessary ROM of the knee?
What is the necessary ROM for the ankle?
- 20* plantarflexion
- 10* dorsiflexion
What is the necessary ROM for the great toe?
what is the MAP for heel strike?
knee extensonrs, eccentri dorsiflexors; initial contact
what is the MAP for foot flat?
eccentric dorsiflexors as loaded gastrocs fire eccentrically to control the forward advancement of the tibia; loading response
what is the MAP for midstance?
extensors active to stabilize limb: hip abductors stabilize the pelvis, plantar flexors propel the body forward
what is the MAP for heel off?
concentric plantarflexors; terminal stance
What is the MAP for toe off?
propulsion hip extensors and ankle plantar flexors; pre-swing
What is the map for midswing?
concentric hip flexors, knee flexors, ankle dorsiflexors
what is the MAP for swing phase-acceleration?
concentric hip flexors and concentric quads in early swing then quads silent; initial swing
What is the MAP for swing phase-deceleration?
eccentric hams to decelerate, concentric quads and ankle dorskiflexors to prepare for heel strike; terminal swing
protective pattern; typically secondary to pain with unequal step lengths
staggering unsteadiness, wide BOS, exaggerated movements
outward circular motion utilized to advance the LE
typically on the toes or high stepping
LE crosses midline upon advancement- mostly neuro
high step utilizing exessive hip and knee flexion to clear the foot; foot slap may be associated with
excessive lateral flexion of the trunk or marilyn monroe walk
stance leg has to elevate thru excess PF and hip hike to advance swing LE
high steppin ataxic gait with foot slapping
walks on toes as if has been pushed forward and falling, gains speed. commonly seen in parkinsons patients
abduct and swing LE around to advance it for gait
increased turnk forward flexion and knee flexion; shuffling, quick small steps
What are the things you would want to prep for pre-ambulation?
- ability to tolerate an erect position
- length of immobility
- strengthen the muscle of the UE and LE
- improve cardiopulm function and endurance
- train in sitting and standing balance
- teach and practive ambulation patterns and functional skills
What are some examples of pre-ambulation activities?
- bed exercises working on ROM, strength, activation and control
- progressions of development through use of PNF and NDT
- balance training
- strengthening and ROM to allow proper gait
What are some specific gait training activites that can be done in the bed/
- glute/ham sets
- heel slides
- PNF in bridging
What are some specific gait training activities that can be done in plantigrade/ // bars?
- weight shift side-> side and stagger stance w/ & w/o PNF
- stepping forward and backward w/ w/o PNF
- heel <> toe rocks/rises
- partial squats
What are some specific gait training activities that can be done with the patient standing alone?
- tape on floor-cue for step length
- cone or cups- step over-can be used for any gait defect
- obstacle courses
What is the typical progression for forward and backward walking techniques?
- assistance: // bars > AD > unassisted
- step length: shortened> lengthened
- speed: reduced > normal
- BOS: wide > narrow
- acceleration and deceleration
- environment: flat > carpet > variable
What is the most restictive AD to the least restrictive?
- // bars
- axillary crutch
- lofstrand crutch
Which weight bearing statsus require an AD?
T/F: No matter what the Dx, not matter what the specific exercise is for, you must ALWAYS perform exercises with proper alignment and recruitment from a stable base.
T/F: repetive movements and sustained positions will cause faults in the movment system elements (musculoskeletal, neurological, biomechanical) which lead to movement imbalance.
T/F: improper central neuromuscular programming of movement can cause impaired function of peripheral tissue leading to pain syndromes.
over lengthened muscles become weak in normal position and strong in lengthened position.
only strong in the shortened position and weak at normal length
What muscles are typically shortened and lengthened in a hyperlordotic posture?
- short: erector spinae; lumber hyperflexion, hip flexors; ant. pelvic tilt
- length: low abs and hip extensors;
- hyper extended kneers
what muscles are typically shortened and lengthened in a hyperkyphosis posture?
- short: upper abs, lat dorsi
- length: thoracic erector spinae
- mid and low traps
what is the treatment for hyperlordotic posture?
- stretch low back muscles
- strengthen lower abs
- stretch hip flexors
- strengthen hip extensors
what is the treatment for hyperkyphosis posture?
- strengthen thoracic erector spinae, mid and lower traps
- strengthen DNF's
- stretch lat dorsi's
- train and strengthen abs
What is typically shortened and lengthened in a flat back posture?
- short: upper abs, hip extensors
- length: lumbar erector spinae, upper back muscles, hip flexors
What is the treatment for flat back?
- strengthen low back and hip flexors
- stretch hamstrings and gluteal musculature
- train abs
What is typically shortened and lengthened in swayback posture?
- short: upper abs, hams, and glutes
- length: lower abs, upper back and hip flexor
What is the treatment for sway back?
- LLD- stand on short LE
- short LE iliopsoas strengthening with lower abs
- short LE posterior glute med strengthening
- stretch right lumbar paravertbral mscles
what is typically shortened and lengthened with a forward head posture?
- short: cervical erector spinae and UT
- length: cervical flexors
What is the treatment for forward head posture?
- stretch sub-occipitals
- strengthen DNF's
- almost always scapular and thoracic intervention (mid-low traps, SA, RC, thoracic extension, and abs)
what is typically shortened and lengthened with forward shoulder posture?
- short: pec minor and UT
- length: mid and low trap
- scapula abducted
What are the things you need to address to truly intervene with posture?
- postural alignment, balance, and gait
- muscular endurance and strength related to postural poition and proper motor control
- proper body mechanics
- ergonomic assessment if indicated
- cardio and aerobi capacity training
What do you need to restore to truly intervene with posture?
- normal ROM
- joint mobility
what is the common joint mobility restriction for the suboccipitals?
what is the common joint mobility restriction for the mid cervical spine?
what is the common joint mobility restriction for the thoracic spine?
general or specific
what is the common joint mobility restriction for the hip?
dependent upon the posture
What are some of the commonly tight muscles that need a good stretch?
- levator scapulae
- pect minor and major
- lat dorsi
- hip flexors
What are some of the common weak muscles due to posture faults?
- UT, MT, LT
- ER of shoulder
- TA's & OA's
- glute med
What do these things all have in common:
pivot prone progressions
supine on foam roller
steam boats for LE
they are exercises that address multiple issues
joints, nerve roots, spinal cord, bone, ligaments & capsule, and muscles have want in common?
they are general anatomic considerations of the spine.
synovial planar joints are what when t comes to the spine?
vertebral joints and the discs
T/F: in regards to facets, orientation dictates the motion available.
There are two different types of spinal stenosis. what are they?
What are some common spine pathologies?
- postural syndromes
- acute & mechanical dysfunctions
- spinal stenosis
- instability vs. hypermobility
- nerve impingement
T/F: typically see a combination of pathologies either occurring secondary to each other or in conjunction with each other.
Originating from a nerve root
radiating pain, numbness and tingling
centralizations: symptoms move back to central spine (good thing)
peripheralization: symptoms radiate away from proximal spine (bad thing)
theses are descriptions for what type of spine presentation?
What are some potential causes for nerve root impingement?
- lateral stenosis
- significant hypermobility
- scarring after surgical intervention
What is the main concern for nerve root impingement?
monitor both motor and sensory function to determine if any progression occurs.
What is the intervention for nerve root impingement?
dependent upon the degree of impingement and if progressing. ranges from nerve glides (typically accompanies ST work and stab trng) to surgical intervention if sever disc or instability.
if you have a LBP pt. when HNP, spondy's, stenosis, and sciatica, what must you always monitor for?
cauda equina syndrome
What changes would you monitor for with cauda equina?
- difficulty with micturation, urination
- saddle anesthesia
- widespread of progressive motor weakness in the LE or gait disturbances
- degree of sensory loss
T/F: spinal stenosis is typically secondary to DJD in the spine when osteophytes form around the facet joints and interfere with the lateral foramen
T/F: Yarjanian JA et al. said "symptomatic spinal stenosis results in greater paraspinal ms atraphy than LBP alone... not significantly explained by the degree of denervation... thus, may be reversible..."
T/F: the conclusion to yarjaninas experiment was that 62% of the manual therapy and 41% of the exercise alone groups had still showed gains from Tx a year later.
T/F: in people with HNP serial MRI's show gradual resorption of the herniated material explaining why 75% of pts with HNP recover non surgically within 6 months
In the study by Jensen what % of people wth no LBP who underwent MRI's had disc abnormailites?
What is the most common level of herniation for HNP?
How much greater risk are pt's who undergo fusion for HNP than those who dont for developing another HNP?
the quick functional test for L4 is _________ and the test for L5 is ______________?
- L4- heel walking
- L5- toe walking
What is the key intervention method with HNP?
stabilization training and movement retraining as indicated.
How would you know if a pt. is weight bearing sensitive for traction?
trial and assess response
What is the medical management for HNP?
- epidural steroid injection (ESI)
- laminectomy & disectomy "decompression"
- microsurgical disectomy
- automated percutaneous disectomy
- lumbar fusion
pars interarticularis stress fracture- "scotty dog". It is a hereditary predisposition + stork test, LBP that occasionally radiates into buttocks and thigh with no true neuro deficit.
when varying degrees of forward slippage of the involved vertebra occur secondary to the presence of the spondylosis.
What is the intervention for acute mechanical LBP?
- manipulation if indicated
- stabilization training
- movement re-training
- main goal: prevent recurrence and develpment of chronic recurrent LBP
What are the different types of fusions for the lumbar spine?
- interbody; posterior, anterior and cages
What are the most important considerations for rehab post fusion?
- know whether the patient was fused with instrumentation or not
- know the individual MD's restrictions and time frames
- know the contra's for the particular technique utilized
post fusion phase 1 is what time frame?
what are the goals for phase 1 post fusion?
pt. education re: precautions and movement, gentle nerve gliding, and home care principles.
what are some of the interventions for phase 1 post fusion?
- proper bed mobility and transfers; log roll
- amubulation starts day 1 post op
- be exervises; QS, HS, GS, heel slides, hip abd/add, ankle pumps; 5-10X each/day
- gentle nerve glides/mobilization
- body mechanics trng
- pt. education: avoid driving, prolonged sitting, lifting, beings and rotating
what is the time frame for post fusion phase 2?
what are the goals for phase 2 post fusion?
increase activity, promost proper tissue healing, control scar tissue, stabilization trng, further body mechanics trng, and conditioning.
what are some of the interventions for phase 2 post fusion?
- increase intensity of stab trng but w/o loading through the spine
- postural trng
- scar tissue mobes
- joint mobes to t spine or hips if indicated
- partial squats or total gym squats
- work up to 20 min cardiovas trng
- add extension exercises gradually w/ limited excurision in ROM; avoid lumbar flexion
- ROM: pelvic tilts in limited range w/o stressing the fusion
- body mechanics in all functional activites
What is the time frame for phase 3 post fusion?
what are the goals for phase 3 post fusion
- return to work
- advance exercise program
- secific skills program
- can implement a weight trng program
what the interventions for phase 3 post fusion?
- proper movement and body mechanics should be becoming automatic
- normalize UE and LE strength
- improve aerobic fitness
- decrease pain and swlling
what are the progressions for functional activites/exercises for phase 3 post fusion?
What is the impairment based classifications for PT Dx and & intervention for non surgical Lbp?
- stabilization: all LBP pt.s need stab trgn
- manipulations: CPR
- traction: you trial this
- specific exercise: mcKenzie based approach
What are the indicators for manipulation for non-surgical LBP?
- more recent onset of s/s <16 days
- hypomobility at any level
- LBP only; no distal s/s
- FABQ work subscale <19 (fear avoidance behavior questionaire)
bilateral or quadralateral limb paresthesia, either constantly or reproducd/aggravated by head or neck movements
positive hoffmans or shimizues reflex
these are all examples of what?
cervical cord compression
what are some of the MOI;s for cerivial cord compression?
- blows to the head
- traumatic injurys
- systemic conditions that affect ligamentous system
what are the places the PT assesses for ligament stability for the cerivical spine?
- jeffersons fx
What is VBI?
vertebral basilar insufficency
What are the things you should monitor for with VBI?
- hx of neck trauma
- dizziness or nausea
- visual disturbances
- facial paresthesias
- hi of ra, htn, or stroke
- steroid use
- increasing s/s with specific cervical movements
dizziness, dysarthria, dysphagia, diplopia, drop attacks are what?
the 5D's for VBI
nystagmus nausea and numbness are what?
the 3N's for VBI
an unsteady gait is a sign for what?
a C1-2 dislocation can only occur with?
- dens fx
- or transverse ligament rupture (trauma)
A spontaneous dislocation of the cervical spine can occur with?
- ankylosing spndylylitis
- forgotten/undiagnosed traumatic injury
what is the clinical indicator for a cerival dislocation?
bilateral or quadiliateral limb paresthesiae and/or weakness
positive hoffmans and/or babinski
sensroy disturbance of the hands
muscle wasting of hand intrinsic muscles
bowel and bladder distubances
these are are s/s of what?
T/F: whiplash is Dx by itself.
What is the MOI for whiplash?
either hyperflexion or hyperextension; hyperextension is more disabling.
what are the injury possiblities for whiplash?
- tears of ligaments
- articular damage
- neuro, vestibular and vascular damage
Why are MD diagnostics not good for Dx whiplash?
they dont show tissue damage. They can show up fine but the pt has s/s.
when we say radiculopathy, what do we mean is involved?
What are some of the causes for cervical radiculopathy?
- arthritic conditions
- discogenic disorders
- segmental instabilites
Why do we use pt. presentation for diagnosing cervical rediculopathy?
large % of asymptomatic subjects will exhibit pathoanatomic changes xonsistent with the suposed nderlying causes of cervical radic on diagnostic imaging studies.
What are the CPR's for cervical radiculopathy?
when 2 of these findings are positive there is a _____ % probility of cervical radic
3 tests______ %
4 tests______ %
- ULTT +
- cervical rotation < 60* affected side
- spurlings +
- distraction relieves s/s (never a good thing)
- 2 tests: 21%
- 3 tests: 65%
- 4 tests: 90%
cervical lateral glides, strengthening of DNF's, t-manip, and intermittent traction are the interventions for?
what is the criteria to determine if a HA is from a cervicogenic issue?
- mechanical precipitation (certain movements, sustained awkard postures)
- decreased c-rom
- diffuse ipsilateral non-radicular neck, shoulder or arm pain (occassionally radicular)
- pain reproduction with palpation over the GON, OA joint line, proximal SCM
moderate to sever, non-throbbing, non-lancinating that typically begins in the neck. can either be varying duration fluctuating or continous.
cervicogenic pain presentation
phono or photo sensitive, nausea, dissiness, blurred vision, difficuty swallowing are what?
less commonly seen s/s of cerviocogenic pain presentation
Cervicogenic HA's can stem from several neck disorders that may involve what?
- nerve root ganglia
- uncovertebral joints
- intervertebral discs
- facet joints
- upper t dysfunctio or TOS
"refers to the concept that seemingly unrelated impairments in a remote anatomical region may contribute to or be associated with the patients primary complaint"- wainner et al
What must you address for both cervical and shoulder patients?
- ct junction segemental mobility
- upper rib mobility
- upper thoracic mobility
the importance of the amount of change demonstrated be a measure is dependent upon the establishment of what?
what is the MCID?
minimum clinicaclly important difference
the smallest change in a scale that is important to the patient
Waht is the importance of the MCID?
allows examination of pre and post treatment scores to determine if the patient has improved an amount that is likely to be perceived as important by the patient.
When would you have a patient fill out a questionaire for MCID?
- once prior to eval
- during tx
- before DC
What would be considered a large change on the MCID?
what would be a small change on the MCID?
+/-1, +/-2, +/-3
what would be a moderate change on the MCID?
Does it measure what it says it will relates to?
can it produce the same results no matter what relates to?
owsestry, GROC, and FABQ are all related to what?
outcome measures for the lumbar spine
NDI and GROC are related to what?
outcome mesures for the c-spine
what is an oswerstry minimal disability?
what is a moderate disability for the oswestry?
what is a severe disability for the oswestry?
what is a crippled disability for the oswestry?
patients are either bed bound or exaggerating their symptoms. this can be evaulated by careful observation during the examination. this is an example of what oswestry disability?
why is the oswestry the gold standard for lumbar patients?
it has a 90% reliability and the validity is very well estabilished.
what is the MCID for the oswestry?
encompasses the axon or nerve fiber; important role in protecting against transmission of substances across the membrane (the blood-nerve barrier)
surrounds each fascicle; provides a perinueural diffusion barrier capable of controlling flow of substances bi-directionally.
outermost connective tissue; highly vascular and provides no diffusion barrier function.
in what three ways is the central and peripheral nerves a continuous system?
- the connective tissues are continuous
- the neurons are interconnected electrically
- the system is continuous chemically
T/F: any stresses that are imposed on the peripheral nervous system are conveyed to the cenetral nervous system and the reverse holds true.
bi-directional nutritional flow
fast 400mm day, carries substances used in the transmission of impulses (neurotransmitters and transmitters vesicles)
200mm/day responsible for carrying extracellular materials from the nerve terminal and trophic messages about the status of the nerve and the target tissues
What are the nutritional requirements for nerve nutrition?
20% of O2 consumption while only composing 2% of total body weight.
provide intrinsic innervation for the nerve
nervi nervorum provide nerve innervation for?
- connective tissues of the peripheral nerves
- nerve roots
- autonomic nervous system
Free nerve endings have been found in the?
body, axon, motor end plate, muscle fiber signs:distal weakness, decreased MSR's, myotomal patterns.
what type of dysfunctions of peripheral nerves does this describe?
cell body in ganglion, axon. reports tingling, burning, dysesthesias, paresthesias dermatome pattern
what type of of dysfunctions of peripheral nerves does this describe?
sweating and or/vascular control; skin changes.
what type of dsyfunctions of peripheral nerves does the describe?
motor weakness and atrophy; ALS, polio (no sensory involvement)
what type of neuropathy is this?
anterior horn cell
both sensory and motor presentation (spinal radiculopathy)
what type of neuropathy is this?
spinal and nerve root
both sensory and motor involvement relative to the specific nerve entrapped (peripheral nerve entrapment syndromes)
what type of neuropathy is this?
peripheral nerve mononeuropathy
weaker distally than proximally; "stocking glove distribution"; diabetic neuropathy, CMT
What type of neuropathy is this?
motor fatigue (sensory intact; myasthenia gravis
what type of neuropathy is this?
motor weakness (sensory intact) muscular dystrophy
what type of neuropathy is this?
small amount of pressure chronically endured over time; posture, repeated compression or dysfunctional movement. -CTS, cubital tunnel, TOS, tarsal tunnel
laceration, severing, blunt or crushing are what kind of MOI for peripheral nerves?
charcot-marie-tooth are what type of MOI for peripheral nerves?
guillain-Barre, post-polio, Herpes-zoster, bells palsy or trigeminal are all examples of what type of MOI for peripheral nerves?
diabetics and alcoholics are at risk for what type of MOI for peripheral nerves?
exposure to toxins is a MOI for peripheral nerves. give an example of this type of MOI
myasthenia gravis and botulism are examples of what type of peripheral nerve MOI?
motor end plate disorders
There are several systemic risk factors for peripheral nerve damage. What are they?
- microvasuclar disease
- thyroid issues
- renal disease
- inflammatory arthritis
- occuational exposure/activities
What are the goals for nerve compression injuries?
- know the major peripheral nerves
- understand the individual motor and sensory function of each peripheral nerve
- be able to establish a treatment plan based upon clinical presentation.
at what level of nerve compression does it lead to:
decreased vascular flow
interrupts axonal transport and conduction
leads to myelin thinning over time
epineural thickening over time
T/F: 20mmHg for 2 hours leads to no congestion, but for 8 hours leads to congestion in peripheral nerves.
How many hours does it take for restoration of axoplasmic flow in peripheral nerves?
T/F: peripheral nerve compression can mimic some tendonosis/tendonitis and can occur concurrently with such.
Peripheral nerve compression can occur concurrent with many other orthopedic injuries. What are some of them?
- lateral ankle sprains (sural or fibular)
- proximal humeral Fx (radial)
- knee scope (saphenous)
- spine hypermobility
T/F: peripheral nerve compression doesn't occur commonly after Fx's?
False- they do commonly occur
What would you grade a MSR with no response and is it normal or abnormal?
0; always abnormal
what would you grade a MSR with diminished/depressed response and is it normal or abnormal?
1+; may or may not be normal
what would you grade a MSR with an active normal response?
what would you grade a MSR with a brisk/exaggerated response and is it normal or abnormal?
3+; may or may not be normal
what would you grade a MSR with very brisk/hyperactive abnormal response?
C1-C3 myotome measures what?
cervical rotation; SCM
C3 myotome measures what?
cervical extension; traps, splenius cap
C4 myotome measures what?
shoulder elevation; traps, levator scap
C5 myotome measures what?
shoulder abduction; deltoid
C5-6 myotome measures what?
elbow flexion; biceps
C6 myotome measures what?
wrist extension; extensors wad
C7 myotome measures what?
elbow extension w/ wrist flexion; triceps, wrist flexor group
C8 myotome measres what?
ulnar deviation w/ thumb extension; FCU/ECU/EPL; thumb extension- APB
T1 myotome measures what?
finger abduction/adduction; interossei
What is the patellar MSR?
- spinal level L3-4
- knee extension
what is the achilles MSR?
- spinal level S1-2
- plantar flexion
what is the L1-2 myotome?
what is the L3-4 myotome?
what is the L4-5 myotome?
dorsiflexion- anterior tibialis
what is the L5 myotome?
great toe extension- extensor hallicus longus
what is the S1-2 ankle eversion?
what is the S1-2 plantarflexion?
gastroc and soleus
Heel walking is the functional testing for innervation for what spinal level?
toe walking is the functional testing for innervation for what spinal level?
What are the main UE peripheral nerves?
What is the difference between ulnar nerve compression at cubital tunnel vs. guyons canal?
- cubital: on the medial (pinky) side of the elbow
- guyons: on the medial side of wrist right above the pinky metacarpal. - bicycle riders most commonly
what are the major nerves of the LE?
- sciatic; tibial (medial and lateral plantar) peroneal (superficil an deep peroneal) sural
What diagnosis is commonly associated with or confused for radial tunnel syndrome?
What are the major MOI for peripheral nerves?
- crush and percussion
segmental de-myelination with normal conduction along the nerve above and below the lesion
your foot falling asleep is an example of what?
axon interrupted but intact connective tissue covering that maintains a road for healing.
when does wallerian degeneration and motor and sensory is loss occur?
disruption of both the axon and the connective tissue covering
When a loss of sensory and/or motor loss along with wallerian degeneration requires surgical intervention for the best chance of recovery?
Recovery from nerve injury is dependent upon:?
- extent/severity of injury
- nature and level of injury
- timing and technique of repair
- age and motivation
- degree of reinnervation.
What must you do to Dx a nerve compression?
- pt. history
- motor exam
- sensory exam
- NTPT (neural tension provocation testing)
- physical findings-atrophy, clawing, etc.
- hand diagrams
- EMG/NCV studies
What can nerve compression lead to?
- decreased vascular flow to the nerve
- interrupts azonal transort and conduction
- leads to myelin thinning
- epineural thickening (connective tissue)
what does ANTT mean?
adverse neural tissue tension
what does ULTT mean?
upper limb tension testing
what does NTPT mean?
neural tissue provocation testing
T/F: initially may not suspect ANTT with straight-forward orthopedic condtions
T/F: the nerve can be a source of the pain
What does AIG mean?
abnormal impulse generating site
What is an AIG?
when a peripheral nerve is injured, it can develop the ability to repeatedly generate its own impulse.
mechano-sensitivity and spontaneous activity are main characteristics of what?
You have a patient who is not responding within the time they and is worsening despite improvements in ROM and describes things such as buring, crawling, electrical, pulling. What would you suspect?
What are the symptoms of ANTT?
- development of pain and paresthesia is gradual
- symptoms radiate
- pain alont the nerve pathway or spot pain
- aggravated y positions or movements that stretch the nerve
- nocturnal s/s not uncommon
what would make a NTPT positive?
- reproduction of s/s
- response is altered by either a distal or proximal component form the location of the s/s
- difference in response from side to side or the expected normal
What are some common MOI's for ANTT?
- external forces
- internal forces
- chronic repeated microtrauma
- double crush
When the patient decribes pain in an anotomic region along the same neural pathway that it shares with another injury this can be described as?
What are some ANTT differential Dx's for lumbar radiculopathies?
- pain with cough, sneeze, valsalva?
- well delineated area of sensory change
- partial weakness, decreased reflexes
- electrodiagnostic testing
What is the key to Dx of ANTT?
- identify a different peripheral nerve with the major contribution from the same root level as the suspected nerve
- or test a more proximal branch originating from the same peripheral nerve
- then compare motor to sensory function
What are some of the principles of management of ANTT?
- intensity directly related tot he level of irritability present- greater the irritability the less intense the glide
- neurological s/s shone not persist after gliding technique or should be improved
- choose one motion of the testing position to utilize as the gliding force
- either floss or glide
- ask re: s/s after each Tx and document changes across the course of Tx
- any worsening at all need to be immediately reported to the PT
- monitor comparable s/s (myotomes, dermatomes, reflexes, pain and s/s)
What are the guidelines for prescription for ANTT?
- educate the pt. on condition and goals of Tx
- emphasize NOT to push Tx- MUST be gentle
- ALWAYS start with assisting to ensure perfect form and determine response; when pt. masters, give nerve glides as HEP
what is the common MOI for femoral nerve?
pelvic fx, scarring after abdominal surgery, tumors, inguinal hernias
most pronounced s/s at the knee, knee buckiling may occur is most commonly what nerve?
What never is most commonly injured during knee arthroscopy, medial meniscal repair and trauma?
sacral dysfunction with seconday piriformis spasm, thick wallets, scarring from hip surgery, injections, gluteal or pelvic tumors are most commonly associated with which nerve injurys?
What nerve is most commonly injured with plantar fascitis and eversion sprains?
Inversion ankle sprains, casts, walking boots, and improperly fitted shoe wear can cause injury to which nerve?
What are the differential s/s of peroneal nerve involvement?
anterior compartment syndrome; extreme pain, pallor, loss of dorsalis pedis pulse, and foot drop.
What would you like to do?
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