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89 Cards in this Set
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Manual therapy techniques that are used to modulate pain and treat joint impairments that limit ROM by specifically addressing the altered mechanics of the joint
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Joint mobilization/manipulation
address restricted capsular tissue minimize compressive force on cartilage definition: Passive skilled manual therapy techniques applied to joints and related soft tissues at varying speeds and amplitudes using physiological or accessory motions for therapeutic purposes |
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Thrust manipulation/high-velocity thrust (HVT)
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High-velocity, short amplitude. Thrust @ end pathological limit
safety comes from short amplitude |
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Self-Mobilization (Auto-Mobilization)
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Self-Stretching that uses joint traction or glides
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Mobilization With Movement (MWM)
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Concurrent application of sustained accessory mob PT with active physiological movement to end-range by patient. Passive end-range overpressure or stretching without pain
you do accessory motion which relieves pain and lets patient do physiological motion |
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Accessory Movements
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Component motion - clavicular elevation is a component of humeral abduction
Joint play: arthrokinematics Distraction Sliding Compression Rolling Spinning |
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Limited: contracture
Try distraction and compression |
Distraction:
Inc pain: tear connective tissue Dec pain: jt surface involved Compression: Increase pain: loose body (piece of something in there) Decrease pain: joint capsule |
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Muscle energy
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use muscle to do accessory motion
for instance, resist hip hyperextension to get hamstring to posteriorly rotate pelvis distal stabilization - proximal motion |
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Joint shapes:
ovoid and sellar |
ovoid - rounded (convex or concave)
sellar - like a saddle |
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Passive-angular stretching versus Joint-glide stretching
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Passive-angular stretching - use bony lever, casuses stretching on one side and compression on the other
versus Joint-glide stretching GLIDE: When therapist passively moves the articulating surface in the direction In which the slide of the bone normally occurs |
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Effects of Joint Motion
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Move joint fluid
Nutrients to avascular cartilage Extensibility and tensile strength Joint motion provides sensory feedback FYI: With immobilization there is fibrofatty proliferation, which causes Intra-articular adhesions as well as biomechanical changes in tendon, Ligament , and joint capsule tissue. This causes joint contractures And ligamentous weakening. progressive limitation - move hips less because knee hurts |
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Indications for Joint mobilization/manipulation
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Pain, Muscle Guarding, and Spasm
Neurophysiological effects Mechanical effects Reversible Hypomobility Positional Faults/Subluxations Progressive Limitation Functional Immobility |
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long-axis traction vs distraction
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pull down on arm, parallel with long bone
vs perpendicular to joint surface |
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Limitations of jt mobilization
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Cannot Change Disease Process
Cannot Change Inflammatory Process Skill of the Therapist Affects the Outcome |
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Contraindications for joint mob/manip
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Hypermobility
Joint effusion Inflammation |
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Precautions for joint mob/manip
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Malignancy
Bone Disease Detectable on Radiograph Unhealed Fracture (With Limitations) Hypermobility in Associated Joints Total Joint Replacements Newly Formed or Weakened Connective Tissue Elderly Individuals |
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Procedures for applying
Passive joint techniques |
Examination and Evaluation
Quality of Pain Capsular Restriction Subluxation or Dislocation Documentation Use of standardized terminology Characteristics of documentation Rate of application of movement Location of range in the available motion Direction of force applied by the therapist Target of force Relative structural movement Patient position Grades or Dosages of movements for non-thrust and thrust techniques Positioning and Stabilization Direction and Target of Treatment Force Treatment plane Initiation and Progression of Treatment Patient Response Total Program |
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Grades for osscilation techniques
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I - small amplitude within beginning range before tissue resistance
II - large amplitude within beginning range before tissue resistance III - large amplitude up to end range (with tissue resistance) IV - small amplitude at end range of motion |
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Dosages for sustained joint play techniques
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traction or distraction
Grade I - small stretch at beginning of available joint play Grade II - large stretch, still within available joint play, use to evaluate Grade III - stretch beyond normal available joint play |
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Mobilization with Movement:
Principles of Application |
Principles and Application of MWM in Clinical Practice:
Comparable sign Passive techniques Accessory glide with active comparable sign No pain Repetitions Description of techniques Patient Response and Progression Pain as a guide Self treatment Total program Theoretical Framework Brian Mulligan |
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Review of peripheral nerve structure
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Alpha Motor Neuron (somatic efferent fibers) - innervates extrafusal fibers
Gamma Motor Neurons (efferent fibers) - anterior horn, muscle spindle Sensory Neurons (somatic afferent fibers) - dorsal Sympathetic Neurons (visceral afferent fibers) - ganglion, fight/flight peripheral nerve issues could involve any of these |
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Mobility Characteristics of the Nervous System
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appreciate the continuity of the nervous system! (dynamic and capable!)
Force dissipates throughout the system Nerves are wavy and can straighten - crimp Connective tissue and bundles of nerves |
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Common sites of injury to peripheral nerves
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Nerve Roots - decreased space in intervertebral foramen due to degenerative joint disease, spurs, bulging disc, spondylolisthesis
Brachial Plexus Upper plexus injuries (C5,6) Middle plexus injuries (C7) Lower plexus injuries (C8,T1) Complete or total injury of the plexus Peripheral Nerves in the Upper Quarter Axillary nerve: C5,6 Musculocutaneous nerve: C5,6 Median nerve: C6–8 Ulnar nerve: C8, T1 Radial nerve: C6–8, T1 Lumbosacral Plexus Peripheral Nerves in the Lower Quarter Femoral nerve: L2–4 Obturator nerve: L2–4 Sciatic nerve: L4,5, S1–3 Tibial/posterior tibial nerve: L4,5, S1–3 Plantar and calcaneal nerves Common peroneal nerve: L4,5, S1,2 Superficial peroneal nerve Deep peroneal nerve |
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Common signs and symptoms of injury to peripheral nerves
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Signs and symptoms
Pain Visible atrophy Pain w palpation Dec AROM/PROM Weakness of nerve dis sensory change |
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Three primary sites of compression of brachial plexus
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Interscalene triangle - anterior and medial scalene and 1st rib
Costoclavicular space - clavicle and 1st rib Axillary Interval - deltopectoral fascia, pec minor, coracoid process Compression at any region can lead to Thoracic Outlet Syndrome (TOS) UE neurological vascular symptoms: pain, paresthesia, numbness, weakness, discoloration, swelling, loss of pulse, ? Raynaud’ s phenomenon |
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Axillary Nerve:
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C5-6
Deltoid (abd), teres minor (ER) sensory - skin on shoulder (superficial to deltoid) can happen with surgical neck fracture of humerus |
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Musculocutaneous nerve: C5-6
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Musculocutaneous nerve: C5-6
innervates elbow flexors sensory - radial forearm |
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Median Nerve
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C6-8
Abductor pollicis, opponens pollicis for instance (lumbricals? digits 2 and 3) ape hand - muscle wasting (has been issue for a while) Carpal tunnel Sensory - thumb and two and a half other fingers on palmar side, tips of fingers on dorsal side hypertrophy of pronator teres can cause issues |
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Ulnar Nerve
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C8, T1
Flexor carpi ulnaris, ulnar half flex digit. profundus Sensory - pinky and half of fourth finger cubital tunnel canal of guyon - hook of hamate |
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Radial Nerve
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C6-8, T1
Triceps and wrist extensors Sensory - posterior arm and forearm, and back of lateral hand (including thumb and most of fingers 2,3,4) anterior to lateral epicondyle under extensor carpi radialis brevis extensors - affects grip, because of length tension relationship |
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Femoral nerve
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L2-4
Sartorius and Quad Sensory - anterior/medial thigh and leg prone, flex knee, see if symptoms are recreated typically not plexus injuries in the lower extremity |
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Obturator nerve
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L2-4
Piriformis Gemellus superior Obturator internus Gemellus inferior Obturator externus Quadratus femoris With damage, adduction and external rotation are weak rare to injure it specifically, uterine pressure or birth are mechanisms |
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Sciatic nerve
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L4-5, S1-3
splits into tibial and common peroneal Plantar flexors, post tib, toe flex sensory - heel? SLR test, slump test |
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Path of the sciatic nerve
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Exit pelvis through greater sciatic foreamen
Courses below 85%; through piriformis 15% Protected under glut max-between ischial tub and greater troch Tibial portion innervates biarticular hamstring and adductor magnus Common peroneal innervates short head biceps femoris Proximal to popliteal sciatic n terminates when tibial and common peroneal nerves emerge as separate |
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Mechanisms of nerve injury
intraneural vs extraneural |
Compression - occludes vascular supply
Laceration/trauma Stretch/posture/extreme motion Radiation Electricity intraneural vs extraneural: affects conductive tissues or nerve bed |
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Classification of nerve injuries
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Seddon or Sunderland (neuropraxia, axonomesis, or neurotmesis vs 5 levels)
Degree of injury to nerve substructures Affect on prognosis |
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Neuropraxia
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Seddon's classification
least pathlology, no surgery required damage just on axon itself? no surrounding layers |
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Axonomesis
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Seddon's classification
degeneration distal to compression more serious than neuropraxia complete disruption, usually full recovery Damage could extend to endoneurium, but not perineureum or epineureum |
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Neurotmesis
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Seddon's classification
Damage through endoneurium, perineureum, or epineureum most severe category, poor prognosis without surgery |
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Recovery from nerve injuries is Dependent on Several Factors
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Recovery is Dependent on Several Factors
Nature and level of injury Timing and technique of repair Age and motivation of the patient Outcomes of Nerve Regeneration |
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Outcomes of nerve regeneration
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about 0.5-9.0 mm/day of nerve regeneration
he said ~1inch in a month, might be a week Better prognosis for radial, musculocutaneous, and femoral nerve worse for peroneal |
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Management Guidelines: Recovery From Nerve Injury
different phases |
Acute Phase
Movement Splinting or bracing (protection) Patient education (sleeping position for carpal tunnel) Recovery Phase Motor retraining - voluntary muscle action Desensitization Discriminative sensory re-education Patient education Chronic Phase all potential recovery has happened, teach compensatory strategies to maximize abilities |
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Neural Tension disorders
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Symptoms and Signs of Impaired Nerve Mobility
History Tests of provocation Causes of Symptoms Principles of Management - Neural tension technique - move joint to pull on nerve - neural glide - move 2 joints in chain - less tension and irritation, more mobility Precautions and Contraindications to Neural Tension Testing and Treatment Acute or unstable neuro cauda equina symptoms Spinal cord injury neoplasm infection |
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Neural testing and mobilization techniques for the upper quadrant
which nerves? |
Median Nerve
Thoracic outlet and carpal tunnel Radial Nerve Tennis elbow and deQuervains syndrome Ulnar Nerve Medial epicondylitis |
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Neural testing and mobilization techniques for the lower quadrant
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Sciatic Nerve: Straight Leg Raising with Ankle Dorsiflexion
Slump-Sitting Femoral Nerve: Prone Knee Bend |
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Thoracic outlet syndrome
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Related Diagnoses
Etiology of Symptoms Sites of Compression or Entrapment Common Structural and Functional Impairments Common Activity Limitations and Participation Restrictions (Functional Limitations/Disabilities) Nonoperative Management |
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TOS - compression at interscalene triangle
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Scalene anterior and medius muscle & 1st rib
Muscles hypertrophied, tight, anatomical variation Proximal portion brach plex compressed Symptoms reproduced with Adson’s test |
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TOS - compression at costoclavicular space
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Clavicle and first rib
Clavicle depressed from carry heavy suitcase for a period of time Fractured clavicle or elevated rib Symptoms reproduced Military Brace test |
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TOS - compression at axillary interval
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Anterior deltopectoral fascia, pect minor, and coracoid process
Pect minor is tight result in scapula tipped forward Reproduction of symptoms when arms abducted Roos test - cactus arms and making and releasing fists Palpation of pect minor may reproduce symptoms Activity limitation: Sleep disturbance Inability to carry-briefcase Inability to maintain prolonged overhead activity Inability to do sustained computer Maybe for all TOS? |
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Carpal Tunnel Syndrome
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Etiology of Symptoms
Examination History Positive clinical findings Associated areas to clear Double crush injury - Symptoms at other areas across its course as well as primary site (hurt elbow and have issues elsewhere) Common Structural and Functional Impairments |
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Common Activity Limitations and Participation Restrictions (Functional Limitations/ Disabilities) with Carpal tunnel syndrome
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Avoid using hand
Decreased fine motor, button clothes Inability to performed sustained work-cashier |
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Treatment of carpal tunnel
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Nonoperative Management - flexor tendon gliding exercises, median nerve glide (work to move up levels of the exercise, as close to symptoms as possible without recreating)
Surgical Intervention and Postoperative Management Maximum protection phase Moderate and minimum protection phases |
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Ulnar Nerve Compression in Tunnel of Guyon
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Etiology of Symptoms
Examination History - maybe FOOSH? leaning, pressing Positive clinical findings Associated areas to clear - cubital tunnel, axillary Common Structural and Functional Impairments Common Activity Limitations and Participation Restrictions (Functional Limitations/ Disabilities) Activity limitations Decreased grip Hand Fatigue with sustained grip Inability to use 4rth 5th fingers Nonoperative Management - US, ionto Surgical Release and Postoperative Management |
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Complex regional pain syndrome: reflex sympathetic dystrophy and causalgia
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Pain reported very high!
Taxonomy CRPS type I (reflex sympathetic pain syndrome) CRPS type ll (causalgia) - develops ofter nerve injury Related Diagnoses and Symptoms Shoulder-hand syndrome Sudeck’s atrophy Reflex neurovascular dystrophy Traumatic vasospasm Etiology and Symptoms Clinical Course Stage I: acute reversible stage, 3 wks to 6 months -pain, swelling, stiffness, and discoloration - got to get them moving Stage II: dystrophic or vasoconstriction (ischemic) phase - 3-6 months -Exercise Stage III: atrophic stage - 6 months to one year |
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SLR test - variations
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ankle DF with eversion - tibial tract
ankle DF with inversion - sural nerve ankle PF with inversion - common peroneal tract hip adduction and IR - global increase passive cervical flexion - pull spinal cord cranially toe extension - strain medial/lateral plantar nerves practice changing aspects and applying tension or sliding |
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C1-2 myotome
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cervical flexion
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C3 myotome
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cervical side flexion
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C4 myotome
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Shoulder elevation
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C5 myotome
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Shoulder abduction
and biceps biceps reflex |
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C6 myotome
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wrist extension/elbow flexion
brachioradialis reflex |
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C7 myotome
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elbow extension/wrist flexion
triceps reflex |
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C8 myotome
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thumb extension, finger flexion
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T1 myotome
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finger abduction
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L1-2 myotome
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hip flexion
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L3 myotome
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knee extension
(L3/4) quadriceps relflex |
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L4 myotome
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ankle dorsiflexion
quad reflex |
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L5 myotome
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extensor hallucis longus
tibialis posterior reflex |
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S1 myotome
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ankle eversion/plantar flexion
achilles reflex |
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S2 myotome
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knee flexion?
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S3 myotome
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intrinsic foot
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Slump test
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sit with back rounded and neck flexed
dorsiflex foot and begin extending knee be observant for tissue resistance and symptom reproduction can apply overpressure to head for more neck flexion for sciatic nerve or others, lots of false positives if symptoms decrease with release of neck flexion, may indicate adverse neural dynamics as source of sxs assess ROM and pain response before, during, and after each added movement |
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What does the sliding technique for the median nerve do, according to Coppieters and Butler?
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alters intraneural pressure that may result in a "pumping action" or "milking effect." THis may then enhance dispersal of local inflammatory products in and around nerves. this will promote health and mobilise inflammatory soup
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What is the loose-pack position for the shoulder?
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55 abd, 30 hor add
slight IR or ER? |
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What mobilization(s) will increase shoulder abduction?
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caudal glide - loose packed
caudal glide progression Sternoclavicular joint: caudal glide of clavicle in supine will increase elevation |
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What mobilization(s) will increase shoulder extension?
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anterior glide - prone, loose-packed
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What mobilization(s) will increase shoulder external rotation?
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anterior glide - prone, loose-packed
arm in resting position with humerus ER as far as possible - perform GH distraction |
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What mobilization(s) will increase shoulder flexion?
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posterior glide - supine, 90 sh flexion, IR, elbow flexed
also increases horizontal adduction Sternoclavicular joint: caudal glide of clavicle in supine will increase elevation |
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What mobilization(s) will increase shoulder protraction?
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SC: anterior glide of clavicle will increase protraction
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What is the loose-packed position of the elbow?
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flexed 70, supinated 10
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What mobilization(s) will increase elbow flexion?
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Distraction with distal glide (scoop motion)
Volar glide of proximal radius at humeroradial joint |
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What mobilization(s) will increase elbow extension?
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Dorsal glide proximal radius at humeroradial joint
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What mobilization(s) will increase elbow pronation?
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in 10 degrees supination, stabilize distal ulna, glide distal radius volarly to increase pronation
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What mobilization(s) will increase elbow supination?
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in 10 degrees supination, stabilize distal ulna, glide distal radius dorsally to increase supination
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What mobilization(s) will increase elbow "mobility"?
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humeroulnar - elbow flexed 70, supinated 10 = distraction
humeroradial - 45 flexed (about), forearm supinated to end range, supine, pull radius distally (long-axis traction) to increase mobility Radial head concave |
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What manual technique will improve knee flexion?
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take joint to end range flexion, internally rotate and apply a sustained grade II distraction
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Foot mobilizations to increase supination and arch of the foot are as follows
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Stabilize cuneiforms and plantar-glide metatarsals I, II, III
Stabilize calcaneus and plantar-glide cuboid Stabilize talus and laterally glide calcaneus |
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Mobilization to increase wrist extension
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stabilize trapezium-trapezoid unit and volar-glide scaphoid
stabilize lunate and volar-glide capitate stabilize radius and volar-glide the lunate |
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What gliding technique distracts weight-bearing surface in acetabulum?
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long axis traction of the femur
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What's a gliding technique that improves supination?
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plantar-glide navicular on talus
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What gliding technique improves knee flexion
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posterior glide tibia on femur
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