Which of the following body movements should indicate to the nurse the patient has full range of motion of the shoulder?
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Range of motion (ROM) refers to how far you can move or stretch a part of your body, such as a joint or a muscle. It’s different for each of us. For example, some people can do complete splits, but others can’t: their joints aren’t loose and their muscles won’t lengthen as far. You can improve your physical well-being and avoid injury if you’re
aware of your ROM. Active Range of Motion (AROM). This is the space in which you move a part of your body by using your muscles. You make the effort without outside help. For example, lifting your arms above your head to stretch the muscles happens within your active range of motion. Passive Range of Motion (PROM). This is the space in which a part of your body
can move when someone or something is creating the movement, such as a massage or physical therapist. You're not the one engaging the muscles you would normally use to start the movement and do the work. There is a middle category for range of motion in which someone helps you move. Assisted active range of motion(AAROM) often happens in physical therapy, when you need to build up
flexibility or strength in a particular body part. For example, you sit down and lift your leg up in front of you as far as you can. Another person, often a physical therapist,
helps you stretch your leg more than you’d be able to if you flexed your own muscles. You can do range-of-motion exercises to hold onto your flexibility and mobility. If you are stiff or see that you can’t stretch as far as you used to, ROM exercises may help you regain what you’ve lost. Over time, they may even give you a better range of motion. PROM exercises are especially beneficial when a situation
such as a stroke or an accident has left you bedridden or wheelchair-bound. If you are unable to move, medical professionals will move your muscles and bend your joints for you on a daily basis, working you toward potential recovery. They may even teach your family members how to help you. With AROM exercises, you strengthen your muscles when you actively engage them in movement. This is good for your overall health and improves your mobility
over time. You can improve your active range of motion by holding movements or stretches for at least 30 seconds. By doing this, you build strength in the muscles needed for a particular movement. Keep in mind that you want to do a variety of range-of-motion exercises that challenge your entire body and not a single muscle group alone. As an example of AAROM exercise, if you break your ankle, you must stop moving that part of your body as it heals. Once your ankle heals and is
ready to bear weight, you may still find it hard to move. That’s because you’ve lost range of motion due to the lack of use. You may lift your foot up and press it down, but it only goes so far. A physical therapist can apply pressure to your foot to move it just a little more than your body allows. This stretches the muscle and joint, increasing the range of motion. Cons of Passive
Range of Motion. When you’re not in control of a movement, there’s a greater chance of injury. Another person can’t tell what your limit is and may move a muscle or joint farther than it is able to go. Stretching a little beyond your limit is good for increasing your range of motion. But pushing too far may lead to a muscle tear or damage to a joint. This is a risk in AAROM as well. No one should push you to the point of pain. There may be instances of
movement where you only use your muscle in a single way. If you keep repeating a particular motion without changing up how you use your muscle, you may limit your range of motion. For example, if you work out in a gym and complete a series of exercises that work your biceps, you strengthen those muscles. If you continue to focus on this muscle group without adding in motions that work your triceps, on the back of your arms, you may limit the range of motion in your arms. Keep in mind
that no range of motion exercise should cause you pain. Listen to your body and stop when you reach your limits. Stretching too far while using passive or active range of motion may cause damage. The physical exam in Parkinson’s disease (PD) is essential both for making a diagnosis and following the patient over time. It consists of a series of tests and maneuvers that help us identify and evaluate the four main characteristics of the disease: - Bradykinesia - Rigidity - Tremor - Gait & Balance abnormalities In order to make a diagnosis, we must observe bradykinesia plus either one of the other motor abnormalities. Once a diagnosis is made and the patient is started on treatment, it is important to check these four features at every follow up visit, so that we can gauge the treatment based on how the exam has changed over time.
Before beginning the interactive part of the physical exam, it is very important to focus on observing the patients while they are giving the history, to notice any motor disturbances present at rest. In particular we should focus on: - Spontaneous movements, generally reduced in PD - Hands gestures while talking, usually reduced or absent - Eyeblink, whose spontaneous rate is reduced - Resting tremor, usually affecting one hand only - Fidgeting and crossing/uncrossing of the legs, that may indicate dyskinesia, a complication of chronic Levodopa therapy It is important to remember that the inspection starts as soon as the patient walks in to the room. Click this link to watch an example of spontaneous resting tremor on the video. Bradykinesia is defined as a generalized slowness of movement, with patients struggling in particular with starting a movement. It is seen in almost every patient with Parkinson’s disease, making its presence essential for diagnosis. It is also one of the most debilitating symptoms of PD. Rapid Alternating MovementsTo test for the presence of bradykinesia we will have the patient perform rapid alternating movements. It is important to remember that these movements must be performed as fast as possible and as big as possible, meaning with the amplest range possible. All these tests are positive for bradykinesia if the range of motion and/or the speed reduce over time. For this reason, it is crucial to ask the patient to do at least ten repetitions for each movement. Also, in both the upper and lower extremities, the movements more affected by bradykinesia are the finest ones, such as the movements of the toes and fingers. Finger tapping In finger tapping the patient is instructed to tap the index finger on the thumb as fast possible and as big as possible. This means that the patient should try to separate the two fingers as much as possible before tapping them. Make sure to test both the right and the left side. Click this link to watch an example for the “finger tapping test ” on the video. Fist Open Close If the patient has arthritis of the hand joints, the finger tapping is not a very sensitive test. In this case, we can use other tests such as the fist open close. To perform this test, instruct the patient to open and close the fist as fast as possible and by spreading the fingers as much as possible. Click this link to watch an example for the “fist open close test” on the video. Rapid opening and closing of the fist. Pronation/Supination of the Hand This represents another alternative to the finger tapping test. The patient is instructed to flex the shoulder forward at 90° and fully extend the forearm. From this position, ask the patient to rapidly alternate pronation and supination of the hand. Again, look for a reduction in the speed and amplitude of movement, no matter how slight this is. Click this link to watch an example for the “pronation/supination test” on the video. Rapid pronation/supination of the hand. Toe Tapping It is possible to test for bradykinesia in the lower extremities too, where the most sensitive test is toe tapping. In this test the patient sits on a chair with both feet on the ground. The patient is instructed to rapidly tap the floor with the toes while the heel is kept in touch with the ground. The test is positive if the speed and/or amplitude of movement reduce over time. Click this link to watch an example of the “toe tapping test” on the video. Fast toe tapping on the ground. Heel Tapping To carry on the test, first the patient has to sit on a chair with the feet on the ground. Then, instruct the patient to repetitively and rapidly tap the whole foot on the ground. This maneuver tends to be less sensitive than toe tapping. Again, the test is positive if the speed or amplitude of movement reduces over time. Click this link to watch an example for the “heel tapping test” on the video. Fast tapping of the heel on the ground. Rigidity is defined as increased resistance to passive movement about a joint. It usually starts on one side and later spreads to the other one. It is similar to spasticity since both conditions show increased resistance to passive movement. However, rigidity is not direction dependent, that means there is the same amount of resistance both in extension and flexion of the affected limb. Also, rigidity is not velocity dependent, meaning that the tone does not change based on the speed of passive motion. Passive Manipulation of LimbsTo test for the presence of rigidity, we need to passively manipulate the limbs of the patient. However, If the disease is in its early stage or the symptoms are well controlled with medications, we may not be able to see rigidity. We will need to use some activation maneuvers, that basically consist in performing repetitive movements with the limb contralateral to the one that is being tested. Also, there are two types of rigidity: - Lead-pipe rigidity: where the tone is uniformly and smoothly increased throughout the entire range of movement - Cogwheel rigidity: where a tremor is superimposed on the hypertonia, making the movement irregular due to intermittent increase and reduction of tone Upper Extremity Testing For the upper extremity the most sensitive joint where to check for rigidity is the wrist. To uncover rigidity, passively rotate the wrist and feel for a resistance to the movement. It is very important that the arm of the patient is fully relaxed when rotating the wrist. To do this, place your proximal hand under the patient’s forearm, while your distal hand grabs and rotates the wrist of the patient. When rigidity is present, the range of motion will be preserved but you will feel a resistance in performing the movement. Wrist rotation with activation maneuver. It is also possible to test for rigidity in the elbow by passively flexing and extending the forearm. In both cases, we can unmask the rigidity by asking the patient to forcefully and repeatedly tap the other hand on the knee as activation maneuver. Elbow flexion-extension with activation maneuver. Lower Extremity Testing To test for the presence of rigidity in the lower extremity, place your top hand under the patient’s knee to fully support the weight of the leg and make sure the extremity is relaxed. Then, grab and rotate the patient’s foot with your bottom hand to test the ankle joint. After that, always by grabbing the patient’s foot, passively flex and extend the knee. The activation maneuver in this case is identical to the one used for the upper extremity. The patient will tap his contralateral hand on his other knee. Again, rigidity is present if a resistance, rather than a limitation to the range movement, is noted. Passive rotation of the ankle. Passive flexion-extension of the knee. Tremor is defined as an involuntary trembling of a body part. There are three main types of tremor: - Resting tremor - Action (Kinetic) tremor - Postural tremor All of these types of tremor can be seen in Parkinson’s disease, even though resting tremor is the more frequently observed one and also the most severe when all three tremors are present in PD. Patients with essential tremor, instead, classically have more severe postural and kinetic tremors as compared to resting tremor. Resting TremorIn Parkinson’s disease resting tremor most commonly manifests in the hands as a rotatory movement of the fingers, especially the thumb and index (pill-rolling). Even though we could observe a resting tremor while the patients are giving the history, sometimes they may assume a position that suppresses the tremor. For example, they could sit on their hands or hold them in their lap. The best position to uncover a resting tremor is with the patient sitting on the chair with both hands lying relaxed on the thighs. Click this link to see an example of resting tremor on the video. Resting tremor on the left hand. Postural TremorPostural tremor is a type of tremor that emerges when the patient maintains a position against gravity. To test for postural tremor, first have the patient fully extend the elbow and flex the arm forward at 90°. Then, ask the patient to spread the fingers out as much as possible and hold this position for a few minutes. This is necessary since a postural tremor in PD is often evidenced only a few seconds or minutes after the position in assumed. Click this link to see an example of postural tremor on the video. Position to test postural tremor. Kinetic (Action) TremorAction or kinetic tremor is a type of tremor that is uncovered only when the patient is carrying out a movement. To test for kinetic tremor we can use the finger to nose test. In performing this test, the patients are instructed to alternatively touch their nose and our finger. In doing so, the patients should stretch their arm completely and should not move too fast. In this way we have more chances of triggering the tremor. There is a different variant of the finger to nose test, in which the finger of the examiner changes position every time that the patient tries to reach it. This variant of the test is used to test for ataxia, rather than for tremor. Click here to jump to the section of the video showing how to perform the finger to nose test.
Finger to nose test: the patient reaches for the finger of the examiner. Finger to nose test: the patient goes back to his nose. Patients with Parkinson’s disease can develop an alteration of the postural reflexes that causes instability in gait and balance control. Such alterations usually develop later in the course of the illness and are a major cause of disability, especially because of the high risk for falls that derives. Using the exam to pick up postural instability is of the utmost importance for the management of patients with PD, since it will trigger either a medication adjustment or a physical therapy intervention both aimed at falls prevention. We have three tests for this part of the PD exam: 1) Standing up from a chair 2) Free walking 3) Provoked “pull test” maneuver for balance Standing From ChairIn this test we want to see if the patient is able to stand up from the sitting position without using the hands. To perform the test, first ask the patient to cross the arms on the chest and then to stand up. Make sure to keep one of your hands behind the patient’s back throughout the test, in order to prevent the patient to fall backwards and hit the head against the wall. In normal conditions the patients will be able to stand up without any difficulties. Standing from chair (1): the patient crosses his arms on the chest. Standing from chair (2): the patient stands up while the examiner keeps a hand on his back. Free WalkingThis part of the exam consists in observing the patient’s gait. To increase the chances of picking up any abnormalities that may be present, the patient should walk back and forth several times, ideally, in a hallway at least 10 feet long. While the patient is walking, we need to look for: - Loss of balance on the turns - Reduced step length - Loss of heel strike - Loss of arm swings These are typical abnormalities of gait in Parkinson’s disease. Also, in the initial stages of the disease, these anomalies tend to be unilateral, making them easier to recognize. Click here to jump to the section on the video showing an example of asymmetric heel strike and arm swing loss. A gait with short steps and absent heel strike bilaterally is called “festinating” or “shuffling” gait and is typical of Parkinson’s disease. Click here to see an example of festinating gait in the video. Observe for arm swinging, step length and heel strike. "Pull Test" for BalanceIn this test the examiner stands behind the patients and by pulling on their shoulder tries to make them fall backwards. If the patients are able to correct their center of gravity in just one or two steps, the test is negative for a balance abnormalities. The test is instead considered positive if the patients catch their balance in more than two steps or if they do not stabilize at all and tend to fall to the ground. Click here to see an example of how the “Pull Test” should be performed. To make sure the test is performed in a safe way, there are some precautions that should be taken: - First, there should be a wall behind the examiner, so that if the patients do not manage to correct their balance and fall backwards, the examiner can grab them and together they can fall on the wall; - Second, the examiner must teach the patients how to perform the test and must explain what is going to happen if they are going to lose balance and fall. Click here to see an example of an abnormal result on the “Pull Test”. Clinical Pearl"When during a follow up visit we notice new worsening bradykinesia, tremor or rigidity, this does not necessary imply that a change in the medication regimen is needed, unless it is significantly impacting the quality of life of the patient. On the other hand, even the slightest impairment of gait and balance control necessitates an intervention, that may be as simple as physical therapy."What body movement indicates full range of motion of the shoulder?A normal range of motion for shoulder flexion is 180 degrees. This involves moving your arms from palms against the side of your body to the highest point you can raise your arms over your head.
Which action is appropriate when getting a client out of bed via a mechanical lift?Which action is appropriate when getting a patient out of bed via a mechanical/hydraulic lift? Place the sling under the patient's center of gravity and greatest portion of body weight. The sling (or hammock) is supplied with the lift.
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