PNE Questions

[physioroman]

Hello Physios out there!

I am preparing myself for the clinical exam in Canada. Therefore, I would like to ask some questions.

Assessing tone on upper extremities after a stroke.

Q1: do I start proximally with scapula or distally with fingers / thumb
Q2: do I assess the other side prior of the affected side ?
Q3: do I assess scapula movements in supine or in sidelying?
Q4: do I have to count one, one thousand as I go through the movement?


Ortho:
How do I mobilize a patient with total hip arthroplasty posterior or
anterior approach on the R-side on day 1 out of bed? Do I go over the
affected side or the unaffected side? I was taught to go over the affected side but reading some notes I've noticed that they might go over the unaffected side.

Any ideas? Shouldn't be too hard for a english-trained physio.
I appreciate your support.
Thank you very much.
Roman

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[mark456]

hi i am mark this is a nice topic

[gcoe]

Hi physioroman

Re: tone questions: I don't know what the Canadian authorities are seeking as an answer. However all the questions are from my view redundant questions. They really make no sense. Rather I think you have to ask yourself 1) why are you assessing tone? 2) what aspect of tone are you wanting to assess? and once you know that 3) how will you measure it using a valid and reliable measure?

Why are you assessing tone?
Tone is simply the magnitude of resistance to passive stretching of a musculotendinous unit or group of units. In terms of impairments that patients with stroke present with increased tone has been overrated as an important problem. Commonly weakness and loss of dexterity are considered way more important (although increased tone may be a more important impairment in the chronic stroke patient or in other neurological problems)

I would only assess for increased tone if I suspected this was affecting the patients function. Otherwise I wouldn’t bother.

Example:

Let’s say the patient is unable to reach for an object. He can’t flex at the shoulder and extend at the elbow appropriately. I would be thinking that this may be most likely due to weakness of the scapular upward rotators, shoulder flexors and triceps. Possibly there could be a dexterity problem so I would be looking for smoothness of movement and interjoint coordination as well. I wouldn’t be that concerned about increased tone in the acute setting although the patient may be developing contracture and the shoulder extensors/scapular retractors or elbow flexors, particularly if not undergoing preventive positioning. Anyhow if I wanted to test for tone I would therefore logically test the resistance to movement of the scapular downward rotators, shoulder extensors and internal rotators and elbow flexors. The order of testing is not important as long as I have tested the key muscles that are antagonistic to the functional movement I am assessing. In another functional task the testing I would do would be related to that task so different muscles.

What aspect of tone are you wanting to assess?

On the whole increased tone is either due to:

1. Contracture: shortening of the non contractile elements. Contracture can be defined by
a) increased resistance through range
b) Loss of end of range
c) Deformity at rest.
2. Spasticity. Spasticity is defined as velocity dependent increased resistance to lengthening the muscle.

So if I want to differentiate contracture from spasticity I need to do passive stretch at slow and fast speeds

How will you measure it using a valid and reliable measure?
There are two clinical tools commonly available: the Ashworth Scale (or Modified Ashworth Scale). The Tardieu scale

Of the two scales the Tardieu Scale has superior validity as well as good reliability. It successfully differentiates and quantifies spasticity from contracture.

Here are two articles on the Tardieu Scale. Both articles have the scale instructions in the back.

I am sorry if my answer is long-winded and doesn’t answer what you wanted. However you have to know what you are intending to do in order answer questions appropriately and know whether a question is valid. These questions seem a nonsense to me

I’ll leave it to an orthopaedic physio to answer the arthroplasty question

[zisuer]

I am preparing for the PNE in canada too, I am a graduate in Canada, but I don't understand the questions you ask, esp, how you assess scapular when patient supine? you mean tranfer pt 1st day after THP?

[physioroman]

Hi zisuer,
how is the studying going?

scapular movements are usually assessed in sidelying but at a 10' station you might want to hurry to assess all the joints. I would prefer doing it in sidelying but I have seen neurophysios doing it in supine with one hand underneath the scapula doing elevation /depression/pro- and retraction. What did they teach you?
About the hip stuff. Yes, I did mean transfer over which side (affected or unaffected). Doesn't really matter which day post surgery but at the hospital patients usually get mobilized on day 1.

About your lumbar decrease in mobility. Sounds good what your doing. Do you know neurodynamcis. How is the SLR? If neural stable, you could try sliders by using DF / PF or via neck flexion / extension. The fracture 2months later should be cleared and stable. Did he get a control x-ray? This patient needs mobility in his lower back otherwise he/she will compensate at the segments above or below (developing hypermobility) and at the hips.

Scalene muscles are usually tight if the deep neck flexors are inhibited. To decrease tension you might want to use manual techniques and mobilize lateralflexion PPIVM of the cervical spine. Check his/her 1st rip. again, also test his neurodynamics. ULTTs. I am pretty sure you will find something. then start recruiting deep flexors.
Wouldn't do modalities on the neck anteriorly. n.vagus....
good luck.

[zisuer]

Thanks for your comments. I just started to review the basic things. I never been taught do scap assessment on supine. About your T/F question, just remember the contraindications about the hip replacement. for example, for post-lat approach, if your way to transfer the pt may cause hip add past neutral, it may not be right. My instructor told me sometime, depend on patient preference.

[zisuer]

Hi, Sir. I just found the specific answer for the questions you asked. You can find the details in the Frank M. Pierson book, patient care. Page:160. You also can find the scapular mob in this book. It is sidelying. you may use other positions. For the T/F, leading with unaffected side, but as I mentioned before, no add past neutral, no rotation, esp Int Rot if post approach. no flexion above 90. Hope it helps! If you need more details, please refer the book, or send message to me
Additional Comment I forgot:
forgot to say, some pt do T/F leading by affect side. so the position of the bed may dectate how the t/f is accomplished