HIP

Trendelenburg ● Eval posture in SLS position

○ Make it harder- eval in SL squat Positive if hip drop own
on non WTB side= weak glut med. Contralateral hip drop
○ Types:
■ A compensated trendelenburg occurs when the
patient's trunk leans ipsilateral to the side of the
stance leg.
■ An uncompensated trendelenburg occurs when the
examiner observes contralateral pelvic drop.
■ A normal test result is when the patient is able to
maintain a level pelvis without either of these
substitutions..

Leg length ● True: ASIS to medial malleolus

● Functional/apparent: umbilicus to medial malleolus
○ Test procedure:
■ Standing posture- a few marches to lvl legs out,
then- any coxa vara and genu valgum= shorter
limb/ coxa valga and genu varum= longer limb?
■ Supine eval where medial malleoli fall relative to
one another
■ Have pt glute bridge to lvl hips out, with knees
bent eval tibial length
■ Measure in CM and mark any differences .

FABER ● In supine pt does figure 4 pose, ankle above the knee.

○ Therapist pushes down to see if the knee can reach
horizontal with the other leg/ table…
○ + Positive test if pt cant get into position, drop to
horizontal, or has pain. Anterior pain= probable hip joint
pathology/ iliopsoas spasms, posterior pain indicates
possible SI pathology .

Anterior labrum ● FADDIR

○ Ant/ superior impingement, anterior labral tear or
iliopsoas tendonitis…
1. Pt supine in flexion, abd, ER
2. Therapist moves hip into ext adduction and internal rotation- this
places greatest strain on anterior labrum
a. + Positive test= any pain, apprehension, clicking,
symptoms reproduced ..

Posterior labrum ● Test for post/inf impingement, posterior labrum tear, anterior
instability
 1. Test in flexion, adduction, IR
2. Therapist moves hip into abd, ext and ER
a. + Test is positive if there is pain, apprehension, clicking,
reproduction of symptoms .

Scour ● .Test for hip joint pathology, also known as quadrant test…
Should be smooth movement, potivie if painful, any catching,
clicking, bumpiness.
1. Pt in supine, flexion hip/knee and adduct hip
2. Therapist applies axial pressure thru femur, keeps hip flexed,
moves between adduction and abduction
a. Lesion will depend on where pain is felt:
i. In adduction, flexion, IR= anterior lesion
ii. In abduction, flexion, ER= posterior lesion .

Sign of the ● .Test to rule out hip pathology

buttock 1. SLR
2. Bend knee and assess further
a. + If pt is unable to go farther for hip ROM with knee bent
it may indicate the presence of pathology, abscess, tumor,
loose bodies. .

Fulcrum ● Assessing presence of a femoral stress fracture

1. Pt will be sitting off EOT and therapists arm will be under
affected leg
2. Therapist presses down on distal leg and assesses for pain, can
move pressure proximally as well.
a. + Positive if painful .

Postural screen ● Coxa varum: SHORTER LIMB

○ Angle of inclination over 125º, usually 110-115º or less
○ Paired often with genu valgum
○ Excessively pronated feet
○ Weak hip MM
○ Increased stresses on lateral meniscus and MCL
○ Tibial abduction
○ Forefoot valgus
○ A Trendelenburg limp is sometimes associated with
unilateral coxa vara and a waddling gait is often seen
when bilateral coxa vara is present. Patients with coxa
vara often show:Limb length discrepancy, Prominent
greater trochanter, Limitation of abduction and internal
rotation of the hip, Patients may also show femoral
retroversion or decreased anteversion

● Coxa valgum: LONGER LIMB

 ○ Angle of inclination over 125º, increased over 140º
usually
○ Associated with genu varum
○ Increased stress on medial meniscus and LCL
○ Supinated feet
○ Tibial adduction
○ Forefoot varus

Piriformis ● Piriformis test

syndrome 1. Side Lying with test leg up
a. Pt flexes hip to 60º and bends knee
b. Therapist stabilizes pelvis/ hip and then applies pressure
downward on the knee, hold for 30-60 sec
2. FAIR
a. Side Lying with test leg up
b. Pt flexes hip to 90º and bends knee to 90º
c. Therapist stabilizes pelvis/ hip and drops test leg down
and into IR
3. Active test
a. Ask pt to clamshell while you apply resistance
b. + Positive test if pain in buttock, or any N pain s/s, testing
to see if piriformis tightness if compressing sciatic nerve
KNEE SPECIAL TESTS

Lachmans Test 1. Patient supine, knee slightly flexed 0-30 degrees

2. Patient stabilizes femur with proximal hand, translates proximal tibia
anteriorly with distal hand
a. + Positive ACL if soft end feel or excess anterior tibial
translation

Anterior drawer 1. Pt supine knee flexed 90 degrees

2. Translates proximal tibia anteriorly
a. + positive ACL if more than 6mm of movement,
3. Can do tibial IR to test anterolateral capsule of tibia or ER to test
anteromedial capsule

Pivot shift test 1. PT holds pts foot/ heel with distal hand while proximal hand is at
knee on posterior head of fibula holding leg in slight IR and apply
valgus force
2. Maintain IR/valgus, in supine hip is flexed and abducted 30 degrees
and relaxed with slight IR knee starts near full extension (unlocked)
a. + Positive ACL if lateral tibial plateau starts in subluxed/
anterior position and then reduces around 20-40 deg flexion,
b. Pt may describe this as same sensation they get when knee
gives way, if click occurs, meniscus pathology may be
 present

Posterior 1. PT supine knee flexed 90 degrees

drawer 2. PT translates proximal tibia posteriorly positive sign would
implicate:
a. articular popliteus complex, posterior oblique lig, can add
tibial IR to test to implicagte posterolat complex
b. + PCL if pain

Valgus stress 1. Pt lies supine and PT applies valgus stress at knee (push and gap
test medially)
2. While ankle is stabilized with PT hand or between PT arm and trunk,
test at 0 degrees then at 30
a. + MCL if pain/ gapping and laxity

Varus stress 1. Pt lies supine, PT applies stress at knee (push and gap laterally)
test 2. While ankle is stabilized with hand or between PT arm/trunk, test at
0 and then again at 30º
a. + LCL if pain/ gapping and laxity

Mcmurrays test 1. Patient in supine

2. PT places knee in full flexion (heel to buttock)
3. Then medially rotates tibia and extends knee (lateral meniscus)
4. Then repeat full flexion with lateral tibial rotation and extend knee
(medial meniscus)
a. Repeat several times, + positive meniscus lesion if click or
pain

Thessaly 1. Pt stands on one leg and holds PT hands for balance

2. Pt flexes knee to 5 degrees and rotates femur on tibia and medially/
laterally
3. Repeat in 20 degrees flexion
a. + Positive meniscus lesion if pt feels joint line discomfort
b. Medial direction: because it is CKC, lateral meniscus
c. Lateral direction: because it is CKC, medial meniscus

Apleys 1. Pt prone with knee at 90

compression 2. PT provides distraction force +IR/ER tibia
test 3. Then repeat with compressive force and IR/ER tibia
a. + Positive for meniscus pain if pain with compression
b. + Positive for ligaments if pain with distraction

Joint line 1. Palpation at 90 degrees and extended

tenderness a. + Meniscus positive if TTP

Dynamic lateral 1. Pt supine with hip flexed, abducted 60 degrees, ER 45 degrees and
meniscus lesion knee in 90 degrees (lateral border of foot will rest on table)
 2. PT palpates lateral joint line while adducting hip
a. + Positive lateral meniscus lesion if pain on joint line or sharp
pain at end of adduction

Ottowa knee 1. Inability to walk 4 weight bearing steps

rules 2. Inability to flex knee 90
3. Tenderness at head of fibula
4. Isolated patellar tenderness
5. Age > 55
a. + REFER FOR IMAGING

PFPS cluster 1. Seated resisted quads

2. Step down
3. Pain with squatting
4. Pain with prolonged sitting
5. Patellofemoral compression
6. Pain with palpation to postero lateral/medial patellar borders
7. Patellar apprehension test- subluxation

ANKLE/FOOT SPECIAL TESTS

NWB ST joint 1. Pt lies prone with feet over EOB

neutral 2. Use one hand on medial side of pt to palpate head of talus with finger
and thumb on dorsum of foot/ ankle
3. Use other hand (on lateral side of pt) to grasp 4th and 5th MT
4. PT passivey DF foot/ ankle to 90 while maintaining DF, move foot
into pronation/supination to feel head of talus
5. When talus is not palpable this is neutral
6. Use this to determine leg- heel alignment and heel forefoot alignment
a. Forefoot varus versus valgus

b. Rearfoot varus versus valgus

Leg to heel 1. Pt prone
alignment in 2. Mark midline of calcaneus achilles insertion
NWB: 3. Make another mark 1cm below as close to midline of calcaneus as
possible,
4. Connect dots= calcaneal line
5. Make two marks on lower 1/3 of the leg to form midline of leg= tibial
line
6. Place pt in STJ neutral and observe positions of lines,
a. Parallel or slightly varus (2-8º) = normal
b. Inverted= rearfoot varus, everted= rearfoot valgus

Foot to leg 1. Pt supine in Magee (can also do prone)

alignment in 2. Put pt in STJ neutral and maintain throughout test
NWB: 3. Pronate mid tarsal joints maximally.
4. Observe position of vertical axis of heel and plane of met heads 2-4
a. Right angle= normal
b. Medial side of foot is raised= forefoot varus
c. Lateral side of foot is raised= forefoot valgus

Navicular drop 1. Pt stands and PT helps place them in STJN

test: 2. PT measures height of navicular from floor,
3. Pt is instructed to relax and PT measures height of navicular from
floor.
4. Difference in heights= navicular drop
a. >10mm is considered abnormal

Anterior Drawer 1. For ATFL injuries

2. Pt is supine, foot relaxed, heel off EOB,
3. PT stabilizes tibia/ fibula, holds patients foot in 20 PF and draws the
calcaneus/ talus anteriorly in the ankle mortise OR pt puts foot on
table
4. PT stabilizes foot and pushes posteriorly on leg OR pt prone pt
stabilizes tibia and fib and push heel anteriorly
a. Positive if dimple over ATFL pain, excessive motion of foot
on leg/leg on foot, sucking in of skin around achilles

ER test: 1. Pt seated on EOB with knees at 90º, feet dangling

2. PT stabilizes leg with one hand, holds foot at 90º and applies passive
ER stress to foot and ankle.
a. Positive for high ankle injury if pain over anterior or posterior
tib fib ligaments or IO membrane
b. Positive for deltoid ligament tear if pain medially and talus
displaces medial malleolus

Squeeze test for 1. Pt supine PT grasps leg at midcalf and squeezes tibia and fibula
ankle sprain: together
2. Then repeats more distally moving to ankle
a. Positive if pain in lower leg , distal to squeeze site

Anterior 1. Patient in sitting

impingement: 2. Therapist grasps the heel and presses the anterior lateral aspect of
ankle with thumb, may be TTP, fully DF ankle while maintaining
pressure with the thumb
a. Positive if pain is reproduced and or TTP with dorsiflexion

Talar tilt: 1. Pt supine or side lying with foot relaxed, knee flexed to relax gastric,
PT holds foot at 90 and then tilts calcaneus and talus into eversion and
inversion
a. Inversion: places stress on CFL,
b. Eversion stresses deltoid ligament, foot PF pain- ATFL, DF-
PTFL
c. + Positive if pain or excessive motion compared to other limb

Thompsons test: 1. Achilles rupture/ calf squeeze

2. Pt prone with feet over EOB
3. PT squeezes calf
4. + Positive if no PF

Homans test: 1. DVT

2. Pt foot is passively DF with knee extended
3. Positive if pain in calf
4. Also confirm with redness, warmth, tenderness in calf, loss of dorsal
pedal pulse

Tinels sign: 1. Anterior tibial branch of deep peroneal nerve: tap anterior to medial
malleolus
2. Posterior tibial nerve: tap posterior to medial malleolus
a. + Positive if pain/ paresthesias distal to tap

Girth 8 1. Start with 0 mark of the tape on the inferior aspect of the navicular
measurement: 2. Wrap tape over dorsum of foot to the lateral 5th MT head
3. Continue to plantar aspect of foot and align tape with plantar aspect of
metatarsal heads
4. After tape is on 1st MT head, wrap diagonally over dorsum of foot
(should cross tape at mid dorsum and proceed tru center of lateral
malleolus)
5. Continue around posterior leg/ankle across the mid achilles, under the
medial malleolus and back toward your starting point on navicular

Ottawa ankle 1. A Patients need XRAY if they ℅:

rules: a. Malleolar or midfoot px and have bony tenderness or
b. Cant WTB for 4 consecutive steps, limping is okay
 c. Dull with blunt trauma to ankle or midfoot in last 10 days
d. Palpation for tenderness, distal 6 cm of entire fibula and tibia,
base of 5th MT, navicular
e. Inaccurate if too much swelling

THORACIC
Thoracic exam: ● cervical, shoulder, and lumbar clearing tests .

Observing ● posture (scoliosis, kyphosis).

posture:

Neuro screening ● Depending on patients signs and symptoms, median/ ulnar/ radial N
ULTT, sensation, tension testing patient is supine no pillow.
reflexes:

ULTT median ● Start with elbow flexed

nerve: ● Prevent shoulder girdle elevation with pt fist on table abduct shoulder
90º
● Supinate forearm, extend wrist/ fingers, ER shoulder to 90º, slowly
extend elbow .

ULTT radial ● Shoulder abducted to 10º

nerve: ● Prevent shoulder girdle elevation with pt hip, extend elbow, medially
rotate shoulder/ whole arm
● Pronate forearm, flex fingers and wrist, avoid any shoulder flexion .

ULTT ulnar ● Put hands palm to palm

nerve: ● Prevent shoulder girdle elevation with PT fist on table, abduct shoulder
90º, ER shoulder 90º
● Pronate forearm, extend wrist and fingers, flex elbow to pts face .

Thoracic AROM/ ● T1 and T2 inclinometerAROM screening .

PROM with
overpressure:

PPIVMS: ● All in SL ( flexion, extension U rotation of top side, U side bend of top
side) .

PAIVMS: ● PA, U rotation, central/ B extension .

Rib Mobility: ● Inspiration/ expiration spring test P/A prone

● Spring test A/P, 1st rib test- cervical rotation and lateral flexion test
(rotate away and bring ear to chest for SB exercise, test left 1st rib and
 rotation R and SB L) .

Resisted tests: ● Gross or MMT LQ, abdominals, and periscapular .

Muscle length and ● Lats and pecs .

flexibility:

Spring test: ● PA mobility test .

1st rib ● Therapist stand behind the patient while pt seated

manipulation: 1. Web space of PT contacts posterior border of 1st rib
2. Therapist supports patient arm on leg and SB pt towards side, position
in neutral putting cervical soft tissue on slack
3. Patient deep breath and on exhalation therapist moves into barrier taking
up slack then provides a high velocity short amplitude thrust on the 1st
rib .

Seated middle ● Patient is seated with arms across body grasping opposite shoulders
thoracic 1. Pt stands in back of patient with his/ her sternum at level of patients mid
manipulation: thoracic spine
2. PT reaches around patient and grasps around the elbows
3. Pt takes up slack, patient takes deep breath and PT can give a slight
distraction
4. PT performs manipulation with thrust thru the patient's arm in an
anterior to posterior direction at the same time keeping his or her chest
forward .

Prone middle ● Patient prone

thoracic 1. PT hypothenar TP right and left at T8
manipulation: 2. Use skin lock right clockwise ventral, left clockwise caudal
3. Patient deep breath in and exhale at the end of exhalation
4. Provide high velocity low amplitude thrust

Supine middle ● PT stands at side PT

thoracic 1. Patient X arms with opposite arm on top and elbows parallel
manipulation 2. Roll patient toward, trigger finger skin lock with ulnar deviation
3. Roll patient onto back with head neck/ in flexion
4. Deep breath in and exhale may need to do more than 1X
5. Sense the fulcrum and give thrust after full exhalation .

LUMBAR
Slump test Pt sitting, thigh fully supported, knees together, hands
behind back:
○ Slump neck, flex neck, extend knee, DF ankle, flex
hip
 ○ Any S/S release with flexed neck?
○ N irritability= sciatic N.

Lumbar ● Pt standing actively moves into extension, SB to painful

quadrant test side and Rot to painful side with overpressure
+ Local pain- facet dysfunction or degeneration
+ Radicular pain- N compression

Prone ● Feet on floor, PT does CPA at suspected level of

instability test instability and notes pain, patient bent over EOT
● Pt lifts feet < 6 inches while PT performing CPA
+ If painful in 1st part but improves and disappears in 2nd
part
+ Movement coordination issue category .

Femoral N ● Prone or SL knee bend/ slump test

1. Prone: knee bend. Slump knee bend
- Pt prone with neutral hip, may tilt head into flexion with
table, PT passively flexes knee
- Take note of any symptoms or resistance
- Add hip extension (sensitization)
- Add PF ( sensitization)
- Add neck extension (releases neural tension)
2. Sidelying: head and trunk in flexion, grasping n on testing
knee toward chest
- PT supports uppermost LE, hip neutral rotation and knee
flexed to 90
- Slowly passively extend hip, take note of any symptoms
- Add knee flexion (sensitization)
- Add PF
Add neck extension (releases neural tension).

Sciatic N ● Slump
1. supine SLR passively lift LE, note angle of hip and onset
of S/S
+ DF
+ Hip IR and adduction
+ Neck flexion
+ 30-70 degrees hip flexion
+ Crossed SLR pain on the other side ..

Core stability ● Baseline core stability measures: AB

● 5-10% of max isometric contraction of trunk Mm
● No attempt at preferential activation
● No spine or pelvis motion
● Abdomen does not go in or out
● Baseline core stability measures: ADIM
 ● Pt in hooklying, relaxed diaphragmatic breathing, draw
navel toward spine and up toward chest 15% max
contraction, hold contraction while breathing normal,
palpable small tension near ASIS no pelvic, spine or rib
motion, palpable bulging= internal oblique.

Repeat motion ● Repeat motor tests: Lateral shift RSGIS

tests ● Stand, side glide hips to non painful side x 10
● Prone shift hips away from painful side
● Repeat motor tests: Extension REIS, REIL
● Stand and do 10 reps, prone, pillow or no pillow, POE,
press up
● Repeat motor tests: Flexion RFIS, RFIL
● Stand and do 10 reps off EOT, hooklying DKTC.

Traction ● S/S of N root compression in butt/ LE, peripheralize with

extension and crossed SLR, cant centralize
● Intervention: extension oriented treatment approach
● Prone and static x 12 min 40-60% BWT
● Supine and static x 10-20 min hip/ knee bent to 90 , 5-60
kg

N ● N mobilizations: Supine
mobilizations - Hip held at 90
- Alternate knee extension (tension) and ankle PF (slack)
with knee flexion and ankle DF
● N mobilizations: Sitting
- Alternate spinal flexion (tension) and knee flexion (slack)
with spinal extension and knee extension
● N mobilizations: standing/ SLS
- Alternate hip extension (tension) and next extension
(slack) with hip and neck flexion.

Nerve tension testing: UE

Nerve How

Neuro screening - Depending on patients signs and symptoms, median/ ulnar/ radial N
ULTT, tension testing patient is supine no pillow.
sensation,
reflexes:

ULTT median - Start with elbow flexed

nerve: - Prevent shoulder girdle elevation with pt fist on table abduct shoulder
90º
- Supinate forearm, extend wrist/ fingers, ER shoulder to 90º, slowly
extend elbow .
ULTT radial - Shoulder abducted to 10º
nerve: - Prevent shoulder girdle elevation with pt hip, extend elbow, medially
rotate shoulder/ whole arm
- Pronate forearm, flex fingers and wrist, avoid any shoulder flexion .

ULTT ulnar - Put hands palm to palm

nerve: - Prevent shoulder girdle elevation with PT fist on table, abduct shoulder
90º, ER shoulder 90º
- Pronate forearm, extend wrist and fingers, flex elbow to pts face .

Nerve tension testing: LE

Nerve How

N mobilizations: - Hip held at 90

Supine - Alternate knee extension (tension) and ankle PF (slack) with knee
flexion and ankle DF.

N mobilizations: - Alternate spinal flexion (tension) and knee flexion (slack) with spinal
Sitting extension and knee extension

N mobilizations: - Alternate hip extension (tension) and next extension (slack) with hip and
standing/ SLS neck flexion

Slump Test - Pt sitting, thigh fully supported, knees together, hands behind back:
- Slump neck, flex neck, extend knee, DF ankle, flex hip
- Any S/S release with flexed neck?
- N irritability= sciatic N

Femoral N - Prone or SL knee bend/ slump test

- Prone: knee bend. Slump knee bend
- Pt prone with neutral hip, may tilt head into flexion with table, PT
passively flexes knee
- Take note of any symptoms or resistance
- Add hip extension (sensitization)
- Add PF ( sensitization)
- Add neck extension (releases neural tension)
1. Sidelying: head and trunk in flexion, grasping n on testing knee toward
chest
- PT supports uppermost LE, hip neutral rotation and knee flexed to 90
- Slowly passively extend hip, take note of any symptoms
- Add knee flexion (sensitization)
- Add PF
- Add neck extension (releases neural tension).

Sciatic N - Slump
 - supine SLR passively lift LE, note angle of hip and onset of S/S
+ DF
+ Hip IR and adduction
+ Neck flexion
+ 30-70 degrees hip flexion
+ Crossed SLR pain on the other side ..

PELVIS
Thigh thrust ● The patient lies supine with the hip and knee flexed where the thigh is
at a right angle to the table and slightly adducted.
● One of the examiner’s hands cups the sacrum and the other arm and
hand wraps around the flexed knee.
● The pressure is applied directed along the line of the vertically
oriented femur. The procedure is performed on both sides.
● The presumed action is a posterior shearing force to the SIJ on that
side.
○ + A positive test is reproduction of the patient’s pain.
Gaenslen ● The patient lies supine near the edge of the table.
● One leg hangs over the edge of the table and the other hip and knee
are flexed towards the patient’s chest.
● The examiner applies firm pressure to the knee being flexed to the
patient’s chest and a counter pressure is applied to the knee of the
hanging leg, towards the floor.
● The procedure is performed on both sides. The presumed action is a
posterior rotation force to the SIJ on the side of the flexed hip and
knee, and an anterior rotation force of the SIJ on the side of the
hanging leg.
○ + A positive test is reproduction of the patient’s pain..
FABER ● .The patient is supine and the hip of the involved side is
simultaneously flexed, abducted, and externally rotated by the
examiner so that the patient’s lateral ankle comes to rest on the
uninvolved lower extremity just proximal to the knee.
● While stabilizing the anterior superior iliac spine on the uninvolved
side, the knee of the patient’s involved lower extremity is lowered
towards the table, with simultaneous external rotation and abduction,
until end range of motion is achieved.
● From this point the examiner applies 3 to 5 small-amplitude
oscillations at end range into resistance.
● The presumed effect is stress on the SIJ as the horizontal abduction
force goes through the femur, thus the tensioned soft tissues transfer
 the forces to the SIJ.
○ + A positive test for SIJ involvement would be reproduction of
pain posteriorly.
Distraction ● The patient lies supine and the examiner applies a posteriorly directed
force to both anterior superior iliac spines.
● The presumed effect is a distraction of the anterior aspects of the SIJ.
○ + A positive test is reproduction of the patient’s pain.
.

Compression ● The patient lies on the side with hips and knees slightly flexed.
● The examiner applies a force vertically downward on the uppermost
iliac crest.
● The presumed action is a compression force to both SIJs.
○ + A positive test is reproduction of the patient’s pain.
.

Sacral thrust ● The patient lies face down.

● The examiner applies a force vertically downward to the center of the
sacrum. The presumed action is an anterior shearing force of the
sacrum on both ilia.
○ + A positive test is reproduction of the patient’s pain.
Active SLR ● The test is performed with the patient in a supine position with legs
straight and feet slightly apart.
● The therapist provides verbal instructions: “Try to raise your leg, one
after the other, above the table without bending the knee.”
● This is done without providing manual assistance (not illustrated).
● Then, the test is repeated while the therapist provides manual
stabilization across the pelvis through the iliac crests (illustrated).
● For each leg and for both versions of the test, the patient is asked to
score their difficulty on a 6-point scale:
○ 0 = not difficult at all
○ 1 = minimally difficult
○ 2 = somewhat difficult
○ 3 = fairly difficult
○ 4 = very difficult
○ 5 = unable to do
● The presumed effect is the action of the hip flexors during the straight
leg raise causing rotational shear at the SIJ and that providing manual
stabilization helps control these rotational shear forces. In addition to
the difficulty rating,
○ + a positive test would be greater ease and/or reduced pain
when the test is performed with manual stabilization from the
therapist.
Lunge ● The patient performs a standard lunge bilaterally.
● The presumed effect is a posterior rotation force to the SIJ on the side
of the flexed hip (front leg) and an anterior rotation force of the SIJ on
the hip in neutral (back leg). This is similar to Gaenslen test, however
in a weight bearing position.
● + A positive test would be reproduction of pain.

CERVICAL
Ligamentous - Sharp purser test
stability - Alar ligament test

Mobility - Cervical rotation lateral flexion test

HA - Cervical flexion rotation test

Muscle - Neck flexor muscle endurance test

performance - Craniocervical flexion test

Neural/ - Spurlings
Radicular - Cervical distraction
- Valsalva maneuver
- ULTT

Sharp Purser - Alleviation/ relocation test to assess stability of C1 on C2= transverse

test ligament integrity
Procedure:
- Pt sit with head in flexion
- Therapist stabilizes C2 with other hand on forehead
- Therapist applies posterior force on forehead
+ If head and C1 slide posterior, there is an audible clunk, no firm end
feel, or this decreases S/S

Alar ligament - Alar lig connects Dens to skull, functions to limit contralateral rotation
test and SB
- MOI: typically flexed and rotated with force
Procedure:
- Pt seated or supine
- Grasp SP of C2 and perform passive SB
- C2 should immediately move opposite direction of SB
+ For alar ligament laxity/ tear if C2 doesn't move

Cervical - For 1st rib and C/T junction mobility

rotation lateral - Test may support a neck pain with nobility deficit hypothesis or ID
flexion test diffuse hypomobility
Procedure:
 - Pt seated
- Therapist places hand on 1st rib to be assessed and passively rotates
head contralaterally
- Also passively SB
- Compare both sides
+ If notable limitation of ROM or hard end feel

Cervical flexion - Test for cervicogenic HA

rotation test - Measures PROM rotation @ C1/C2 segment
- Do test @ the end of session, may provoke S/S
Procedure:
- Pt. supine
- Therapist maximally flexes and rotates to the R/L (stop at pain or end
feel)
+ If rotation < 32º, norm is 45º

Neck flexor - Deep neck flexors= longus capitis Mm and Longus Colli Mm
muscle Procedure:
endurance test - Pt supine and hook lying with hands on abdomen
- Place hands under pts head and que them to perform a chin tuck and lift
head 1 inch from table
- Observe and time patient, stop timer when patient loses skin tuck (skin
protrudes or back of head touches hands for > 1 second)
Norm values: 39s in Males, 29s in Females

Craniocervical - Tests activation and control of deep neck flexors

flexion test Procedure:
- Patient supine, neck in neutral (may need towel under occiput)
- Use biofeedback stabilize/ BP cuff, put under C/S lordotic curve and
inflate to 20 mmhg
- Ask patient to slowly nod and then hold (head/ neck flexion)
- Dose; 5x10s on/10s off @ certain pressures going up by 2 from 22 to 30
mmhg
- Record performance, any aberrant motions, mouth movements, inability
to return to baseline, SCM contraction, max pressure achieved for 10 sec
hold

Algometric - Measures local pain threshold at upper trap

Assessment of - Can do on unaffected area 1st to see if hypersensitive
Pressure Pain Procedure:
Threshold - Pt seated
- Use perpendicular to UT Mm fiber 5-8 cm superomedial to scapula
superior border
- Ot reports when pressure feeling becomes pain
- Repeat B 3 times with 30 seconds between each trial

Spurling's test - Decrease diameter of neural foramen

 Procedure:
- Pt seated and actively SB to symptomatic side
- PT adds compression
- Variation: pt ext/SB/Rot
+ If reproduces neuro S/S not recommended if S/S are active at time

Cervical - Increases diameter of neural foramen decreasing radicular S/S

distraction Procedure:
- Pt supine
- PT grasps under chin and occiput
- Flex neck to position of comfort and distract
+ If decreases or eliminates S/S, most useful when pt actively having S/S

Valsalva - Increases intrathecal pressure

maneuver Procedure:
- Pt holds breath and bears down 3sec
+ If neuro S/S are provoked

SHOULDER
Scapular: ● Scapular assistance test
● Scapular reposition test

Subacromial pain ● Neer sign

syndrome: ● Hawkins sign
● Jobe test
● Painful arc
● Pain and weak ER
● Best cluster= Hawkins, painful arc, resisted ER

RTC tear: ● Drop arm sign

● ER lag sign at side
● ER lag sign at 90
● IR lag sign
● Lift off test
● Belly press test
● Bear hug test

Labral tear ● Anterior slide test

● Bicep load test 1 and 2
● Kims test
● Obriens active compression

Bicep tendon ● Speeds

lesion ● Yergasons

Instability ● Anterior apprehension

● Relocation
 ● Release
● Posterior apprehension

AC jt lesion ● Horizontal ADD test

TOS: ● Adsons Maneuver

● Costoclavicular

ULTT

Scapular ● Manually assist scap retraction and upward rotation

assistance test ● Posterior tilt with AROM elevation
● + if painful (scapular dysfunction)

Scapular ● Manually posteriorly tilt and ER scapula with AROM elevation or

reposition test empty can resisted elevation
● + if pain decreases between AROM or PROM (scapular dysfunction)

Neer sign ● Full passive shoulder flexion with overpressure (can add IR)
● Compresses any structure in subacromial jt space
● + if pain (impingement)

Hawkins sign ● Passively place shoulder in 90º`scaption and IR

● + if pain with IR (impingement)

Jobe test ● Pt actively performs scaption to 90º, max IR and holds

● Examiner applies downward force while pt resists
● + if pain/ weakness (testing RTC tendon integrity)

Painful arc ● Pt elevates arm in scapular plane (abduct)

● + for SPS if pt has pain between 60º to 120º for elevation
● + for AC jt lesion if pain @ top of range 170º to 180º

Drop arm sign ● Shoulder abduct to 90º and remove support

● + if arm drops quickly or loses control (suggesting supraspinatus)

ER lag sign at ● PROM elevate arm to 20º scaption near max ER ROM
side ● Ask pt to hold for 10s as examiner removes support of ER but
supports elevation at elbow
● + if patient cant hold ER (likely infraspinatus or teres minor)

ER lag sign at 90 ● Repeat above at 90º scaption

IR lag sign ● Examiner passively puts pts hand behind back, lifts and and releases
support
 ● + if pt can not hold hand lifted (subscapularis)

Lift off test ● Examiner passively puts pts hand behind back
● Pt actively lifts hand
● + if patient is unable to lift arm/ action happens from extending elbow
or shoulder (subscapularis)

Belly press test ● Pt puts arm at side side- palm on belly, arm at 90º
● + if unable to attain position of arm in abduction (subscapularis)

Bear hug test ● Examiner passively positions shoulder in 90º flexion while pt IR and
reach to opposite shoulder
● Examiner tries to push
● + If unable to hold (subscapularis)

Anterior slide test ● Pt stands with hand on hip

● Examiner stands behind and gives long axis ant/ superior force thru
elbow/ humerus when pt resists
● + if pain clicks in anterior shoulder (SLAP tear)

Bicep load test ● Supine and elbow flexed to 90º, forearm supinated
● Test 1: Abduct shoulder to 90º
● Test 2: Abduct shoulder to 120º
● Perform apprehension test in this position (move to full ER)
● - for SLAP if apprehension decreases with elbow flexion resistance
● + for SLAP if apprehension increase with pain in shoulder (superior
labrum)

Kims test ● 90º shoulder abductor and flexed

● Examiner applies axial compression to glenoid via humerus/ elbow
● Maintain axial compression with elevate arm in diagonal arc while
using to proximal hand to apply downward and posterior force to
humerus
● + if pain and clicking (post/ inferior labrum)

O'brien's active ● Shoulder flex to 90º, horizontally adduct 10º and IR

compression ● Examiner gives downward force
● Return to start position (ER/sup) and give eccentric downward force
● + Labrum- Pain/ click deep joint with resisted thumb down or
decreased ER and supination
● + AC jt- If pain superiorly increasing c thumb down, decrease c thumb
up
● PAIN DEC THUMB UP

Speeds ● Bicep/Straight arm test

 ● Examiner resists shoulder flexion of pt c extended elbow and
supinated forearm, then pronated
● Ask pt to resist eccentric movement into 1. Extension 2. Supination 3.
Pronation
● + Test if TTP bicipital groove with arm supination indicates
tendinosus

Yergasons ● Flex to 90º, pronate, IR

● Examiner resists as pt tries to do supination and ER
● Palpating biceps tendon during pronation to supination, feel pop out=
transverse humeral ligaments is torn
● + if bicipital groove is tender (pop or no pop)

Anterior ● Pt supine passive movement to 90 ABD, ER

apprehension ● + if pt exhibits S/S of apprehension (instability)
● Pain posterior = internal impingement

Relocation ● Move slightly out of ER, sink into humeral head and add ER back
● + if pain decrease or increases with ER (Anterior instability)

Release ● Release anterior support quickly

● + if apprehension or pain
● Dont need if other 2 are positive (Anterior instability)

Posterior ● Pt supine and elbow flexed to 90º

apprehension ● Move arm to 90º abduction/ flexion and adduction
● Push body through humerus and exert posterior force on capsule and
add IR to stress capsule
● + If pain/ apprehension (Posterior instability)

Adsons Maneuver ● Locate radial pulse, turn pt head to test side and extend
● Examiner ER and extend shoulder, ask pt to take deep breath and hold
it
● + Test if pulse disappears suggesting inter scalene compression as
TOS cause (Thoracic outlet syndrome)
● N or blood vessel? N root or whole hand

Costoclavicular ● Exaggerated military posture

● Draw shoulder down and back palpate radial artery
● + Test if radial pulse diminishes implying 1st rib and clavicle space
too narrow (heavy backpack or clavicular fracture) (Thoracic outlet
syndrome or clavicular syndrome)

Horizontal ADD ● + If pain felt over AC jt

test ● Active or passive
● Reach hand to opposite shoulder
 ELBOW:
Lateral elbow ● Cozen test
tendinopathy ● Maudsley test
(LET) ● Mill test

Cubital tunnel ● Elbow flexion test

syndrome: ● Pressure provocation test
● Tinel's sign
● Scratch collapse test
● Crossed finger test
● Shoulder IR test

Posterolateral ● Chair sign

rotatory ● Push up sign
instability: ● Table top relocation

UCL pathology: ● Valgus stress test

● Milking maneuver (anterior band)
● Moving valgus stress test

Medial elbow ● Passive test

tendinopathy ● Active wrist flexion against resistance test
(MET)

Distal biceps ● Biceps squeeze test

tendon rupture:

ELBOW TESTS:
Elbow flexion ● Pt seated with GH jt in neutral
test: ● Elbow in max flexion, forearm supinated and wrist in neutral
● Maintain position for 60 seconds to 3 minutes depending
● + test= if patient had paresthesias or worsening of preexisting
paresthesias in the ulnar N distribution

Pressure ● Patients UE is positioned in the elbow flexion test

provocation ● Clinician applies pressure to ulnar N at cubital tunnel for 30 seconds
● + test= reproduced tingling and numbness in 4th and 5th digits

Tinel's sign: ● Clinician taps lightly at ulnar N around medial epicondylar groove
● + test= patient reports tingling or electrical sensations to fourth and
fifth digits

Scratch collapse: ● Pt seated facing clinician

● Arms adducted, elbows flexed to 90, and with both hands outstretched
and wrists in neutral
● Pt asked to perform simultaneous bilateral shoulder ER keeping arms
adducted
 ● Clinician gently pushes against both of the patients forearms into IR,
asking them to resist
● Using fingertips clinician scratches or swipes skin overlying the course
of potentially compressed nerve (ulnar= over cubital tunnel at medial
elbow)
● += if the patient demonstrates momentary loss of ER tone on the
affected side after scratching over cubital tunnel

Crossed finger: ● Pt seated with forearm in pronation

● Clinician instructs patient to cross middle finger over the index finger
for both hands
● + test is recorded if patient cant cross on involved side

Shoulder IR: ● Pts UE maintained 90º of abduction and maximal IR and 10º shoulder
flexion, with 90º elbow flexion and neutral position of the forearm and
wrist with finger extension.
● + Test of any slight symptoms attributable to cubital tunnel syndrome
in 10 seconds

Chair sign: ● Pt seated, elbow flexed to 90º and forearms are supinated. Pt pushes on
the arms of the chair and extends elbows.
● Elbow extension creates axial and valgus load to the supinated elbow
while the patient rises
● +test indicates PLRI will cause apprehension wit terminal extension of
involved elbow or resistance to push through the arms

Push up sign ● Pt assumes a push up position with the forearm supinated

● From this position the pt pushes up from 90º elbow flexion
● + Positive test in a pt with PLRI will cause radial head subluxation or
pain

Table top ● Pts forearm supinated and around edge of table

relocation ● 1. Patient applies axial load to the elbow while flexing the elbow
which causes apprehension at 40º of flexion
● 2. Pt repeats the first maneuver and clinician applies pressure on the
pts radial head, attempting to prevent any subluxation and symptoms
● 3. Clinician removes his or her thumb from partially flexed elbow and
the radial head subluxes and reproduces symptoms

Valgus stress test ● The patient is seated or supine

● Clinician flexes patients elbow to 25º and while holding the distal
forearm with one hand stabilizes the distal humerus and applies lateral
force to stress UCL

Milking ● Humerus is extended and ER to neutralize GH joint motion

maneuver ● Forearm is supinated and elbow flexed to 90 º
● Clinician applies valgus stress to the elbow by extending patients
 thumb
● AUCL is palpated a + test is if there is any apprehension, reproduction
of pain or symptoms along the course of UCL complex between 30 to
60 degrees of elbow flexion

Moving valgus ● Pt is seated and the clinician applies and maintains a constant
stress test: moderate valgus torque to the patients fully flexed elbow and then
quickly extends the elbow
● + Test is recorded if medial elbow pain is reproduced at the UCL and
is at max between 120 to 70 degrees elbow flexion (which is evocative
of the elbow position between the late cocking and early acceleration
phases of throwing- AKA shear range)
● Pain with extension beyond 70º suggests condyle injury to the
humeroulnar joint

Passive medial ● Examiner palpates the medial epicondyle and supports the patients
tendinopathy elbow with one hand while the other hand passively supinates the
test: patient's forearm and extends the wrist
● + Pain at medial epicondyle

Active wrist ● Pt is seated with forearm supination and elbow flexed to 90º
flexion against ● Using one hand the clinician palpates the medial epicondyle while
resistance: supporting the patient's forearm
● The patient is asked to make a fist and flex the wrist while the
clinician applies resistance
● + test if this maneuver reproduces medial elbow pain

Cozen test: ● The patient makes a fist while the clinician supports the elbow with
one hand thumb over the lateral epicondyle
● Patient is then asked to extend the wrist against resistance with the
forearm pronation and the wrist radially deviated
● + if there is any reproduced pain over lateral epicondyle region

Maudsley test: ● Patients forearm and hand are positioned on a flat surface with the
elbow extended
● Patient asked to extend middle finger and clinician gives pressure over
extended digit
● + Test is considered positive if there is any reproduction of pain over
the lateral epicondyle region

Mill test: ● Pt seated with upper arm in a neutral position

● Elbow is flexed at 90º and forearm parallel to the floor in pronation
● Clinician supports the patients elbow with one hand, while using the
other hand to flex the patient's wrist
● + Positive if there is any reproduction of pain over the lateral
epicondyle region
Biceps squeeze: ● Pt is seated with elbow flexed approximately 60-80º and with a
slightly pronated forearm resting in their lap
● Clinician stands on the side of the extremity being tested and squeezes
the biceps brachii firmly with both hands one hands at the
myotendinous junction and the other hand around the muscle belly
● + a positive test is a lack of forearm supination indicating s biceps
brachii

HAND AND WRIST

Radial wrist ● De Quervain's tendinopathy
pain: ○ Finkelstein's test
○ Eichoff test
● Intersection syndrome
● Scaphotrapeziotrapez oid joint OA
● CMC grind test for first CMC OA

Ulnar wrist pain: ● TFCC load compression test

● Pisiform boost test
● Piano key sign

Instability/ ● Scaphoid shift test

Ligamentous ● Scapholunate ballottement test
integrity: ● Lunotriquetral ballottement test
● 1st MP UCL stress test

Other: ● Bunnel littler test

● Allen test

Neurological ● Tinel's sign

integrity: ● Phalen test
● OK sign
● Froment sign

HAND AND WRIST TESTS

Finkelstein's ● Pt actively UD wrist, examiner passively flexes thumb across palm
test ● + Pain along abductor pollicis longus and extensor pollicis brevis
tendons on radial wrist/ 1st MC

Eichoff test ● Pt places thumb in clenched fist, examiner passively UD wrist

● + Pain along abductor pollicis longus and extensor pollicis brevis
tendons on radial wrist/ 1st MC
Intersection test ● Pain with resisted wrist extension may report squeaking.
● Pain 2-4 cm proximal to wrist (dorsal) at site where APL and EPB
tendons cross ECRB and ECRL

Scaphotrapeziot ● Forearm neutral, examiner places pressure on scaphoid tubercle while

rapezoid joint RD/UD wrist
OA ● + If pain

CMC grind test ● Examiner grasps first MC and presses it into trapezium with axial load
for first CMC then rotates MC
OA ● + Pain in CMC joint

TFCC load ● Pt sits with elbow on table, hand up in the air (neutral rotation)
compression ● Examiner grasps radius and ulna at wrist, with other hand, grasp pts
test hand at MCs and then move hand into UD and place axial load thru ulna

Pisiform boost ● Ulnomeniscal Triquetral dorsal glides

test ● Same position as above
● Examiner pushes pisiform dorsally and ulna palmarly.
● + if excessive laxity or reproduces symptoms

Piano key sign ● DRUJ instability

● Examiner stabilizes radius and pushes ulna in palmar direction
● + if it pops back up

Scaphoid shift ● Scapholunate ligament integrity test

test ● Pt seated with elbow flexed and supported, hand in air
● Examiner grasps wrist from ulnar side
● Places their thumb on palmar aspect of pts scaphoid and puts dorsal
glide force
● With other hand, grasp MC, put wrist in UD/ extension, move wrist into
RD and flexion while keeping pressure on scaphoid
● Scaphoid will shift or sublux in dorsal direction if ligament is ruptured
(listen or feel for clunk)

Scapholunate ● Forearm pronated

ballottement ● Examiner:
test ○ Scaphoid lunate (SL): stabilizes lunate, move scaphoid dorsal/
palmar
○ + If laxity or reproduces S/S

Lunotriquetral ● Forearm pronated

ballottement ○ Lunotriquetral (LT): Stabilize lunate, move triquetrum/ pisiform
test complex dorsal/ palmar
○ + If laxity or reproduces S/S

1st MP UCL ● Examiner applies valgus force to MP jt at 0 and 30º flexion

stress test ● + if laxity at either angle

Bunnel littler ● Help determine intrinsic muscle tightness vs joint capsule restriction
test ● All passive
● Examiner holds wrist in extension, MP joint in hyperextension, then
flexes PIP joint
● Note PIP flexion if there is a restriction you don't know if is muscular or
joint capsule
● Perform again but with MP joint in flexion
● If PIP flexion increases= intrinsic muscle tightness
● If PIP flexion is still restricted= joint capsule tightness

Allen test ● Patient opens and closes fist several times

● Then make a tight fist
● Examiner compresses radial and ulnar arteries simultaneously at wrist
● Patient is asked to open hand, which should should be white or lighter
● Examiner releases one artery and observes blood flow back into hand
● Repeat test for other artery
● + Positive if hand does not revascularize or is sluggish to revascularize

Tinel's sign ● Tap wrist at carpal tunnel (median N) or radial styloid (sensory branch
radial N)
● + If reproduces nerve sensory

OK sign ● Tip to tip normal; pulp to pulp AIN lesion

Phalen test ● Median N

● Hold max wrist flexion with finger extension x 1 minute
● CCPT says with elbow extension but commonly done with elbow
flexion
● + if reproduces nerve symptoms
● **** reverse prayer

Froment sign ● Ulnar N

● Ask pt to use key grip to hold index card, try to pull card out
● + if IP flexion occurs (adductor pollicis = ulnar N, compensation with
FPL = AIN of median N)
Kapandji Scale

MOBILIZATIONS WITH MOVEMENT

Cervical ● Cervical distraction around your hands as you pull

Elbow ● Lateral elbow pain

● Find ulna on the side and pulling up (lateral glide)
● With middle finger extension or holding a weight

Hip ● Laterally distract

● Laterally distract and add IR or ER
● Go into lateral traction and flexion
● Lateral traction and resist (NM re ed)
Hip/ Knee/ Low ● Long axis traction: different angles (elevation and scaption)
back ● Sciatica= long axis traction open things up

Lumbar traction
Ankle

Thoracic Rotation:
● Assess rotation with arms across body
● Pt puts elbows up
● Therapist hand on hypomobile part, trying to mob into direction thats
decreased, rotate and pushing

Extension:
● Mobing up
● Important if they cant reach overhead
 ●

Shoulder IR ● Mob for people who cant reach behind them

● Traction like maneuver- posterior and inferior
● They pull with other hand and pull medially
DF

Shoulder ● Posterior inferior glide of humerus

● Hands on scapula upward rotation and posterior tilt
● + Abduction and IR, hold weight in hand or dont let me move you top
hand - belt posterior glide so when he goes into IR or ER humerus
stays in place posteriorly

TAPING TECHNIQUES:
Rigid tape for ● Open packed position of the tibiofemoral joint:
patellar ○ 25- 30º flexion
tracking ● Open packed position of the patellofemoral joint:
○ Full extension
● Can correct:
○ Medial or lateral glide: Start tape on contralateral side of patella
■ Lateral: stretch lateral retinaculum prolonged stretched,
patella in better alignment with femoral groove, medial
sitting patella
■ Longer piece
○ Tip: start tape at center of patella
■ Laterally tipped and want to tack it down
■ Shorter piece, put tape on it and pull it down (either from
edge or middle)
○ Rotation: Start tape on contralateral side near inferior pole
○ Combo of each
● Cover roll and the tape. Cover roll protects the skin
● Tape will be really tight at first, have them move after
● Rigid taping: stability and alignment
● Can make brace with it (lat/ medial/ posterior)
○ Make big Xs, center of the X on the thing you want to stabilize

● Pt education: wear tape for 2-3 days (3+= irritate skin)

○ Please do not rip it off because itll cut you:
■ Peel edge off (use lotion)
■ Hold skin down and away while grabbing tape
○ If it is itchy for longer than 30 mins take it off
● PFPS pain: KT taping
○ For lateral tracking:
Postural ● For both put in corrected posture first and then apply tape
correction ○ Lumbosacral:
taping for ■ 2 vertical strips to prevent spinal flexion
scapulothoracic ■ 2 diagonal strips to promote stability in 3 planes
and ■ All across lumbosacral junctions (SIJ)
lumbopelvic ● Iliac crest towards contralateral PSIS, crosses
regions contralateral SIJ

○ Scapulothoracic:
■ Clavicle toward medial aspect of inferior angle of
contralateral scapula
■ Going for criss cross ending at inferior angle of opposite
scapula
■ For scapular control and postural stability- keeps from
slouching
Shoulder ● Open packed position of the shoulder:
stability taping: ○ Abducted slightly (scaption is true open packed)
● Use for shoulder instability
● Pt seated
○ 1st piece anterior shoulder to posterior (clavicle back to scap)
○ 2nd piece where deltoid would insert
○ Next 3 pieces making deltoid (ant/ mid/post fibers)
○ With leukotape go from inferior to superior mimicking the
insertion to origin over those 3 fibers
○ Use more tape to anchor
○ For AC joint: tack it down with tape anterior to posterior
● Anchors at deltoid tuberosity and from spine of scapula to just inferior to
AC joint, can be done with cover roll only no tension
● Support humerus at 30º abduction “middle deltoid” piece pulling distal to
proximal
● Can do cross pieces or mimic deltoid muscle alignment
● For support pieces, no tension needed to due UE elevated position

Kinesiology ● Used for soft tissue change

tape: ● Stretchy, allows free movement
● Directly to skin
● Wear 3-5 days
● Relatively waterproof and breathable
○ If skin irritation occurs such as burning or itching, remove tape,
wash skin and use Milk of Magnesia to reduce irritation
● Does not stick well to itself- much touch skin
○ Mixed results in research very individualized
○ Adjunctive treatment
○ Cut corners and make round
● Uses and tension:
○ Re educate neuromuscular system, reduce inflammation, prevent
injury and promtoe good circulation, takes pressure off bodies
pain receptors, theraputic elastic tape that creates a lifting effect
on the skin
■ Tissue support or functional correction 75-100%
■ Facilitation of muscle, origin to insertion 50%
■ Inhibition of a muscle, insertion to origin 50%
■ Fascia correction 25%
■ Edema paper off
■ Pressure reduction paper off
○ NEVER PLACE TENSION ON ENDS
○ ROUND EDGES FOR BETTER ADHESIVENESS
● Help muscle:
○ Tack down on origin
○ 50% tension
○ Tack down insertion
● Inhibit muscle:
○ Tack down on insertion, stretch muscle alittle bit
○ 50% tension
○ Tack down on origin
○ Wont let mm over contract
● Joint: correct alignment
● Swelling: decrease it faster
● ITB syndrome:
○ Soft tissue area they say 50-35% tension
○ From O to I with one strip
○ Lateral femoral condyle strip, 50%
○ Cross or star over pain for the lifting technique
Rigid tape/ ● Used for movement restriction, stability, or alignment changes
McConnell ● Cover roll for skin protection
tape ● Wear maximum 2 days
● Not breathable
● VERY adhesive
○ Mixed results in research very individualized
○ Adjunctive treatment
● Techniques: medial patellar glide, shoulder dislocation support, posture
scapulothoracic
● Leukotape: stabalize joints, high tensile properties, CONTAINS LATEX

Edema taping: ● Octopus, 4-5 tentacles

● Base of tape goes proximally
● Spreads tails to capture more surface area
● Cross with other tails but remember to stick tape to skin not other tape
Combined ● Deltoid: Y strip, stretch anterior and apply tail, stretch posterior and
muscle apply tail, apply base at deltoid tuberosity
facilitation ○ 50% tension
movement ● Shoulder elevation: Y strip, humerus at 45º, pull proximally toward mid
taping superior shoulder
○ 75-100% tension

● Quad muscle facilitation and patellar stabilizing

○ Origin to insertion and put mm on stretch on the way (bend knee
and tape)
○ Inferior pole of patella using 100% smiley face sword
○ PFPS or tendinitis

Muscle ● I strip
inhibition ● Stretch UT mm, apply at distal/ insertion
taping: ○ 25% tension, apply at proximal/origin
Documenting: ● KT Y strop 50% tension O;I ant delt + KT fxl shoulder elevation: I strip
75% started in 45 º abduction, mid humerus to mid supraspinatus

IASTM (instrument assisted soft tissue mobilization)

Graston ● Stainless steel tools, use lotion

technique ● GT= CV warm up, targeted strengthen, ice
● Angle= 30-60 degree beveled edge is rx surface
● Fq: 2x/wk
● Certification required
● GT pairs tools with a target exercise program
● Allow you to detect/ locate and treat soft tissue dysfunction
○ Good results
○ Can feel adhesions underneath skin when using tool
● UT, quads, forearms, wrist
○ Size of tool depending on area
 CARDIO PULMONARY:
Lab skills:
Auscultation

Lung sounds:
● Upper lobe: between mid clavicular line and nipple, lateral to T3
● Middle lobe: Just inferior to breast tissue anteriorly
● Inferior lobe: Posterolateral to T12
● Breath sounds
○ Emphysema:
■ Cough is weak, raspy with minimal sputum.
■ Sounds of course rhonchi in area of more secretions
■ Expiratory wheeze that worsens with exertion or anxiety
○ CF:
■ Cough is course, often productive, can be wheezy and
usually hs significant tan sputum or with advanced
disease hemoptysis (blood due to infection, > 2 year
mortality after this in CF patients)
■ Coarse crackles often worse in ULs, expiratory wheeze
○ IPF:
■ Weak cough, no sputum
■ Fine, velcro crackles on inspiration
○ Pneumonia
■ Frequent coughing, + sputum green to yellow to mucoid
■ Course wet crackles often during inspiration and
 expiration (I>E)
● Breath sounds (embedded in cases)
○ COPD: Decreased sounds, breathlessness/wheeze on exertion,
wheezing, prolonged expiration, crunch
○ IPF: Inc breath sounds, dry velcro crackles, cough
○ CF: Wheeze, crackle, rales, stridor, crunch
○ Pneumonia: rubs, crackles, crunch
○ Crunch sound: COPD, pneumonia, CF, collapsed lung
○ Stridor sound: obstructive
○ weak sound transmission=hyperinflation/emphysema
● SpO2 accuracy 1-2 questions
○ All dz have low SPO2 that gets lower with activity
○ Pneumonia specifically might have hypotension if infection
spreads to blood stream
○ Pulse oximeters are most accurate when blood oxygen
saturation is between 90% and 100%. Accuracy decreases
when blood oxygen saturation is between 80% and 90%, and the
devices are least accurate when saturation is below 80%.
○ Imbalance of RBcS SO LESS PERFUSION, SPO2 MAY READ
FINE BUT ITS NOT ACTUALLY
Heart sounds:
● Lubb/ dubb S1/S2
● HF patient= S3 gallop present = cardiomyopathy or mitral valve issue
(kentucky) or S4 lubb dubb dubb tennessee
○ Best to listen with patient in lateral decubitis position (best
listening with bell, not diaphragm of stethoscope)
● Murmur= blood leaking through space that should be closed
○ If atrial/ ventricular septal defect= wooshing
○ Commonly mitral/ aortic valve
■ During systole mitral valve should close= wooshing
■ Aortic problem, cant go through= harsher woosh
■ Hear at A or M

Cardiac exam 1. Prevention

and eval a. Primary
b. Secondary
c. Tertiary
2. ID risk factors
3. Vital signs
a. Abnormal: decreased SBP, decreased SPO2, decrease HR, new
murmur/ exacerbated murmur
b. Exercise max HR
4. Fitness test
5. Ankle brachial index
a. Supine and 5 mins rest
b. Ankle and brachial SBP
c. Highest between L/R
i. Normal: > 1.0
ii. Intermittent claudication: .80- .90
iii. LE ischemic pain at rest: .70-.50
iv. Tissue necrosis likely < .40
6. Rate pressure product
a. RPP= HR x SBP
b. Work the heart is doing = O2 consumption
7. Pulse pressure
a. SBP- DBP= pulse pressure mmhg
b. Normal= 40 (120-80)
c. High: ventricular wall tension and increased cardiac risk
d. Low: CHF/ other conditions
i. Force heart generations with each contraction
8. Mean arterial pressure
a. DBP+⅓ x (SBP-DBP)
b. Indication of circulatory pressure load
c. Less uyseful in older pop= stiffened vessels
d. Often used in esrtimating cerebral perfusion with acute neuro
event (high enough to perfuse brain)
e. MAP-ICP= cerebral perfusion
9. Karvonen formula for target HR
a. Target HR= (HR max- HR rest) x desired % intensity + HR rest
10. Capillary refill time
a. Squeeze nail/ nail bed
b. Squeeze hard enough for blanching
c. Record # of sec it takes to return
d. Norm= return < 2 sec
11. Borg (6-20) perceived exertion scale, modified (0-10)
12. Angina (0-4) levels
13. Pitting edema scale
a. 1+ to 4+
b. 1+ malleoli
c. 2+ mid calf > 5
d. 3+ to knee > 5-10
e. 4+ above knee > 10
14. Pulse strength/ quality
a. 0 absent
b. 1+ diminished
c. 2+ normal
d. 3+ strong
e. 4+ bounding
15. MET levels:
 a. 1 MET= VO2 at rest in supine
b. Fitness capacity
i. < 3= light
ii. 3-6= moderate
iii. > 6= vigorous
c. Quantifies energy costs of activities
16. Neck vein assessment: looking for venous enlargement
a. Jugular venus distention
b. Abdominal jugular reflex
i. Like hymlic maneuver in and up
ii. Pushing vena cava: will jump up and down quick=
healthy heart will absorb and be negative
iii. With HF= altered hemodynamics and back up
iv. Looking for enlargement and pulsating
v. Transgental lighting and youll see
Signs of Fluid Overload:
Pitting edema
Inspiratory crackles (pulmonary edema)
Abdominal ascites
JVD
Improve the specificity & sensitivity by:
● Abdominal jugular reflex
Orthopnea
# of pillows to not be SOB
…or… moved to recliner to sleep
Paroxysmal nocturnal dyspnea
DOE
+S3 heart sound (aka S3 gallop)
Wt gain – out of proportion to intake 😊
3-5#/day
First thing in morning AFTER voiding

-----------
Other consequences of HF exacerbation:
Signs of Decreased tissue perfusion
● Decreased pulse strength
● +/-cyanosis
 ● +/- alter

EKG

Assess pt: This must come first! There are many clues you can learn when
obtaining the EKG that will help you analyze and act on what you see.
 ● Is the patient’s skin warm and dry, or is it damp and clammy?
● How is their color?
● Are they having chest or referred (arm) pain?
● When does the pain usually occur – morning, afternoon, or night?
● Would you describe it as more of a dull pressure or squeezing or more
of a sharp, stabbing, or
● ripping feeling?
● Do you smoke or have you ever smoked? If so, how many packs per
day?
● Can you palpate peripheral pulses?
● Is your patient talking to you or are they struggling to catch their breath?
● What is their capillary refill?
● Do they have underlying heart conditions?
● What is their baseline physical activity?
● Have they ever had an EKG before?
● Have they ever been diagnosed with a heart condition?
● Are you feeling nauseous, dizzy, lightheaded, or tired?

Normal heart rhythm contains a P wave, a QRS, and a T wave.³ Knowing the
normal amplitude, deflection, and duration of each component is essential to
accurate rhythm and EKG/ECG interpretation.

● Amplitude: This measures the voltage of the beat and is determined by

how high the wave reaches, as measured by each square vertically on
the chart. 10 mm = 1 mv. 5 squares = .5 mV and 2.5 squares = .25 mV
● Deflection: Which lead on the patient it’s coming from
● Duration: How long it is, as measured by squares going horizontal

Heart rate:

● Normal = 60 – 100 bpm

● Tachycardia > 100 bpm
● Bradycardia < 60 bpm
Leads and heart view:

The twelve leads show the electrical current through the heart from different
planes. Think of each lead as a different snapshot of the heart you are trying to
interpret.

There are six limb (I, II, III, AVR, AVL, AVF) leads and six precordial (V1-
V6) leads. The limb leads look at the heart from a vertical perspective; the V
leads show a horizontal perspective.

Lead placement:
 ● V1: at the 4th intercostal space (ICS), on the right sternal border
● V2: 4th ICS, along the left sternal border
● V4: 5th ICS, at the mid-clavicular line
● V6: 5th ICS, mid-axillary line (same level as V4)
● V5: 5th ICS, at the anterior axillary line (same level as V4)
● V3: midway between V2 and V4
1. First, determine the rate, and if any tachycardia (more than 100
beats/minute) or bradycardia is present (less than 60 beats/minute).
2. Next, determine whether your rhythm is regular or irregular; you
can use calipers if you have them or use a simple piece of paper and
track your P waves and QRS complexes with a pencil mark and see
if they march along or have gaps.

If a patient has a regular heart rhythm, determine their heart rate by,

● Count the number of large squares present within one R-R interval.
● Divide 300 by this number to calculate heart rate.

If the heart rhythm is irregular, then you will not be able to use the
aforementioned method. Instead, a different method will need to be used,

● Count the number of complexes on the rhythm strip

● Multiply the number of complexes by 6

This will identify the average number of complexes in one minute.

3. After determining this, next decide if your rhythm is fast or slow,

irregular or regular (more on this in the next section).
4. Lastly, examine the ST segments for any elevation or depression;
again, you can use a sheet of paper to help you evaluate this. If you
can tell elevation or depression without the help of paper, be
prepared to act and inform the provider immediately.
5. Heart rhythm

Look at the EKG/ECG to see if the rate is regular and how fast the heart is
beating; both are important for rhythm interpretation. The pace at which a
rhythm is conducting can help determine the stability of the rhythm. A stable
rhythm often correlates with a stable patient. Slow or fast can be “good” or
“bad” depending on the patient presentation and corresponding rhythm.

Rate is usually determined by which electrical circuit is “conducting” the heart.

Rhythms conducted above the atria are usually above 60 and tend to be
abnormal when the rate is fast (atrial flutter, atrial fibrillation, supraventricular
tachycardia). Rhythms conducted below the atria are slower and tend to be
unstable when the rate is irregular (heart blocks).

Another comment about rate: know what medications your patient is taking.
Many heart medications have beta-adrenergic effects which correlate to slower
heart rates such as beta-blockers.

It is important to determine if a heart rate is regular or irregular. A regular heart

rhythm has all of the aspects previously discussed.

Irregular rhythms can be either:

● Regularly irregular (i.e. a recurrent pattern of irregularity)

● Irregularly irregular (i.e. completely disorganized)

In order to determine if a rhythm is regular, mark out several consecutive R-R

intervals on a piece of paper, then move them along the rhythm strip to check if
the subsequent intervals are the same.

6. Cardiac axis

The axis of an ECG is the major direction of the overall electrical activity of the
heart. The QRS complex is used to identify this. There are several different
findings related to the axis including,

● Normal - QRS complex is upright in both lead I and lead aVF

● Leftward (left axis deviation, or LAD) - QRS is upright in lead I
(positive) and downward in lead aVF (negative)
● Rightward (right axis deviation, or RAD) - negative in lead I and
positive in lead aVF
● Indeterminate (northwest axis) - downward (negative) in lead I and
downward (negative) in lead aVF

Causes related to left axis deviation include,

● Normal variant
● Left anterior fascicular block
● Left ventricular hypertrophy (rarely with LVH; usually axis is normal)
● Left bundle branch block (rarely with LBBB)
● Mechanical shift of heart in the chest (lung disease, prior chest surgery,
etc.)
● Inferior myocardial infarction
● Wolff-Parkinson-White syndrome with “pseudoinfarct” pattern
● Ventricular rhythms (accelerated idioventricular or ventricular
tachycardia)
● Ostium primum atrial septal defect

Causes related to right axis deviation include,

● Normal variant
● Right bundle branch block
 ● Right ventricular hypertrophy
● Left posterior fascicular block
● Dextrocardia
● Ventricular rhythms (accelerated idioventricular or ventricular
tachycardia)
● Lateral wall myocardial infarction
● Wolff-Parkinson-White syndrome
● Acute right heart strain/pressure overload — also known as McGinn-
White Sign or S1Q3T3 that occurs in pulmonary embolus

7. ID lethal rhythms

Some dangerous heart rhythms are:

● Mobitz Type II (Type 2 Heart Block)

○ Consistent PR interval with intermittently dropped QRS
complexes
● Third Degree Heart Block
○ No electrical communication between the atria and ventricles
due to a complete failure of conduction.
○ Presence of P waves and QRS complex with no association
● Ventricular Tachycardia
○ Widened QRS complex with a rate greater than 100 beats per
minute
● Idioventricular Rhythms
 ○ Absence of P waves, prolonged QRS interval, and rate of less
than 50 beats per minute

Pulmonary ● Obstructive lung disease: CANT GET AIR OUT

exam and eval ○ Emphysema:
■ Pursed lip breathing
■ Dont want to lie flat, gravity pulling abdominal content
away= cant press on diaphragm
■ At risk for CO2 retention: titration, HA, decreased PH.
Want to titrate to 90
■ Barrel chest
■ Increased WOB
■ Distressed
■ Tripod position
■ Cyanotic S/S
● Nail clubbing: chronic cyanosis
■ If any HTN: likely wont be on BB (increased
bronchospasm beta 2 agonist)
■ SOB, DOE, cough, wheezing, chest pain
■ PVO2 is good prognostic indicator
■ FINE CRACKLE
○ CF:
■ Kyphosis
■ Low SPO2
■ Collapse down and expiratory wheeze
■ Peripheral Mm leg strengthening
■ Posture, pursed lip breathing
● Restrictive lung disease: CANT GET AIR IN
○ IPF:
■ Balance/ falls
■ T/S mobility, breathing
■ Lower costal expansion
● Upper: around axillary.. If you think chest
breather lower should be more than upper
■ Symmetrical teat
● Hands on chest and back
■ Inspirometer= SM response, Mm strength and
neuromuscular control
■ DRY CRACKLE
○ Pneumonia:
■ Breathe control and performance
■ Exam will be similar to IPF
■ No expiratory wheeze, spasmatic cough, pursed lip
 breathing
■ Likely rapid tachypnea
■ 6MWT, strength, pulmonary rehab, progressive exercise
wth O2 titration
■ No CO2 retainer risk
■ Decrease diffusion
■ Likely pre treat with extra O2 by exercise
■ WET CRACKLE
● Airway clearance
○ Evaluate cough
■ Strong vs weak
■ Dry vs wet/ junky
■ Productive vs non productive
■ Spasmodic or controlled
○ Evaluate sputum
■ Quanity
■ Color
● 1 tbsp or more= hemoptysis
● Coffee grounds= blood from upper GI tract
● Green= infection
● yellow= on antibiotics, chronic bronchitis, COPD
● Tan= CF, lung CA, TB
● Mucoid= clear/ whitish appearance- COPD/
pneumonia
● Pink and frothy= pulmonary edema
● Mediated percussion
○ Increased tympany= hyperinflation- would occur throughout
lung fields
○ Dullness= lung consolidation- will occur only in areas on
consolidation
○ Able to determine diagphragmatic excursion
● Aerobic capacity
○ RPE
○ 6 MWT or other submaximal test
■ Predicted VO2 max
■ FiO2 requirements
■ Peak vital signs RPE
○ VO2 max test
○ MET capacity
○ Ability to tolerate positional changes

Spirometry and 1. Assess breathing:

breathing ○ Observe
techniques: ○ Accessory Mm at rest: upper chest versus diaphragm breather
○ Dyspnea scale
○ Abitlity to generate a good strong cough
 ○ Tape measure for lower costal expansion
○ Deep breathe/hold for 2 seconds and then let it out with hand
chest and diaphragm- lower should move more
■ Looking to see if it is a diaphragm motor control issue or
rib mobility
● If they can use diaphragm and push more with
cueing it is motor control, if they can not push
more at all then mobility
○ Upper chest breathing= psychological component to it, abnormal
movement pattern, anxiety, MDD
○ Rapid/ shallow breathing- bad gas exchange
1. Diagphragmatic breathing:
a. Pt in reclined position, assess for diaphragmatic breathing. Can
also do upright sitting, but be sure feet on floor and should have
chair with firm back support
b. Use in people with neuromuscular weakness/ abnormal breathing
motor control
c. Cue: push into hand on belly or put a theraband and cross it
i. For AROM and then wrap and keep tension
ii. Intervention RROM
d. With sniffing:
i. If patient demonstrates considerable difficulty above,
instruct patient to inhale through nose or sniff several
times in succession to improve diagphragmatic
recruitment
ii. Deep breathe in and at end of sniff= diaphragm use,
stacks on more air- dont do COPD, already retaining
2. Pursed lip breathing for breathe control:
a. COPD, asthma attack, splints airways open
b. Breathe in slowly and out like youre blowing out birthday
candles
c. Stop exhaling when abdominal contraction is detected
3. Segmental breathing (localized expansion):
a. PNF resistance/ quick stretch to intercostals and diaphragm
b. Local lung expansion increases
4. Lateral costal expansion:
a. Assess sitting behind pt, make “baby butt”, lateral excursion and
symmetry. Work on sitting or S/L (S/L on unaffected side)
b. PNF: S/L, breathe in (give alittle pressure), breathe out, give
quick approximation of ribs in and up (hand posterior= more
comfortable, might need 2 hands 1 in front and 1 in back)
c. Resisted throughout expiration
i. Apply quick stretch to ribs in the downward and inward
direction
ii. Reapply tracking resistance with expiration to assist with
downward and inward rib cage movement
 5. Posterior basal expansion:
a. Pt is positioned in sitting learning with head supported on table
or plinth
b. Therapist stands behind the patient with hands along aspect of
ribs or area of hypomobility
c. Sit and lean forward= CKC of UE, focus on lower rib breathing
6. Teach patient self technique using hands or towel to facilitate expiration
in obstructive disorders
a. Instruct patient to wrap a towel around lower ribs or use hands to
gently squeeze ribs in while breathing out
b. Apply less pressure while they take a deep breathe in
c. TRAINING EXHALATION: towel around chest, as they exhale
pull towel crossed
7. Nasal breathing:
a. Increase diaphragm recruitment, better/ more efficient alveolar
ventilation, sinus clearing
8. Diagphragmatic strengthening:
a. Patients with fair strength: put resistance over diaphragm using
weight, manual resistance, trendelenburg
b. Patients with less than fair strength: abdominal binder/ support
consider resistive muscle training devices
i. SCI: Should have diagphragmatic function (maybe not
intercostals), use this way
9. Coordinate breathing with thoracic maneuvers
a. Seated on ball activities
i. Shoulder abduction, H ab/add, shoulder forward flexion,
PNF patterns
b. Prone on ball activities
i. Side bending (modified plank), thoracic extension
c. Standing activities
i. Repeat seated on ball activities

Airway 1. Postural drainage:

clearance: a. Harder to cough laying down
b. Upper lobe
i. Anterior upper lobes= lean back to drain back and down
ii. Posterior upper lobes= drain down and in, head down in
the lat stretch position
c. Middle lobe
i. S/L and anterior
d. Lower lobe
i. Prone
ii. Lateral S/L and posterior
e. 5-10 mins in this posture, may add chest PT while in position
f. Contraindications:
2. Percussion:
a. Makes people want to cough, shake mucous loose
b. Dont do on bare skin, stand contralateral to treatment side
c. Cupped hands and rhythmic firm taps
d. 3-5 minute treatment
e. Upper lobe
i. Anterior upper lobes= lean back, tap chest
ii. Posterior upper lobes= head down in the lat stretch
position, tap over mid scapular region
f. Middle lobe
i. S/L and anterior
g. Lower lobe
i. Prone: tap T3-T6
ii. Lateral S/L and posterior
h. Can do on infant using one hand/ finger
i. Contraindications:

3. Vibration/ Shaking
a. After PD/ percussion
b. Deep breathe in and
i. Vibration: jerking fast, want oscillation of air
ii. Shaking: guide ribs and compress (jerk slow)
c. Guiding exhalation
4. Active cycle breathing technique:

5. Autogenic drainage:
a. Controlled expiratory flow to mobilize secretions
i. Unstick peripheral secretions by breathing at low lung
volumes
ii. Collect mucous in middle airways by breathe at mid lung
volume
iii. Evacuating secretions by breathing at high lung volumes
1. Low: normal breathe in and followed by slow/
deep expiration
2. Mid: increase both I and E
3. High: Increase inspiration and do stronger/
forceful expiration
6. Positive expiratory pressure:
a. Resistence splints airway
b. Increase time, add pressure, increase collateral ventilation to
clear airways
c. Oscillating is more common, increase vibration

7. Oscillating positive expiratory pressure:

 a. Breathe in and out via device or in nose out device
b. Want 1:4 ratio IE
c. Vibrating, prolong exhalation x 15 times
d. Can add face mask if not enough orofacial control/ deformity

8. High Fq chest wall oscillation

9. Forced expiratory technique

● Huff cough- get things central and up (especially if post rib fracture or
pain with cough/ contraindication percussion)
● Keep glottis open (fog glasses up) and tissue
● If they have wheeze can do it forcefully and close airway
● All technique: Huff cough will move tissue/ ball= flow and movement
● O shape, little tube stops people from closing glottis if you want to use a
straw

10. Exercise

11. Assessing cough techniques:

12. Manually assisted cough techniques:
 ● For B UE D2 PNF pattern assist
○ 1 hand on at a time
○ Posterior hand on scapula and anterior hand on humeral head
○ S/L, PNF of scapula
○ D2 diagonal scap moves down to the spine
○ Time with breathing- usually using PNF for postural control but
can use it in this case as I/E training
○ Breathe in and push back with scap and shoulder = EXPAND
○ Breathe out and push forward with shoulder= FLEX AND
ROTATE
13. Self assisted cough techniques:
● Self mob with ball

Managing O2: ● Considerations:

○ Lines and leads management
○ Highly flammable, no spark/ flame near it- NO SMOKING
■ O2 still flowing out at rate, smoke with it near you= flash
burn on the face
○ Compression= pressure
■ Could explode
■ Without regulator little nozzle on the top, JACO violation
in hospital if it is not in an approved holder, can remove
tank from holder
● Falls over and shears top off= potentially could be
projectile through a wall
○ Orientation in hospital=
■ Safety
■ EMR training
■ Documentation
■ Department specific orientation
■ Ask for help changing O2 tank: nurse, CI, respiratory
therapist
● Components:
○ Compressed O2 = pressure
 ■ L/min
■ E cylinder is bigger, B is smaller
■ Gauge on it tells you how much O2 is in it- in acute care
dont want to pick one almost empty, or have backup
ready to go
■ Higher L/min= faster they go thru O2
■ Charts with size of tank, E cylinder at 2l/min will be 4 hr/
tank- pt will know what they need
○ Regulators= change how much comes out, will learn how to
change, open valve itll show you how much
■ Red warning zone- dont go without backup tank in the
red zone OR red means suction
■ Green- everything oxygen has green coloring on it
■ Yellow- compressed air, no extra oxygen
● Uses: nebulizer/ drive through medication
● Someone on 100% O2 at rest:
○ Mask and bag O2 supply is 100%
○ Probably not good to stress the system
● Make sure someone has nasal cannula on right:
○ Risk for injury on ears from pressure
■ Pressure relief:
● Padding: 2x2 gauze and silk tape wrap around and
pad it
● Take pressure off, elevate cannula on side to side
via tie over the head to hold it up so its not resting
on the ears
● Risk: someone always wearing, older adults
thinner skin, pressure causing wound and issue=
DM poor healing
● Room air= 21% O2
○ 2 L= 24% O2, not a whole bunch, okay if disconnected at a point
○ 6 L= 44% O2, disconnected= cut O2 in half, bad
■ Over 2L of flow rate, add in bubbler, air runs through
water= humidify a bit
● Guarding and managing O2 at the same time
○ Inpatient = you will probably pull O2 tank, that would increase
their metabolic work and if they dont use at home
■ If they use at home= you want them to do it and try it
○ 6 MWT: Do you carry or do they?
■ Trying to compare results to someone else you want to
pull it so they dont pull it and need adaptation
■ BUT if they always carry O2 and want to track patient
against themselves then have them carry it
■ Home O2 often not an E cylinder with the holder, more
likely to use smaller tank= change more frequently, in a
sling bag
 ■ ARE THEY THE RIGHT Pt FOR 6MWT, NEED
100FT/30M FOR 6MWT- WHEN YOU ARE READY
WE ARE GONNA GO, THEY SAY STOP ___ HERE
ARE RESULTS
● SLING BAG not GREAT:
○ Hurts posture: kyphotic, decrease thorax
space
○ Maybe wear in a fanny pack- near COG,
not weighing on thorax the same way,
arms still can help breathing

MET lvls
METs -- what does 1 MET mean; how does physical capacity (amount METs
that can be sustained 10 min) correspond w mortality rates; how can you use
exercise level in clinic to assign safe vocational tasks/ hobbies/ etc (MET Chart
notion)

- 1 metabolic equivalent task O2 consumed or calories burned during

exercise, working at rest at 1 met= 3.5 mL
- Used to quantify energy costs of tasks for exercise rx
- Light intensity: <3 mets
- Moderate: 3-6
- Vigorous: > 6 mets
- Physical activity: > 3 mets sustained for > 10 min

Cvp skills list:

1. Cardiovascular
a. Palpate & assess quality carotid, brachial, radial, femoral, and dorsalis pedis pulses.
2. Measure HR (ventricular rate) via palpation, auscultation or EKG.
3. Recognize & appropriately respond to EKG Rhythms: sinus rhythm, sinus
bradycardia, sinus tachycardia, atrial fibrillation, atrial flutter, 1st degree AV
block, 2nd degree AV block type I, 2nd degree AV block type II, 3rd degree AV
block, premature ventricular contraction (PVC), ventricular tachycardia,
ventricular fibrillation.
4. Measure & record blood pressure at rest and during activity.
5. Measure & interpret orthostatic vital signs.
6. Auscultate heart sounds of normal S1 and S2 and identify presence of heart
murmur – utilizing appropriate technique, at appropriate surface landmarks.
7. Instruct patient in warm-up & cool-down activities to:
i. Decrease risk of arrhythmias.
ii.Prevent LE venous pooling after exercise/ decrease risk of post-exercise
hypotension.
 iii. Decrease stress on heart associated with starting & stopping exercise/
increased myocardial load.
8. Assess tissue perfusion Measure & Interpret:
i. Pulses, as above
ii. Capillary Refill
iii. ABI
iv. Rubor of dependency

2. Pulmonary
1. Accurately measure O2 saturation via pulse oximeter, at rest and with activity
2. Auscultate lung sounds identifying normal breath sounds, as well as adventitious
breath sounds of crackles, and wheezes – utilizing proper techniques, at
appropriate surface landmarks, and auscultating at least one area in each lung lobe
bilaterally.
3. Inspect patient for signs of respiratory distress, body habitus (cachexia, obesity,
etc.), chest wall deformities (e.g., barrel chest, pectus excavatum).
4. Inspect posture for alterations to thorax, e.g., forward heard, rounded shoulders,
kyphoscoliosis.
5. Evaluate/palpate chest wall movement for symmetry & overall excursion,
including disuse from surgical site pain, chest hyperinflation from COPD, and
hemi-diaphragm paralysis from phrenic nerve injury.
6. Palpate thorax to evaluate for symmetry & mobility(e.g., rib mobility, rib
springing, PA thoracic mobility) or accessory muscle hypertrophy.
7. (Performs &) interprets basic spirometry – e.g., FVC, FEV1.
8. Assess cough quality & effectiveness and other components of airway clearance
9. Perform airway clearance techniques, including:
i. Place patient in the appropriate postural drainage positions to assist
airway clearance of the indicated lobe(s).
ii. Perform percussion, vibration, and shaking to indicated lung lobe(s).
iii.Instruct patient in deep breathing, segmental breathing, splinted cough,
and huffing/ huff cough to assist airway clearance &/or prevent atelectasis/
pneumonia from post-op chest complications.
iv.Performs assisted cough techniques relative to patient needs, i.e.,
neuromuscular weakness.
V. Adapt breathing exercises for patient developmental level, e.g.,
blowing games for young child.

3. CV/P Integrated
1. Assess overall signs of impaired tissue oxygenation &/or decreased cardiac output
(perfusion)
i. Low cardiac output s/s:
1. DOE/SOB
2. Hypotension or orthostatic hypotension
a. +/-Tachycardia
3. Decreased mentation – confusion, brain fog, to dizziness
4. Possible syncope or near syncope
ii. Decreased tissue perfusion
 1. DOE/SOB
2. Tachypnea
3. Cyanosis
4. Usually tachycardic
2. Measures, records & interprets VS at rest & w/ exercise/activity
3. Perform 6-minute walk test & interpret results.
4. Able to use MET charts to prescribe exercise intensity
5. (Use mediate percussion over thorax locating the extent of lung parenchyma and
detecting variations in density of structures; e.g., pleural effusions, pulmonary
edema, lobar consolidation. Or at least understand implication of + mediate
percussion in chart notes)
6. Applies & titrates supplemental oxygen and records use/VS response accordingly.
7. Screen neurologic status in patients s/p cardiothoracic surgeries, especially
patients that have been on cardiopulmonary bypass machine.
8. Utilize results from exercise test(s) to devise an exercise program.
9. Prescribe & monitor exercise for given patient cases/conditions.
10. Adapt exercise & monitoring for specific patient developmental level.
11. Assess & interpret cool-down time (time to get to 10% baseline) and 1-min VS
post-activity/exercise response.
12. Documents needed components of CV/P exam/eval, intervention, PT prognosis &
care plan on a standardized form.
i. Include statement on vital sign ? hemodynamic response to exercise
was it normal? Abnormal? Was it so abnormal that you had to terminate
session?
13. Responds to change as appropriate for changes in patient response, e.g., acute
onset CP, SOB/DOE, VS/EKG changes, etc. More narrowly: assess & respond to
cardiac, respiratory &/or vascular decompensation.
14. Identify & address potential musculoskeletal complications associated with
various thoracic surgery techniques.
i. Provide exercise, stretches, positioning to prevent musculoskeletal
complications from thoracic surgeries, e.g., prevent frozen shoulder or
kyphotic posture
ii.Observe sternal precautions and other thoracotomy precautions
1. How to assess risk of potential abnormal sternal healing
2. Keep Your Move in the Tube

Required Components for Mastery

Category/Item

EXAMINATION

1. VS at · 5-min rest; Cuff size; B/L comparison; cuff level w/

rest (BP, RR, phlebostatic axis; technique including stethoscope placement,
HR, SpO2) rate of cuff release
· HR on pulse oximeter corresponds to HR by palpation
· Able to obtain HR by palpation & auscultation
 · RR by distraction technique

2. VS · Stabilizes limb & levels w/ phlebostatic axis for BP

during exercise · Pulse ox stabilized to improve reading/signal
(BP, SpO2, HR)

3. · Accurate location of pulses; appraises pulse strength,

regularity; identifies bruits/thrills; measures capillary refill
Peripheral
Vascular Exam
(Pulses &
Capillary Refill)

4. · Uses diaphragm; listens over bare skin; compares B/L

& cephalad to caudal; listens to at least one spot every lobe (4
Pulmonary anterior; 4 posterior)
Auscultation

5. Airway · Assess cough strength

Clearance (incl · Assess sputum color, consistency, quantity
cough)

6. ABI · supine; 5-min rest; accurate location cuffs; uses

Doppler appropriately
· Evaluates & interprets number

7. Thoracic · Assesses lower costal expansion at xyphoid -- keeps

Expansion & tape measure in circumference
Mobility · Assesses sidebending, rib springing; thoracic
intervertebral accessory motion

8. 6MWT · Follows ATS Guidelines (see Moodle posting)

9. EKG – · Accurate assesses rate (ventricular & (if possible) &

Single Lead rhythm (normal sinus, sinus brady, sinus tachy, atrial flutter,
atrial fibrillation, 1st dregree heart block, premature
ventricular contraction, ventricular tachycardia, ventricular
fibrillation)

10. · Measures & interprets FVC & FEV1 (absolute & %

predicted)
Spirometry

INTERVENTION

11. Postural · Places in appropriate position for mock case;

drainage & percussion w/ appropriate technique/force
percussion
 12. Huff · Full ventilation breath, 3-second breath hold
cough/ forced
expiratory
technique

13. · Apply accurately; if lobar technique should

correspond to pt need
Breathing
exercises –
segmental,
lateral costal,
assisted cough

14. TWO – · Includes mode, intensity, frequency, duration

Aerobic · Should be functional to pt – incorporate ADL, exer &
exercise Rx occupation
Plans (incl · Should include plan for monitoring and progression
treadmill/walkin · Apply outcome tool (e.g., DASI, St George’s Resp
g prgm) based Questionnaire, etc.)
on 6MWT
results or other
graded exercise
test – be specific
(i.e, include
METS, etc.) –
one pulmonary;
one cardiac

15. Thoracic · Provides both appropriate manual therapy, as well as

mobility – pt home prog
including rib · Techniques include pectoral stretch, PA thoracic
springing mobs, rib springing; towel-roll stretches

16. Oxygen · Demonstrates knowledge of limitations of nasal

application & cannula and benefit of high-flow face masks
titration (mock)

17. · Incorporates reproducible, accurate information

Documentation
of SOAP note of
a Rx session
(one cardiac;
one pulmonary)

RESPONSE TO
CHANGE
 18.

Responds to
abnormal status
&/or VS change
– appropriately
& safely,
including:

· Cardiac · Assess VS including OH; assess EKG

decompenstatio · Responds to pt – assists in positioning as necessary
n dizziness, (ie,Trendelenberg)
arrhythmia, · Integrates info to decide if pt requires referral or other
hypotension, action
HTN

· · Assess pt oxygenation & work of breathing (RR,

accessory muscle use, cyanosis)
Respiratory · Integrates info to decide if pt requires referral or other
decompensation action
desaturation
&/or excessive
wheezing/SOB/
WOB

● Vascular · Assess peripheral pulses; uses DVT clinical prediction

decompensation rules
high risk acute · Integrates info to decide if pt requires referral
DVT; vascular
insufficiency

NEURO
CN I: Olfactory
- Smell, foul odor rouse consciousness?
II: Optic
- Acuity
- Field
III: Oculomotor, IV: Trochlear, VI: Abducens
- Smooth pursuits
- Saccades
- Vergence
V: Trigeminal
 - Mastication strength
- Facial sensation: jaw, cheek, forehead
VII: Facial
- Facial expression, puff cheeks and smile
- Eye open/shut
- Taste, salty/sweet
VIII: Vestibulocochlear
- Hearing
- VOR
IX: Glossopharyngeal
- Mouth and tongue movement
X: Vagus
- Mouth and tongue movement
- VITAL SIGNS
XI: Spinal Accessory
- SCM MMT
- UT MMT
XII: Hypoglossal
- Tongue movement

Sensory DCML:
- Light touch: tissue/ cotton ball
- Proprioception: jt positioning
- Vibration: tuning fork
Spinothalamic:
- Pain: pin prick, sharp/dull discrim
- Crude touch: pressure/fingertip
- Temperature: discriminate cold/ warm
Sensory perception:
- 2 point discrimination
- Localization
Dermatomes:
UE:
- C2: Posterior neck
- C3: Anterior neck
- C4: Clavicular area
- C5: Lateral shoulder over deltoid into arm
- C6: Thumb and pointer
- C7: Middle finger
- C8: Pinky and ring finger
- T1: Medial arm
LE:
- L1: Groin
- L2: Medial anterior thigh
- L3: Medial aspect of the knee
- L4: Medial foot
 - L5: Dorsum of the foot
- S1: Lateral foot/ 5th digit
- S2: Posterior mid leg
Myotomes:
UE:
- C4: Upper trap
- C5: Deltoid
- C6: Elbow flexors and wrist extensors
- C7: Elbow extensors and wrist flexors
- C8: Thumbs up
- T1: Thumbs out abduction/ adduction
LE:
- L2/3: Hip flexion/ Femoral N/ Iliopsoas
- L2/3/4: Knee extension/ Femoral N/ Quads
- L5/S1/S2: Knee flexion/ Sciatic-Tibial/ HS
- L4/L5: Ankle DF/ Deep Fibular N/ Tibialis
Anterior
- L4/5: Great toe extension/ Deep Fibular N/
Extensor hallicus longus
- L5/S1: Toe extension/ Deep fibular N/
Extensor digitorum
- L5/S1: Ankle eversion/ superficial fibular N/
Fibularis longus and brevis
- S1/S2: Ankle PF/ Tibial N/ Gastroc, Soleus
- L5/S1/S2: Hip extension/ inferior gluteal N/
gluteus maximus

Tone 1. Slow velocity PROM

2. Fast velocity PROM
Clonus:
- Quick stretch to the G/S
- Quick jerk of the ankle into DF.
- Looking for oscillations as a hypertonic
response
Hypertonic:
- Resistance to velocity dependent quick stretch
Hypotonic:
- Decreased muscle activation, muscle and tone
flaccidity
MODIFIED ASHWORTH:
0: No increase in muscle tone
1: Slight increase in muscle tone, manifested by a
catch release or minimal resistance at the end range of
motion when affected parts are in flexion/ extension.
1+: Slight increase in muscle tone, manifested by a
catch followed by minimal resistance through
 remaining ROM (less than half).
2: More marked resistance through ROM but affected
parts move easily.
3: Considerable increase in muscle tone, moving
through passive movement difficult
4: Affected parts rigid in flexion/ extension
Appearance:
- Stiff?
- Floppy?

Motor control I. Voluntary action

-Can you generate volitional movement
-What is the quality of the volitional movement:
- Isolated vs non isolated
- Initiation
- Sequencing
- Timing/ onset/ duration of activation
- Force production
- Accuracy
- TRUNK
º Seated: rotate, rotate, flex, extend, side bend, side
bend
º Supine/ S/L: rotation upper and lower, flexion lower
II. Fractionation
- Synergies: obligatory and stereotypical
- UE synergy pattern: flexion
- LE synergy pattern: extension
III. Strength
- MMT
IV. Coordination:
- Dysdiadokinesia testing rapid alternating
movement
- Heel to shin/knee and draw straight line down
the leg
- Draw a circle with your leg
- Finger taps
Able to straighten leg without moving hip, isolated
movement/ synergy patterns, any compensation?
● Postural extensors: PF, hip extensors
- Glute bridge
- SLR
- Heel to butt
- Knee to chest
CAN'T DO IT= S/L GRAVITY REDUCED

Reflex testing UE:

 I. Bicep
II. Tricep
III. Brachioradialis
IV. VOR
LE:
I. Patella tendon
II. Achilles
III. Babinski
Grading:
0 : Absent
1+ : Hypoactive
2+ : Normal
3+ : Hyperactive with no clonus
4+ : Hyperactive with clonus

Video analysis Looking for:

V. Voluntary action
VI. Fractionation
VII. Strength
VIII. Coordination:
To guide:
CN
Tone
Reflex
Sensory
Standardized measures

Standardized testing 5XsTS: Power

6MWT: Endurance
9 HOLE PEG TEST
10 MWT
12 ITEM MS WALKING SCALE
30 SEC STS: Endurance
30 SEC ARM CURL: Endurance
ABC SCALE: Fall risk/previous faller
ASIA IMPAIRMENT SCALE
BEST TEST: Anticipatory/ reactive balance
BBS: Community ambulator
DISABILITIES OF THE ARM/SHOULDER/HAND:
DGI:
FOOT AND ANKLE ABILITY MEASURE:
FGA:
RIVERMEAD:
TUG: Risk for falls, slow walkers, community
ambulators
TRUNK IMPAIRMENT SCALES: Hemiplegia, stroke
 patients

Cognition - Consciousness
- Alert
- Aware
- Stupor: Need painful stimuli
- Obtunded: Need constant stimuli
- Coma: Can't rouse
- Mental Status: Mini Mental Status Exam
- Orientation
- Location
- Date
- Year
- Current president/ last few presidents
- Language
- Speech
- Dual task: Attentional
- Count backwards by…..
- Repeat story
- Talk test

Examination of people with dizziness:

Name Technique

History: ● Do you have vertigo?

○ How long, when will it last?
○ Spontaneous, motion induced, positional?
● Do you have an imbalance?
○ Constant, spontaneous, motion or position dependent; worse with
fatigue, in dark, outside?
● Do you lose balance or drift when you are walking?
● Best/worst time of day?
● Fall history
● Previous and current activity levels

✭ Screen ✭ ● Cervical ROM

● Sensation
○ Dermatomal, myotomal
● CN
○ Visual fields and acuity
● Gross strength
● Posture
● Coordination
● DECISION MAKING:
Labrynthitis/ ● Infrared goggles
UVH ○ Make it hard to find gaze stabilization
○ Suppression of nystagmus using gaze stabilization is harder
● Peripheral, unilateral disorder
○ Eyes will acutely demonstrate nystagmus

Dizziness ● Cluster for BPPV

Handicap ● Psychosocial factors
Inventory

Head Impulse ● ✭ Screen cervical ROM before you do this

Test ● Vestibular function
● VOR to slow and rapid thrusts
● Sitting first, maybe more challenging position in standing after that
○ Give them target and then move head
○ Look between my eyes at my nose, tilt head 30º, hold head
○ Looking at eyes for corrective saccades, retinal slip
○ Head movement to ipsilesional side will trigger, some people
have B
○ 2 MgHz metronome moving head to and at some point shake,
shake, then one side
Oculomotor ● Function: Pursuit, saccades, vergence
● Ocular alignment:
○ Tropia: Deviation of eyes during binocular viewing
○ Phoria: Deviation of eyes during monocular viewing (eye drifts
when covered and actively viewing)
● Alignment may need orthopedic exercises (vision therapy)

Dynamic ● Snellen chart:

Visual Acuity ○ 10-15 feet
○ 2 cycles per second
○ Degradation of 3 or more lines is indicative of oscillopsia
● Baseline: lowest line you can read comfortably
● While patient moves head at correct speed whats the lowest line you can
read comfortably, normal to not be the same but if it's worse than 3
levels= pathological
○ Metronome 180, 2 cycles per second
● Patient moves head themselves to metronome
○ Examiner may need to cue the pace

Eye head ● 2 targets

coordination ● Align head and eyes to target, keeping eyes on target realign your head
testing to other target with eyes on original target and then shift

Vestibular ● May be indicative of concussion related issues and retracted post

Ocular Motor concussion recovery, often in context of a concussion workup
Screening ● Visual motion sensitivity test: stay on target of overlapped thumbs in
(VOMS) front of you and do a large swing (need spinal ROM), 6 reps back and
 forth
○ Do in a busy background
○ Speed: 50 metronome
● VOR: Shaking, stabilize visual field while moving head
● Monitoring symptoms, people who feel sick doing these things is
indicative of mild brain injury
● Gives insight into vestibular/ ocular behaviors that trigger variety of
symptoms

Subjective ● Bucket test: normal is alignment of the bar within 2.5 degrees of vertical
Visual ● Acute peripheral or central vestibular disorder averages 8-9 degrees off
Vertical vertical
(SVV) ● Anyone with head tilt/ lateral pulsion

Hallpike Dix ● Dizziness that is: (for this do this test first)
○ Episodic vertigo
○ Does not have hearing loss associated with it
● Rather than… (for these go through other tests first)
○ Sudden onset
○ Vertigo for awhile
○ Severe imbalance for awhile
○ Suspecting peripheral lesion (✭ red flags for central disorders=
screen)
○ Thinking ULH, sometimes BLH
● Provocation tests:
○ ✭ Sitting, pick ear, rotate head 45 º to test side
○ Very quickly bring person to recumbent position and extend head
30º , shoulders at EOB
○ Keep eyes open, ideally they have frenzel lenses or infrared
goggles on
■ Onset of symptoms may be quick or latency 15 seconds
■ Symptoms: vertigo/ nystagmus
■ Keep them here for a minute or until symptoms resolve
■ ✭ IF SYMPTOMS PERSIST AS LONG AS THEY
ARE IN THIS POSITION: Cupolothiasis
(symptoms persist as long as in position)
■ ✭ IF SYMPTOMS STOP WITHIN 1 MINUTE:
Canalithiasis
■ Diagnostic for BPPV
○ Identifying canal involved: Depends on direction of nystagmus
■ Keep eyes open
■ ✭ PCC: Most common canal of involvement,
ipsilateral and upbeating (fast phase direction, slow
drift down and to the left, fast correction up to the right)
■ ✭ ACC: Ipsilateral and down beating
● WARN THEM IT WON'T FEEL GREAT
● Don't just let go, way up: tell them to push through hands, or hold your
arm. Keep hold of head and of the patient, they will feel dizzy no matter
+/- test (Head was just below heart)
● Pick one spot in eye to watch and you may see torsional component of it

● Alternative positions to hallpike dix: Those who cant tolerate supine /

extension
 ● Reverse trendelenburg position
● Sidelying
● Table with pillows/ wedge using pillows/wedge as EOB rather than off
bed

Supine roll ● ✭ For HCC: Nystagmus horizontally

test ○ Wedge/ pillows prop the head up
○ In supine, tilt 30º to align canal with vertical pull of gravity
○ Nose to ceiling →
○ Rapid turn to first test side (pause and wait for symptom onset)→
○ Return to neutral →
○ Rapid turn to other test side
Balance/ gait
measures

Treatments: ● Epley Maneuver

○ For canalithiasis in PCC
○ Resolves BPPV in one or 2-4 treatments 89% of the time
○ Stay in each position for 30 seconds or until symptoms resolve

- 1. A to B: Dix hallpike
- 2. C: Quick head turn
- 3. D: Trunk and head roll in unison, maintaining extension and rotation=
patients nose down
- 4. D to E: Switch hand placement
- 5. E: Sit up, tell pt keep looking up at my hand, other hand moves to
shoulder
 -**** Recommendation- 2-4 times. At least twice, if they are still
having nystagmus on dix hallpike they are positive and the
crystals still displaced- do again! Take a few minutes between
- TAKE TIME BEFORE DRIVING HOME or ask for someone to
drive them home
- HIGH RECCURENCE RATE
- If pt not tolerating well (throw up, hot, sweaty), not going to do a
third time right then= follow up in a few days and do again.
- This is usually treatment session, afterwords pt is alittle bit off=
vestibula hangover fogginess/ tired/ off balance, not gonna feel
good after this BUT will most likely wake up tomorrow morning
doing great
- In this session this is it
- Balance screen on FU
- Billing: Eval code is low/mod/high evals, straight forward low
complexity, CPT code for epley, FU= therapeutic activity code
for pt education, depending on how long for NMR coe for
vestibular rx or procedural code (along these lines)
- If multi canal is suspected: do the more severe canal first
- 9/10 symptoms in dix hallpike (PCC)
- 4/10 in roll over (HCC)
- RX PCC first
● Liberatory/ Semont Maneuver
○ For cupulothiasis
○ 180º swing in < 1.5 seconds
○ Short term
○ Effectiveness < 80%
○ IF SOMEONE TEST + IN DIX HALLPIKE BUT S/S DONT
RESOLVE

- Rotate head contralateral to treatment side

- Come down quickly to side of treatment ear
- S/S: Wont resolve, wait a minute in each position
- Then go to opposite side sidelying, head wont change position on body
- Can use hand on pelvis, dont want to pull on head- the hand on skull
maintains rotation. Staggered stance legs with their legs, then hand on rib
cage/ elbow and forearm on hip to help them sit up
-
● Brandt- Daroff Exercises:
○ If Epley maneuver fails
○ 5 reps, 3x/day, 2-3wks

● Log roll maneuver:

○ Horizontal canal involvement
○ Success rate 71%

● Lempert roll maneuver:

○ 75% effective in treating lateral BPPV
○ Supine, turn head toward non affected side
○ Maintain each position for 15 seconds
○ Complete maneuver bring patient upright with head at 30º
- Head on body, then body on head
- Segmentally- head and body do not move together as a unit
- 1. Supine
- 2. Rotate to the L
- 3. Roll on side keeping head rotated L (need assistance= tell them to
leave head pointed that way and you help them roll, give alot of VC to
keep head in position)
- 4. Turn and look down to floor
- 5. Roll into prone ( alot of back pain- alot of older adults dont go into
prone at all, maybe try it= part of getting rid of dizziness, you dont stay
there long)
- 6. When in prone rotate head other way
- 7. Roll onto side
- 8. Head stays rotated and they roll onto back
- 9. Supine and turn head back up to sky
● Gufoni Maneuver:
○ For geotropic HC
○ Debris in posterior aspect of HCC

● For apogeotropic HC
 ○ Cupulothiasis or debris in anterior aspect of HCC

● Modified liberty maneuver

○ ACC
○ Nose down at first, up second

● Forward particle repositioning maneuver for ACC:

○ 3 repetitions
● Deep head hanging for ACC:

● Cawthorne:
● Viewing exercise:

- Speed, Position
- Faster= harder
- Adding DOF= sitting to standing, semi tandem, tandem
- Adding smaller target= harder, target in busy environment = harder
● Adaptation:
○ Context specific: vary fq/speed/positions of movement
○ Progress to noisy and crowded environments
○ Best exercise pushes limits of stability
○ Several times a day, 2 minutes at a time
● Habituation:
○ Rx for motion sensitivity
○ Repeated exposure to provocative stimulus results in reduction of
 pathological response to stimulus
○ May take more than a month to see change
○ Exercise guidelines:
■ 4 movements using motion sensitivity testing chart
■ Perform movements quickly 2-3x 2x/day
■ Wait between reps for symptoms to subside
■ Continue rx for 2 months, then do 1 time a day
● Substitution:
○ Use of visual and somatosensory cues instead of vestibular cues
○ Not sufficient for all situations
■ Poor lighting
■ Rapid head movements
● UVL:
○ Adaptation
■ Improve gaze stability
■ Veiwing x1 and x2
○ Balance retraining
■ Habituation
● Decrease motion sensitivity
● Repeat movements into provoking positions
■ Substitution
● BVL:
○ Adaptation
■ Improve gaze stability
■ Viewing paradigms
■ Postural retraining activities
○ Substitution
● Central VL:
○ Adaptation
○ Primarily substitution
■ Fall prevention
■ Postural retraining
○ Habituation

Concussion

Cover test ● Identifies tropia

○ Tropia is present during binocular viewing
● Fixation is broken and you see misaligned eye moves to fixate
● When you cover other eye, see movement for the only open eye to fix
on target
○ Indicating it was not fixed on target prior
● Not caused by concussion but will make healing harder
Uncover test ● Only do if cover test was negative= no tropia
● Identifies phoria
○ Deviation of eyes during monocular viewing
● Eye drifts when covered
● Not caused by concussion but will make healing harder

Maddox Rod ● Determine ocular misalignment either vertically or horizontally

test ● Maddox rod over pt R eye and in examiners L hand
● Examiner will hold pen light over their right shoulder and ask patient
the position of the light in relation to the line the patient sees which
will be horizontal or vetical depending on the position the maddox rod
is held
● Small deviations (less than 1 cm) from vertical is normal
○ Difference greater than 1 cm abnormal
● Any deviation from horizontal midline is more likely to be abnormal

Manual traction ● May decrease S/S of dizziness

Cervical neck ● Subject is seated on a rotating stool, head is stabalized by examiner,

torsion trunk is turned right, center, left, center for 30 seconds each position
○ Nystagmus may indicate cervical contribution to dizziness
 ○ Dizziness, nausea imbalance may be present and indicative of
cervical cause

INTEG:
Test Components

Turgor ● Elasticity
● To test: Gently grasp and pull up fold of skin, should return

Edema ● Pitting edema scale:

Temperature ● Use back of hand and both hands

● Look around a wound for warmth
● Similar bilaterally?
● Might be sign of infection/ abnormal circulation

Vascular flow/ ● Grading:

pulses ○ 0: Absent
○ 1: Weak, hard to palpate
○ 2: Normal, as expected
○ 3: Full
○ 4: Strong and bounding
● Bruit: present, sound of blood passing over an obstruction

Doppler ● Graded present or absent

● Probe at 45º angle to skin over artery
○ Dorsalis pedis
 ○ Posterior tibialis
○ Popliteal

Capillary refill ● Surface blood flow return to toe following it being cut off
1. Observe color
2. Push distal tip of toe for blanching
3. 5 second hold
4. Count # of seconds to refill
● Do on multiple toes
● Normal = 3 seconds to return
● Longer = + for arterial insufficiency

Rubor of ● Pt supine,
dependency 1. Note color of plantar surface of foot
2. Elevate LE to 60º for 1 min
3. Note color:
○ Normal flow is slight or no change in color
○ Insufficient flow is pale color
4. Bring limb to dependent position and count # of seconds it takes to
refill
● 15 seconds is normal
● 30+ seconds or red hyperemic= insufficient + for arterial
insufficiency (if its too fast = venous)

Venous fill ● Measure venous and arterial insufficiency

time 1. Pt seated, mark borders of multiple surface veins
2. Elevate limb for 1 minute to 60º and notice vein emptying
3. Then drop into dependent record time it takes to refill
● Normal= 15-20s, 30+ seconds + for arterial insufficiency, under 15s
+ for venous insufficiency

Ankle brachial 1. Brachial BP

index 2. Posterior tib BP
3. Dorsalis pedis BP
a. Use higher between PT and DP in each leg for calculation
4. Calculate: Ideally the same
a. Highest R leg/ highest both arms
b. Highest L leg/ highest both arms
5. Score:
a. < .5: Severe insufficiency, limb threatened, pain at rest
b. .5-.8: Moderate insufficiency, IC likely, compression
contraindicated
c. .8-1: Narrowing of 1 or more LE vessels, mild occlusion
d. 1-1.3: Normal
e. > 1.3: Abnormally high, indicates vessel calcification
Semmes ● Testing for loss of protective sensation in pts with DM
Weinstein ● Apply pressure to bend monofilament to a C curve
Monofilament ● + If client feels, - if client does not feel
● Loss of protective sensation= plantar surface of toe and 3 more spots
missing (4+ total)
● Use 5.07 monofilament

Reflex and ● Achilles reflex:

vibratory ○ In pts with DM the reflex will be diminished/ absent
assessment ○ LE reflexes most sensitive for detecting neuropathy
● Vibratory:
○ 128 Hz tuning fork on IP joint of hallux
○ Detects early neuropathy

Girth ● UE: smallest part of the wrist to the axilla

measurements ● LE: just above malleoli
● Taken ever 4cm and Bilaterally