Special Tests

Calf strain:

rehabilitation-protocol-for-hamstring-injury-non-operative.pdf (massgeneral.org)

The Assessment, Management and Prevention of Calf Muscle Strain Injuries: A Qualitative Study of the Practices and Perspectives of 20 Expert Sports Clinicians (springeropen.com)

Meniscal:

https://www.brighamandwomens.org/assets/BWH/patients-and-families/rehabilitation-services/pdfs/knee-meniscal-tears-bwh.pdf

12/12/23.

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SkM

Hypermobility component. Doctor believes they would benefit from cervical and core strengthening.

SoC

Presentation and physical therapy management of upper cervical instability in patients with symptomatic generalized joint hypermobility: International expert consensus recommendations - PMC (nih.gov) 

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MaF - Eval for R shoulder scope, R sub pec biceps tenodesis performed Feb 9th, 2024 (10 days post op)

Biceps tenodesis:

https://medicine.osu.edu/-/media/files/medicine/departments/sports-medicine/medical-professionals/shoulder-and-elbow/bicep-tenodesis-2020.pdf?rev=055004fd34654e669047eff02f3015ba&hash=BD9EAB39873AF986C568495FD2156E7C

SLAP repair:

https://medicine.osu.edu/-/media/files/medicine/departments/sports-medicine/medical-professionals/shoulder-and-elbow/arthroscopic_slap_repair.pdf?rev=ca495b3896bf475ea245cd401e9ea318&hash=8FF8BE1BE989954D4C0735F178717F15

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3/1/24

CaH

-Bike with yellow TB around knees

-Adductor squeezes with ball 

-Sit to stands with band 

-Terminal knee extension with step up and appropriate knee position

JaS

Asses knee strength MMT

Assess hip strength MMT

MaK

Seated ER with shoulder propped on table at 90 deg abd

Prone ER with shoulder at 90 deg abd

Assess tolerance to rows at home

ChW

Seated flexion stretch

Posterior and anterior pelvic tilt

LTR

Ball rolling in seated stretch

Bridges

Hip extension leaning on table

Pallof press

TA bracing

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3/4/24

VeS

Hip flexion isometric at 90 deg, LTR with feet shoulder width to patient's tolerance, upright bike, hip AROM to patient's tolerance, ball rolling into hip and knee flexion in supine, Standing calf raise double leg

Next visit, should be able to add more.

SkM

Quadruped cervical retraction with rotation

KrN

Stationary bike Retrograde massage. Heel slides Standing weight shifts without walker Knee flexion stretch for 2 min at seated position Heel raises Standing hip abduction Standing marches 

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3/5/24

MaK

Elbow flexion in seated

Elbow flexion in supine

Shoulder flexion with cane to work increasing AROM with less pain

Supine AROM in flexion

MaF - (Day 25) Continue same precautions this visit. 

Bike with the R UE passively performed and the L UE performing 100% of the activity, 2 min forward, 2 min backward

Shoulder isometrics in neutral position (add to HEP)

GeR

Progress note. Discharge if everything is going okay or schedule out one more visit if progress vertical VOR.

Progress vertical VORx1 as indicated with speed and duration 

SaV

Passive stretches

Passive range of motion

STM with cupping

Cervical AROM with pillows under arms 

Assess cervical deep cervical flexor strength for time

Sensory integration with touch discrimination.

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3/6/24

CaO

Start with soft tissue mobilization while seated

Assess technique with HEP: flexion walkouts 2x10

Shoulder PROM in reclined position.

Trial AAROM with cane: flexion, abduction, ER

Isometrics: flexion, abduction, adduction, extension

Scapular squeezes, shoulder rolls

Pulleys

Add to HEP: isometrics

EdH

Knee extension with yellow TB 

Stool scoots forward and backward but in W/C

Step ups

Reclined hip flexion

BrC

TF distraction

Quad sets

Clam shells

LAQ and knee extension with isometrics with ankle weights 

chair scoots in W/C forward and backward 

SkM

Low-frequency TENS

Rows with cervical retraction 

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3/7/24

VeS

LAQ with 1 lb weight

hamstring stretch

Bridges are fine at 0-2 weeks

MaF

Same protocol

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3/11/24

SkM

Quadruped cervical retraction and rotation

Foam roll

T's

Rows

VeS

20 days post op

Single leg stance

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3/13/24

MaF

32 days post op. At 35 days, we can start with the 5 week protocol. This will be after her next visit.

LuP

>5 min on bike for warmup

>Perform slump test again

>Assess flexion/extension ratio

--Biering-Sorensen for extension set-up: on high-low table and two belts anchored around ankles and below glutes with torso hanging off table. Elbows placed on rolling stool. For the test, move the stool and allow them to balance in neutral extension. Normal individuals can balance for 1.5-2 min. If patient starts to creep into flexion, time will stop. Also compare the ratio of extensors to flexors.
--Assess flexion:extension ratio with the the Biering-Sorensen test to the abdominal isometric hold. In hooklying position, hip ankle should be about 30 deg and the head is straight in that position. Compare the two results. Extensors should be stronger. For example, if able to hold extension for 120 sec/2 min, flexion should be held for 100 sec.

>CPA to lumbar, 40 sec grade 3-4 oscillation, 3x
>Press ups repeatedly 
>Cupping, STM, trigger point release

>Run through HEP: 

-quad stretch: 2x30 sec, 2x/day

-hamstring stretch: 2x30 sec, 2x/day

-massage ball to back: 5 min, every other day. 

>Clam shells

>TA bracing

>TA bracing with hedgehog rocking and rolling

>Pallof press and give as HEP

Update HEP:

-Add hip abduction in sidelying

-Isometric extension as indicated

-Pallof press

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3/26/24

ZaW

STM to paraspinals, BIL UT, cupping

CPA to C5 and C6

Sideglide mobility

Suboccipital release

Thoracic CPAs 

upper cervical neck flexion endurance test

Sensory re-integration

Cervical isometrics

Cervical retraction in seated

Cervical retraction with rotation

MaM

Sensory re-integration

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Headache, dizziness, and feeling foggy

EVALUATION

Visual/Vestibular Exam:

-Spontaneous Nystagmus: Holding pt's head still and looking for nystagmus while they look straight.

-Fixed Gaze Nystagmus: Use pin to take pt's vision up, down, side-to-side only 30 deg and look at nystagmus at end of motion while they hold their vision.

---Alexander’s Law: with unilateral nystagmus, if looking to the right with left issues, it will speed up fast phase toward the right, but looking to the left, you still get fast to the right, but slower. If central, it would be fast no matter where you are looking. 

-Occulomotor range of motion: Looking to see if the eyes move conjugately and smoothly. 18-24 in. Small amount of end-range nystagmus is normal. Small jump in eye movement as eyes cross mid-line is normal.

-Smooth pursuits: 24-36 in. from pt. 60 deg of total arc of motion. Small jump in eye movement as eyes cross mid-line is normal. Smooth pursuit eye  movements may be slightly saccadic in older people.

-Convergence: Hold finger 2 ft away and bring closer to nose. Eyes should converge and pupils should constrict. Ask when the patient sees 2 fingers (pens) or it becomes blurry.

Convergence should be sustainable <6cm from tip of nose.

-Saccades (vertical and horizontal): Pt looks at 2 objects 15 deg apart. Looking for number of eye movements it takes for patient’s eyes to reach target. Normal is < or equal to 2 movements. Overshoots are always a positive test!!

-Can also assess ocular alignment.

-VOR Cancellation: Head tilted 30 deg. Head and hand moving in same direction. Assessing for saccadic eye movements (central dysfunction).

-VOR (vertical and horizontal): Head tilted 30 deg.

-Head Thrust Test: Tilted 30 deg downward. 10 deg only for the thrust. Looking for corrective saccades back to target. Positive test indicates vestibular hypofunction on ipsilateral side.

-Head Shaking Nystagmus: Tilt pt's head down 30 deg. Close eyes and shake their head 20x at 2 Hz. Have pt open eyes and fixate vision on a target. Look for nystagmus. Works best with VNG goggles or Frenzel lenses. If nystagmus present, positive sign for unilateral vestibular hypofunction.

-Visual Acuity/Dynamic Visual Acuity.

TREATMENT

Migraine:

-Pt's who are motivated do quite better than pt's who are less motivated.

-Vestibular rehab as indicated. Starting light and progressing.

-Exercise 30 min per day.

-Regular sleep.

-Drink 8 glasses of water per day.

Vestibular migraine isn't fully understood but seems to result from overlapping pathways that modulate pain and vestibular inputs into the brain.

Vestibular:

-If central dysfunction: work on saccades and smooth pursuits as indicated.

-Wonderful visual exercises under semester 5 concussion and TBI folder

For improving Saccades:

-https://eyecanlearn.com/tracking/saccades/ 

-This is a website the patient can access.

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4/16/24

BrMe

RTC repair, subacromial decompression, bicep tenodesis: 4/3/24. Day 15.

PROM flexion, external rotation, internal rotation, abduction to patient's tolerance

Bicep tenodesis: no ER greater than 40 deg for 4 weeks.

PROM shoulder flexion/extension, pronation/supination to tolerance

HEP:

Table walkouts in flexion

PROM shoulder flexion/extension, pronation/supination

Supine shoulder ER with wand

Scapular retraction

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4/17/24

DeFe, cevical arthroplasty

Gentle STM to paraspinals as needed

Grade I-II joint mobilizations above/below surgical site for pain

Light cervical AROM with neutral spine

Avoid sitting for prolonged periods of time

Lift no more than 10 lbs.

-Cervical retractions 

-Scapular retractions

-Shoulder shrugs, scapular clocks 

-Biceps/triceps/shoulder ER/IR/Flex/EXT - Fine motor function with hands 

-Core: tra/multifidi/glute med/max isometrics

HaKu, Ehler's Danlos Syndrome for cervical, upper back and low back pain

Strengthening and STM

High repetition resistance training for cardiovascular fitness

Strength training

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5/29/24

ChLi

May 12th can transition to no lifts.

Weight shifts

Light stretch into DF but not to exceed 0 deg