1

Summary

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• General Principles: In Rehabilitation Medicine, the "right time" to start is "now" (upon admission) to prevent complications like contractures and cardiovascular deconditioning.
• General Principles: For Deconditioning Syndrome, immobility is considered debilitating and disabling regardless of whether the individual is sick or healthy.
• General Principles: In the United States healthcare system, rehabilitation is often automatic; nurses call therapists as soon as a patient is transferred to a station/floor.
• General Principles: In the Philippines, rehabilitation is often treated as an "add-on" or "additional baggage" rather than an integral part of care.
• General Principles: The Physiatry specialty was formerly called Physical Medicine and Rehabilitation, emphasizing the use of physical modalities (EMG, electrotherapy, exercise).
• General Principles: For Physiatrists, the focus of treatment is a process designed to improve daily function through medications, physical energy interventions, and experiential training.
• Clinical Application: Regarding Back pain prevention, individuals in a period of physical inactivity for more than 30 minutes are at risk and should move or walk every half hour.
• Clinical Application: In Stroke Recovery, mature cortical neurons do not regenerate; recovery is achieved through motor relearning and cortical reorganization.
• Clinical Application: In Cardiovascular health, a resting heart rate exceeding 80 beats per minute is an indicator of significant deconditioning and increased mortality risk.
• Clinical Application: For Abdominal Surgery, mobilization is critical as early as post-op Day 1 to prevent adhesions; surgeons must reassure patients that sutures (multiple layers) are unlikely to dehisce unless infected.
• Clinical Application: In Oncologic Rehabilitation, the objective is to ensure the patient "dies happy," involving a multidisciplinary team including chaplains.
• Referral Systems: A Blanket Referral (as used in VSMMC/Sotto) allows the Rehab team to treat admitted patients even without a specific formal request, ensuring early mobilization.
• Referral Systems: In the Philippine Referral System, a patient typically sees a specialist (e.g., Ortho/Neuro) BEFORE being referred to Rehab, which can increase the financial burden.
• Historical Background: In 12th Century Medicine, Maimonides emphasized that a sedentary life leads to pain and waned strength despite good nutrition.
• Historical Background: In 20th Century Cardiac Care, old guidelines recommended 3–8 weeks of bed rest for MI; modern medicine rejects this due to the deleterious effects of immobility.
• Space Medicine: In the Space program, exercise is a positive treatment mode used to counteract muscle atrophy caused by weightlessness/lack of gravity.
• ICF - Impairment: An Impairment is defined as a loss or abnormality in body function (physiological) or body structure (anatomical).
• ICF - Activity Limitation: An Activity Limitation is the new term for "disability," referring to difficulties an individual may have in executing activities (e.g., difficulty walking or eating).
• ICF - Participation Restriction: A Participation Restriction is the new term for "handicap," referring to problems in involvement in life situations (e.g., inability to attend church or work).
• ICF - Examples: For a Stroke patient, hemiparesis is the impairment, difficulty swallowing is the activity limitation, and inability to dine out with family is the participation restriction.
• ICF - Examples: For Leprosy, the social stigma is an environmental barrier that leads to unemployment, which is a participation restriction.
• Public Health: The World Health Organization (WHO) predicts that by 2030, there will be more patients in the community than in hospitals due to an aging population.
• Public Health: The Philippine Demographic is projected to become an "aged population" (14% aged 65+) by the year 2050.
• Philippine Law: The Magna Carta for PWDs stipulates that at least 10% of a company's workforce should be PWDs, though implementation remains a challenge.
• Philippine Law: The Accessibility Law and White Cane Act are primary legal bases for the rights and mobility of PWDs in the Philippines.

DIFFERENTIAL COMPARISONS FOR EXAMS

1. Activity Limitation (Disability) vs. Participation Restriction (Handicap): Activity Limitation is a personal difficulty in executing a task (e.g., can’t climb stairs), whereas Participation Restriction is a societal difficulty in life situations (e.g., can’t enter a building because there are only stairs).
2. Body Functions vs. Body Structures: Body Functions are physiological or psychological (e.g., hearing, pumping blood), while Body Structures are anatomical parts (e.g., the ear, the heart muscle).
3. Capacity vs. Performance: Capacity is what a patient "can do" in a controlled clinical environment; Performance is what they "actually do" in their usual home or social environment.
4. Environmental Facilitator vs. Environmental Barrier: A facilitator assists function (e.g., a prosthetic limb or a ramp), while a barrier hinders it (e.g., lack of public transport or negative social attitudes).
5. Primary Prevention vs. Secondary Prevention: Primary prevention uses exercise to prevent disease onset in healthy individuals; Secondary prevention initiates rehab during the acute phase of an illness to prevent complications.
6. Restoration vs. Optimization: Rehabilitation medicine prioritizes Optimization (maximizing residual function) over Restoration (returning exactly to the pre-injury state), especially in neurological injuries.
7. Old MI Guidelines vs. Modern MI Guidelines: Old guidelines required up to 8 weeks of bed rest; modern guidelines start cardiac rehabilitation as early as Post-Op Day 1 to avoid immobility effects.
8. Aged Population vs. Aging Population: A population is "Aging" when 7% are 65+; it is "Aged" when 14% are 65+.
9. Skilled Nursing Facility vs. Assisted Living Facility: Skilled nursing provides 24/7 medical/nursing care; Assisted living is for independent individuals who need help with minor tasks like marketing or therapy.
10. Impairment (Stroke): In stroke, Hemiparesis is a physical impairment, whereas Aphasia is a communication impairment; both can lead to different activity limitations.
11. Direct Referral (International) vs. Indirect Referral (Philippines): Internationally, therapists (DPT) can be first-contact practitioners; in the Philippines, specialized doctors usually act as the mandatory primary gatekeepers.
12. Physiatry vs. Physical Therapy: A Physiatrist is a Medical Doctor (MD) who diagnoses and prescribes; a Physical Therapist (PT) implements the physical interventions and exercises.
13. Labile Cells vs. Nerve Cells: Labile cells regenerate easily; Nerve cells do not regenerate, necessitating Neuroplasticity for functional recovery.
14. Tertiary Prevention vs. Hospice: Tertiary prevention aims for the highest independence (e.g., walking); Hospice focuses on comfort and "dying happy" when recovery is no longer the goal.
15. Personal Factors vs. Environmental Factors: Personal factors are internal to the patient (age, grit, education); Environmental factors are external (laws, architecture, family support).

QA

text TOPIC: SCOPE AND TIMING OF REHABILITATION MEDICINE

1. What is the primary goal of Rehabilitation Medicine? | Optimization of function
   (and quality of life rather than absolute restoration).
2. When should Rehabilitation initiation ideally begin? | At onset of disease
   (or upon hospital admission, not at discharge).
3. Regarding the Continuum of Care, when does rehabilitation stop? | It does not stop
   (it must continue post-discharge).
4. Enumerate the expanded clinical areas of Rehabilitation scope. (4) | 1) Cardiovascular
   2) Pulmonary
   3) Oncologic
   4) OB-GYN
5. What is a Physiatrist? | Medical doctor (MD)
   (Specialist in Physical Medicine and Rehabilitation).
6. What is the specific focus of a Physiatrist? | Function and performance
   (focusing on disorders that alter these).

TOPIC: LEVELS OF PREVENTION IN REHABILITATION 7. What serves as the foundational defense in Primary Prevention? | Exercise
(acts like a vaccine against chronic conditions). 8. Cardiovascular disease is specifically targetted by what level of Rehabilitation prevention? | Primary Prevention 9. When does Secondary prevention rehabilitation involve initiating processes? | Immediately during acute treatment
(once stabilized, even in ICU/coma). 10. What is the objective of Tertiary prevention? | Maximize residual function
(and reduce caregiving burden). 11. A transition from bed-bound to ambulatory represents what level of Rehabilitation prevention? | Tertiary Prevention

TOPIC: THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING (ICF) 12. Define Body Functions (ICF Part 1A). | Physiological functions
(includes psychological functions like endurance). 13. Define Body Structures (ICF Part 1A). | Anatomical parts
(e.g., limbs and organs). 14. What is the definition of Activity (ICF Part 1B)? | Execution of a task
(subjective or personal level). 15. What is the definition of Participation (ICF Part 1B)? | Involvement in life situations
(societal level). 16. What components make up Environmental Factors (ICF Part 2A)? | Physical, social, attitudinal environment
(can be facilitators or barriers). 17. What are Personal Factors (ICF Part 2B)? | Individual's background
(age, education, beliefs not part of health condition). 18. Give examples of Body Functions in the ICF model. | Heart rate and endurance 19. Give examples of Body Structures in the ICF model. | Limbs and organs

TOPIC: KEY TERMINOLOGY & CONCEPTS 20. Define Neuroplasticity. | Brain's capacity to reorganize
(forming new synaptic connections). 21. What is the core theory of recovery in Stroke? | Neuroplasticity 22. Define Deconditioning Syndrome. | Physiological effects of immobility
(affects cardiovascular health/muscle atrophy). 23. In rehabilitation, what is Capacity? | Function in clinical setting
(what a patient "can do"). 24. In rehabilitation, what is Performance? | Function in actual environment
(what a patient "actually does"). 25. Define Environmental Facilitators. | Factors improving participation
(e.g., ramps). 26. Define Environmental Barriers. | Factors restricting participation
(e.g., stairs, social stigma).

GENERAL PRINCIPLES 27. When is the "right time" to start Rehabilitation Medicine? | Now (upon admission) 28. Why is starting rehab upon admission critical for General Principles? | Prevent complications
(contractures and deconditioning). 29. Who is affected by Deconditioning Syndrome? | Sick or healthy individuals
(immobility is always debilitating). 30. How is rehabilitation initiated in the United States healthcare system? | Often automatic
(nurses call therapists upon transfer to floor). 31. How is rehabilitation often perceived in the Philippines? | "Add-on" or "baggage"
(rather than integral care). 32. What was the Physiatry specialty formerly called? | Physical Medicine and Rehabilitation 33. What physical modalities are emphasized in Physiatry? | EMG, electrotherapy, exercise 34. For Physiatrists, how is function improved? | Medications and physical interventions
(and experiential training). 35. What is the focus of treatment for Physiatrists? | Improving daily function

CLINICAL APPLICATION 36. In Back pain prevention, when are individuals at risk? | 30 minutes of inactivity 37. What is the recommendation for Back pain prevention? | Move every half hour 38. Do mature cortical neurons regenerate in Stroke Recovery? | No 39. How is recovery achieved in Stroke Recovery? | Motor relearning
(and cortical reorganization). 40. In Cardiovascular health, what heart rate indicates deconditioning? | Exceeding 80 bpm (resting) 41. What does a high resting heart rate indicate in Cardiovascular health? | Increased mortality risk 42. When should mobilization begin after Abdominal Surgery? | Post-op Day 1 43. Why is early mobilization critical in Abdominal Surgery? | Prevent adhesions 44. Why are sutures unlikely to dehisce during Abdominal Surgery mobilization? | Multiple suture layers
(unless infected). 45. What is the primary objective in Oncologic Rehabilitation? | Patient "dies happy" 46. Which specific professional is noted in the Oncologic Rehabilitation team? | Chaplains

REFERRAL SYSTEMS 47. What is a Blanket Referral? | Treatment without formal request
(allows early mobilization). 48. Which hospital is cited for using Blanket Referrals? | VSMMC (Sotto) 49. In the Philippine Referral System, who does a patient see first? | Specialist
(e.g., Ortho or Neuro). 50. What is a disadvantage of the Philippine Referral System? | Increased financial burden

HISTORICAL BACKGROUND 51. What did Maimonides state about 12th Century Medicine? | Sedentary life leads to pain
(despite good nutrition). 52. What were the old MI guidelines in 20th Century Cardiac Care? | 3–8 weeks bed rest 53. Why does Modern medicine reject long bed rest for MI? | Deleterious effects of immobility

SPACE MEDICINE & ICF CONCEPTS 54. How is exercise used in the Space program? | Positive treatment mode
(counteracts muscle atrophy). 55. What causes muscle atrophy in the Space program? | Weightlessness
(lack of gravity). 56. Define Impairment according to the ICF. | Loss/abnormality in body function/structure 57. What is the new term for "disability" in ICF - Activity Limitation? | Activity Limitation 58. What does Activity Limitation refer to? | Difficulty executing activities
(e.g., walking/eating). 59. What is the new term for "handicap" in ICF - Participation Restriction? | Participation Restriction 60. What does Participation Restriction refer to? | Problems in life situations
(e.g., attending church/work). 61. For a Stroke patient, what is the impairment? | Hemiparesis 62. For a Stroke patient, what is the activity limitation? | Difficulty swallowing 63. For a Stroke patient, what is the participation restriction? | Inability to dine out with family 64. In Leprosy, what is the environmental barrier? | Social stigma 65. In Leprosy, what is the participation restriction? | Unemployment

PUBLIC HEALTH & LAW 66. What is the World Health Organization (WHO) prediction for 2030? | More patients in community than hospital 67. Why will community patient numbers increase by 2030? | Aging population 68. When will the Philippine Demographic be an "aged population"? | Year 2050 69. What percentage defines an Aged population? | 14% aged 65+ 70. What is the workforce requirement in the Magna Carta for PWDs? | At least 10% 71. What are the primary legal bases for PWD rights and mobility in the Philippines? | Accessibility Law and White Cane Act

DIFFERENTIAL COMPARISONS 72. Compare Activity Limitation vs Participation Restriction. | Activity: Personal task difficulty
Participation: Societal involvement difficulty. 73. Compare Body Functions vs Body Structures. | Functions: Physiological/Psychological
Structures: Anatomical parts. 74. Compare Capacity vs Performance. | Capacity: Clinical "can do"
Performance: Usual "actually does". 75. Compare Environmental Facilitator vs Barrier. | Facilitator: Assists function
Barrier: Hinders function. 76. Compare Primary vs Secondary Prevention. | Primary: Prevent onset (exercise)
Secondary: Starts during acute phase. 77. Compare Restoration vs Optimization. | Restoration: Return to pre-injury
Optimization: Maximize residual function. 78. Which is prioritized in neurological injuries: Restoration or Optimization? | Optimization 79. Compare Old vs Modern MI Guidelines. | Old: Weeks of bed rest
Modern: Mobilize Day 1. 80. Compare Aging vs Aged Population. | Aging: 7% are 65+
Aged: 14% are 65+. 81. Compare Skilled Nursing vs Assisted Living Facility. | Skilled: 24/7 medical care
Assisted: Independent with minor help. 82. In Stroke Impairment, distinguish Hemiparesis vs Aphasia. | Hemiparesis: Physical
Aphasia: Communication. 83. Compare Direct vs Indirect Referral. | Direct: Therapist is first contact
Indirect: Physician is mandatory gatekeeper. 84. Compare Physiatry vs Physical Therapy. | Physiatrist: Medical Doctor (Diagnoses)
PT: Implementing physical intervention. 85. Compare Labile Cells vs Nerve Cells. | Labile: Regenerate easily
Nerve: Do not regenerate. 86. Compare Tertiary Prevention vs Hospice. | Tertiary: Highest independence
Hospice: Comfort and "dying happy". 87. Compare Personal vs Environmental Factors. | Personal: Internal (Age, Grit)
Environmental: External (Laws, Architecture).

ADDITIONAL ICF & TERMINOLOGY BREAKDOWN 88. What level of the ICF is Activity focused on? | Individual/Personal 89. What level of the ICF is Participation focused on? | Societal 90. Give an example of an Environmental Facilitator. | Prosthetic limb (or ramp) 91. Give an example of a Personal Factor in rehabilitation. | Grit (or education/age) 92. Give an example of an Environmental Barrier. | Lack of public transport 93. In Stroke Recovery, what allows healthy regions to assume damaged functions? | Neuroplasticity 94. Does Deconditioning Syndrome only affect the sick? | No (affects healthy if immobile) 95. What systems are affected by Deconditioning Syndrome? | Cardiovascular and Musculoskeletal 96. ICF Part 1A consists of which components? | Body Functions and Structures 97. ICF Part 1B consists of which components? | Activity and Participation 98. ICF Part 2A consists of which component? | Environmental Factors 99. ICF Part 2B consists of which component? | Personal Factors 100. What is Neuroplasticity's role in stroke? | Reorganize and form new connections 101. Define Capacity setting. | Controlled clinical environment 102. Define Performance setting. | Home or social environment 103. Exercise acts like a "vaccine" in which level of Prevention? | Primary Prevention 104. Which professional implements interventions prescribed by a Physiatrist? | Physical Therapist 105. What is the significance of 2050 in Philippine demographics? | Projection of "Aged Population" (14%)

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Summary

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PHYSIATRIC HISTORY AND PHYSICAL EXAMINATION

SPECIALIZED PHYSICAL EXAMINATION SIGNS

SENSORY EVALUATION (DERMATOMES)

MOTOR EVALUATION (KEY MUSCLES FOR SCI)

FUNCTIONAL ASSESSMENT SCALES

FIM LEVELS AND SCORING ALGORITHMS

TARGETED FUNCTIONAL PERFORMANCE TESTS

• Nine-Hole Peg Test: A timed test of fine motor coordination where subjects place and remove 9 tiny dowels in holes.
• Jebson-Taylor Hand Function Test: A timed assessment of 7 items representing common hand tasks (e.g., writing, feeding, turning pages).
• Wolf Motor Function Test: A 15-item timed and 2-item force-based lab test focusing specifically on individual joint and total arm function.
• Motor Activity Log (MAL): A self-reported "real world" measure of 30 tasks scored on how often and how well they were performed during the previous week.
• 6-Minute-Walk Test: A measure of the maximum distance a patient can walk in 6 minutes; MCIDs for this test vary depending on if the condition is cardiac, respiratory, or neurologic.

COMPARISON OF CONFUSING CLINICAL CONCEPTS

• For FIM vs. Barthel Index, the FIM includes a Cognitive domain (Communication/Social Cognition) and uses a 7-point scale, whereas the Barthel Index focuses primarily on physical ADLs and assigns specific point values (5, 10, 15) per task totaling 100.
• In FIM Levels 6 vs. 5, Score 6 is used if the patient applies an orthosis or assistive device independently; Score 5 is used if a helper must apply the device for the patient.
• In FIM Levels 3 vs. 2, Score 3 (Moderate Assist) implies the patient does at least half (50%+) of the work; Score 2 (Maximal Assist) implies the helper does more than half, and the patient does only 25-49%.
• Regarding ADLs vs. IADLs, grooming and feeding are ADLs as they are self-directed, while "marketing" (grocery shopping) and laundry are IADLs as they involve interacting with the environment.
• Regarding Open vs. Closed Kinematic Chains, a bicep curl is an open chain because the hand moves freely, while a pull-up is a closed chain because the hand is fixed on the bar and the body (insertion/origin) moves toward it.
• In C fibers vs. A-beta fibers, C fibers are slow and unmyelinated carrying dull pain, while A-beta fibers are fast and heavily myelinated carrying touch/warmth; this is the basis for using heat packs for pain relief.
• Regarding Origin/Insertion vs. Proximal/Distal Attachment, Rehabilitation Medicine prefers "proximal/distal attachment" over the classical anatomical terms "origin/insertion."
• For Beevor's Sign (T10), a positive sign is the umbilicus moving UP (towards the head), while a negative sign is no movement; however, if all abdominal muscles are paralyzed, it may appear as a "false negative."
• Regarding Litten's Sign vs. Diaphragm Paralysis, a healthy patient shows a depression moving down the lateral chest on inspiration; if the diaphragm is paralyzed, this flickering movement disappears.
• In Complete vs. Incomplete SCI, the defining factor is often the presence of sacral sparing, specifically perianal sensation (S4-S5); if sensation is absent, the injury is generally classified as complete.
• For FIM Scoring Level 7 vs. 6, Level 7 is "Normal" speed and safety without tools; Level 6 is independent but involves a "Modified" factor such as an assistive device, extra time, or a safety risk.
• Regarding Pott’s Disease vs. Metastatic Cancer, both can cause spinal cord compression and back pain, but Pott's is associated with TB exposure (e.g., family history), while cancer is suggested by rapid weight loss and history of primary tumors (e.g., Prostatic Cancer/BPH).
• For Hyperreflexia vs. Hyporeflexia, hyperreflexia in the lower extremities indicates a lesion in the spinal cord (UMN), whereas hyporeflexia generally indicates a lower motor neuron (LMN) lesion or nerve root injury.

QA

PHYSIATRIC HISTORY AND PHYSICAL EXAMINATION

1. What is the primary focus of a Physiatric History? | Function and deterioration.

2. What three (3) components must be included in a Functional History? | Mobility, ADLs, and IADLs.

3. Compare ADLs vs. IADLs based on the nature of the tasks. | ADLs: Self-care tasks.
   IADLs: Environmental tasks.

4. What is the primary Rehabilitation Goal when reviewing Past Medical History? | Pre-admission functional level.

5. According to Gate Control Theory, which fibers prioritize warmth over dull pain? | A-beta fibers.

6. What condition is suspected in back pain caused by lifting heavy objects without radiation? | Lumbar strain

SPECIALIZED PHYSICAL EXAMINATION SIGNS

7. What does the absence of Litten's sign indicate during deep inspiration? | Diaphragm paralysis/pleural effusion.

8. A positive Beevor's sign (cephalad umbilicus movement) often indicates a lesion at what level? | T10 spinal cord lesion

9. What does hyperreflexia and a Babinski sign suggest in a Neurological PE? | Upper Motor Neuron lesion.

10. In spinal cord injuries, the absence of perianal sensation signifies what? | Complete spinal cord injury.

11. Contrast the distal limb movement in an Open vs. Closed Kinematic Chain. | Open: Free movement.
    Closed: Fixed end.

SENSORY EVALUATION (DERMATOMES)

12. Identify the key bony landmarks for C2, C3, and C4. | C2: Occipital protuberance
    C3: Supraclavicular fossa
    C4: Acromion process

13. Identify the sensory landmarks for C5 through T1. (5) | C5: Lateral epicondyle
    C6: Thumb
    C7: Middle finger
    C8: Little finger
    T1: Medial epicondyle

14. Identify the sensory landmarks for T2, T4, T6, and T10. | T2: Axillary fold
    T4: Nipple line
    T6: Xiphoid process
    T10: Umbilicus

15. Identify the sensory landmarks for T12 through L3. (4) | T12: Inguinal area
    L1: Proximal thigh
    L2: Middle thigh
    L3: Medial knee

16. Identify the sensory landmarks for L4 through S4. (5) | L4: Medial femur
    L5: Middle toe
    S1: Lateral heel
    S2: Popliteal fossa
    S4: Perianal area

17. Define the Sensory evaluation grading scale (0-2). | 2: Normal
    1: Impaired
    0: Absent

MOTOR EVALUATION (KEY MUSCLES FOR SCI)

18. What key muscles are tested for C5 and C6? | C5: Biceps
    C6: Extensor carpi radialis

19. What key muscles are tested for C7, C8, and T1? | C7: Triceps
    C8: Finger flexors
    T1: Abductor digiti minimi

20. What key muscles are tested for L2 and L3? | L2: Iliopsoas
    L3: Quadriceps

21. What key muscles are tested for L4, L5, and S1? | L4: Tibialis anterior
    L5: Big toe extensor
    S1: Gastrocsoleus

22. What is the criteria for a 5/5 Manual Muscle Testing grade of the Gastrocsoleus (S1)? | 25 single-foot tip-toes.

FUNCTIONAL ASSESSMENT SCALES

23. What are the two domains of the 18-item FIM instrument? | Motor and Cognitive.

24. What is the maximum score of the Barthel Index? | 100 points.

25. What is the pediatric version of the Functional Independence Measure called? | WeeFIM

26. Which assessment quantifies motor recovery stages in stroke patients using a 226-point scale? | Fugl-Meyer Assessment

27. What scale is used for the acute assessment of deficits during hospital admission for stroke? | NIH Stroke Scale

28. When selecting a Functional Assessment Tool, what should the interrater reliability coefficient be? | Greater than 0.9.

29. Define Minimal Clinically Important Difference (MCID). | Smallest significant perceived change.

FIM LEVELS AND SCORING ALGORITHMS

30. Define FIM Level 7. | Complete Independence.

31. What characterizes FIM Level 6 (Modified Independence)? | Assistive device/extra time.

32. Define FIM Level 5. | Supervision or Setup.

33. What percentage of effort defines FIM Level 4 (Minimal Contact Assistance)? | 75% or more.

34. What percentage of effort defines FIM Level 3 (Moderate Assistance)? | 50% to 74%.

35. What percentage of effort defines FIM Level 2 (Maximal Assistance)? | 25% to 49%.

36. Define FIM Level 1 effort percentage. | Less than 25%.

TARGETED FUNCTIONAL PERFORMANCE TESTS

37. What does the Nine-Hole Peg Test measure? | Fine motor coordination.

38. Name the timed assessment of 7 common hand tasks like writing and feeding. | Jebson-Taylor Hand Function Test

39. What is the focus of the Wolf Motor Function Test? | Individual joint/arm function.

40. What real-world measure uses a 30-task self-report log of the previous week? | Motor Activity Log

41. What does the 6-Minute-Walk Test measure? | Maximum walking distance.

COMPARISON OF CONFUSING CLINICAL CONCEPTS

42. Contrast FIM vs. Barthel Index in terms of domains. | FIM includes Cognitive domain.

43. Compare FIM Level 6 vs. 5 regarding assistive devices. | 6: Independent use
    5: Helper applies device

44. Differentiate effort in FIM Level 3 vs. 2. | 3: Patient ≥50%
    2: Patient 25-49%

45. Categorize "grooming" and "marketing" using ADLs vs. IADLs. | Grooming: ADL
    Marketing: IADL

46. Compare Open vs. Closed Kinematic Chains using bicep curls and pull-ups. | Bicep curl: Open
    Pull-up: Closed

47. Compare C fibers vs. A-beta fibers regarding myelination and speed. | C: Slow, unmyelinated
    A-beta: Fast, myelinated

48. What terminology does Rehab Medicine prefer over Origin/Insertion? | Proximal/distal attachment.

49. In Beevor's Sign, which direction does the umbilicus move for a positive result? | Cephalad (Upward).

50. Contrast Litten's Sign in a healthy person vs. diaphragm paralysis. | Health: Downward flickering depression
    Paralysis: Movement disappears

51. What is the defining factor in Complete vs. Incomplete SCI? | Sacral sparing (perianal sensation).

52. Differentiate FIM Level 7 vs. 6. | 7: Normal
    6: Modified (device/safety)

53. Contrast Pott’s Disease vs. Metastatic Cancer history markers. | Pott's: TB exposure
    Cancer: Rapid weight loss

54. Compare Hyperreflexia vs. Hyporeflexia lesion levels. | Hyperreflexia: UMN (cord)
    Hyporeflexia: LMN/root injurycode fences

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Summary

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Manual Muscle Testing (MMT) and Goniometry Fundamentals

• For Manual Muscle Testing (MMT), each muscle or body part evaluation must include proper positioning of the patient, proper positioning of the examiner, the specific maneuver, dexterity (right or left), and testing at different muscle grades.
• The Goniometer Fulcrum must be placed over the joint axis during range of motion measurement.
• The Goniometer Stationary Arm is aligned with the proximal bone.
• The Goniometer Moving Arm is aligned with the distal bone.

Joint Classifications: Anatomic Structure and Movement

• Cartilaginous Synarthrosis (Synchondrosis) consists of fibrocartilage and allows for bending and twisting.
• Fibrous Synarthrosis (Suture) consists of fibrous tissue and allows no movement.
• Ligamentous Synarthrosis (Syndesmosis) consists of ligaments and allows limited or no movement.

Classification of Diarthrodial (Synovial) Joints

Synovial Joint Structure and Function

• Synovial fluid functions to provide nutrition and lubrication for the articular cartilage.
• The Knee Cruciate Ligaments (ACL/PCL) are an exception to extra-articular tissue rules as they are considered intra-articular.
• Synovial Joint Components include bone/subchondral bone, intra-articular tissues (hyaline cartilage, capsule, synovial membrane/cavity), and extra-articular tissues (ligaments, muscles, tendons, meniscus, bursa, labrum, fat pads, plica).
• The primary Functions of Synovial Joints are to provide motion (mobility) and maintain stability.
• Synovial Joint Structure is affected by factors including aging, immobilization, trauma, disease, habit, and psychological status.

Joint Kinematics: Osteo- vs. Arthrokinematics

• Osteokinematic Movements are physiological movements occurring between two bony segments.
• Swing is an osteokinematic rotary motion about a fixed axis at the proximal segment (e.g., knee flexion).
• Spin is an osteokinematic axial rotation about a longitudinal axis of the distal segment (e.g., forearm pronation).
• Arthrokinematic Movements are accessory movements (joint play) occurring between two articular surfaces.
• Distraction (Traction) is an arthrokinematic separation of two articular surfaces along the longitudinal axis of the distal segment.
• Compression is an arthrokinematic "meeting together" of two articular surfaces along the longitudinal axis of the distal segment.
• Glide is an arthrokinematic combination of roll and slide between two incongruent joint surfaces.
• Roll occurs when new points on one rotating articular surface meet new points on another articular surface.
• Slide occurs when the same point on one rotating articular surface meets new points on another articular surface.

Concave-Convex Rule

• In Concave on Convex movement, the concave articular surface moves in the same direction as the moving bone (physiological movement); e.g., Tibia moving on the Femur during knee flexion involves a posterior glide.
• In Convex on Concave movement, the convex articular surface moves in the opposite direction of the moving bone; e.g., Humerus moving on the Scapula during shoulder abduction involves an inferior glide.

Joint Stability and Kinetic Chains

• Collagen fibers provide strength to ligaments; 94% of the ACL is composed of collagen.
• Elastin fibers provide flexibility to ligaments; 60% of the ligamentum flavum consists of elastin.
• Rectin fibers provide mass to the ligamentous structure.
• Open Kinetic Chain (OKC) exercises involve a free terminal segment (hand/foot), which isolates muscles and increases range of motion.
• Closed Kinetic Chain (CKC) exercises involve a fixed terminal segment, promoting stability, co-contraction, and functional movement.
• The Closed-Packed Position is the state of maximum congruency and greatest stability, where ligaments and capsules are most taut.
• The Glenohumeral Closed-Packed Position occurs at 90° abduction and full external rotation.
• Loose-Packed Positions refer to all joint positions other than the closed-packed position.

High-Yield Clinical and Exam Facts

• Tennis Elbow (Lateral Epicondylitis) primarily involves the Extensor Carpi Radialis Brevis (ECRB).
• De Quervain’s Tenosynovitis involves the Abductor Pollicis Longus (APL).
• Thumb CMC Abduction occurs in the sagittal plane.
• Shoulder Extension is primarily driven by the Latissimus Dorsi.
• To test Gluteus Medius MMT Grade 5, the patient must be in the sidelying position.
• Cervical Extension has a normal range of 0 to 30 degrees.

MMT: Range of Motion (ROM), Prime Movers, and Innervation

Differential Headings and Comparison Points

• Hinge vs. Pivot Joints: Both are uniaxial (1 DOF), but a hinge joint (Ginglymus) allows flexion/extension (e.g., humeroulnar), while a pivot joint (Trochoid) allows rotation (e.g., radioulnar).
• Condyloid vs. Saddle Joints: Both are biaxial (2 DOF), but Condyloid joints (Ovoid) have an ellipsoidal surface (e.g., wrist), while Saddle joints (Sellar) have a reciprocally concave-convex surface (e.g., thumb CMC).
• Synarthrosis vs. Amphiarthrosis: Synarthrosis allows little to no movement (e.g., sutures), whereas Amphiarthrosis allow some movement and are typically linked by fibrocartilage (e.g., pubic symphysis).
• Osteokinematics vs. Arthrokinematics: Osteokinematics describe visible physiological movement of bones (swing/spin), while Arthrokinematics describe invisible accessory movements between joint surfaces (roll/slide/glide).
• Roll vs. Slide: In a Roll, new points on one surface hit new points on another; in a Slide, a single point on one surface hits multiple new points on the other.
• Concave Rule vs. Convex Rule: Moving concave surfaces glide in the same direction as the bone; moving convex surfaces glide in the opposite direction of the bone.
• Open vs. Closed Kinetic Chain: OKC has a free distal end and is non-weight bearing/isolating; CKC has a fixed distal end and is weight-bearing/functional.
• Closed-Packed vs. Loose-Packed Position: Closed-packed is the position of maximum stability and congruency; Loose-packed (open-packed) refers to any other position where the capsule is lax.
• Collagen vs. Elastin: Collagen provides tensile strength (dominant in ACL); Elastin provides flexibility (dominant in ligamentum flavum).
• Swing vs. Spin: Swing is rotation around a fixed axis at the distal segment's end; Spin is rotation of a segment around its own longitudinal axis.
• Tennis Elbow vs. De Quervain’s: Tennis elbow involves the wrist extensors (ECRB) at the lateral epicondyle; De Quervain’s involves the thumb abductor (APL) and extensor (EPB) at the radial styloid.
• Distraction vs. Compression: Distraction pulls joint surfaces apart (traction), while compression pushes them together.
• Stationary vs. Moving Arm: The stationary arm of the goniometer stays with the proximal segment, while the moving arm follows the distal segment being moved.

QA

Manual Muscle Testing (MMT) and Goniometry Fundamentals

1. What 5 components must be included for a Manual Muscle Testing (MMT) evaluation? | 1) Patient position
   2) Examiner position
   3) Maneuver
   4) Dexterity
   5) Muscle grades
2. Where must the Goniometer Fulcrum be placed during measurement? | Over the joint axis
3. Which bone is the Goniometer Stationary Arm aligned with? | Proximal bone
4. Which bone is the Goniometer Moving Arm aligned with? | Distal bone

Joint Classifications: Anatomic Structure and Movement

5. What does the prefix for Diarthrosis mean? | Double
6. What does the prefix for Synarthrosis mean? | Together
7. What does the prefix for Amphiarthrosis mean? | Both
8. Identify the synovial components present in a Diarthrosis joint. (3) | Cavity, capsule, synovial membrane
9. Do Synarthrosis or Amphiarthrosis joints have an articular cavity? | No articular cavity
10. What articular surfaces are found in Diarthrosis joints? | Hyaline or fibrocartilage
11. What links the articular surfaces of a Synarthrosis? | Fibrocartilage, fibrous, or ligaments
12. What links the articular surfaces of an Amphiarthrosis? | Fibrocartilage and/or hyaline cartilage
13. Describe the movement function of a Diarthrosis. | Maximum motion
14. Describe the movement function of a Synarthrosis. | No/little motion
15. Describe the movement function of an Amphiarthrosis. | Some motion
16. Give an example of a Synarthrosis joint. | Cranial suture
17. Give an example of an Amphiarthrosis joint. | Intervertebral joint
18. What tissue composes Cartilaginous Synarthrosis (Synchondrosis)? | Fibrocartilage
19. What tissue composes Fibrous Synarthrosis (Suture)? | Fibrous tissue
20. What tissue composes Ligamentous Synarthrosis (Syndesmosis)? | Ligaments

Classification of Diarthrodial (Synovial) Joints

21. How many axes/DOF are in a Plane Joint? | Non-axial
22. How many axes/DOF are in a Hinge Joint? | Uniaxial (1 DOF)
23. How many axes/DOF are in a Pivot Joint? | Uniaxial (1 DOF)
24. How many axes/DOF are in a Condyloid Joint? | Biaxial (2 DOF)
25. How many axes/DOF are in a Saddle Joint? | Biaxial (2 DOF)
26. How many axes/DOF are in a Ball-and-Socket Joint? | Triaxial (3 DOF)
27. What are the alternative names for a Plane Joint? (3) | Irregular, arthrodal, or arthodia
28. What is the alternative name for a Hinge Joint? | Ginglymus
29. What is the alternative name for a Pivot Joint? | Trochoid (screw joint)
30. What is the alternative name for a Condyloid Joint? | Ovoid (ellipsoidal)
31. What is the alternative name for a Saddle Joint? | Sellar joint
32. What is the alternative name for a Ball-and-Socket Joint? | Spheroidal joint
33. Give an movement example of a Pivot Joint. | Proximal radioulnar joint
34. Give an example of a Condyloid Joint. | Radiocarpal joint
35. Give an example of a Saddle Joint. | First carpometacarpal joint
36. Identify the ideal surface shape of a Saddle Joint. | Sellar

Synovial Joint Structure and Function

37. What are the two primary functions of Synovial fluid? | Nutrition and lubrication
38. Why are Knee Cruciate Ligaments (ACL/PCL) unique regarding joint anatomy? | Considered intra-articular
39. What are the 3 intra-articular components of a Synovial Joint? | Hyaline cartilage, capsule, membrane
40. Define the two primary Functions of Synovial Joints. | Mobility and Stability
41. List 3 factors that affect Synovial Joint Structure. | Aging, immobilization, trauma (etc)

Joint Kinematics: Osteo- vs. Arthrokinematics

42. Define Osteokinematic Movements. | Physiological movements between bony segments
43. Define the osteokinematic term Swing. | Rotary motion; fixed axis
44. Define the osteokinematic term Spin. | Axial rotation
45. Define Arthrokinematic Movements. | Accessory movements (joint play)
46. Define the arthrokinematic term Distraction (Traction). | Separation of articular surfaces
47. Define the arthrokinematic term Compression. | Meeting together of surfaces
48. What is a Glide in arthrokinematics? | Combination: roll and slide
49. Contrast Roll vs. Slide based on surface points. | Roll: new-to-new; Slide: same-to-new

Concave-Convex Rule

50. In Concave on Convex movement, what is the glide direction relative to the bone? | Same direction
51. In Convex on Concave movement, what is the glide direction relative to the bone? | Opposite direction
52. During knee flexion (Tibia on Femur), what is the Concave-Convex glide direction? | Posterior glide

Joint Stability and Kinetic Chains

53. Which fiber provides strength, making up 94% of the ACL? | Collagen fibers
54. Which fiber provides flexibility, making up 60% of the Ligamentum Flavum? | Elastin fibers
55. What is the function of Rectin fibers in ligaments? | Provide mass
56. Define an Open Kinetic Chain (OKC). | Free terminal segment
57. Define a Closed Kinetic Chain (CKC). | Fixed terminal segment
58. What defines the Closed-Packed Position? | Maximum congruency and stability
59. What is the Glenohumeral Closed-Packed Position? | 90° abduction, external rotation
60. Define Loose-Packed Positions. | All non-closed-packed positions

High-Yield Clinical and Exam Facts

61. Which muscle is primarily involved in Tennis Elbow (Lateral Epicondylitis)? | Extensor Carpi Radialis Brevis
62. Which muscle is involved in De Quervain’s Tenosynovitis? | Abductor Pollicis Longus
63. In what plane does Thumb CMC Abduction occur? | Sagittal plane
64. What is the primary muscle for Shoulder Extension? | Latissimus Dorsi
65. What is the patient position for Gluteus Medius MMT Grade 5? | Sidelying position
66. What is the normal ROM for Cervical Extension? | 0 to 30 degrees

MMT: Range of Motion (ROM), Prime Movers, and Innervation

67. Capital Flexion: Normal ROM? | 0 to 10-15°
68. Cervical Flexion: Normal ROM? | 0 to 35-45°
69. Cervical Flexion: Prime Movers? (3) | SCM, Longus colli, Scalenus
70. Trunk Flexion: Normal ROM? | 0 to 80°
71. Trunk Extension: Normal ROM? | 0 to 25°
72. Shoulder Flexion: Normal ROM? | 0 to 180°
73. Shoulder Flexion: Prime Movers? (2) | Anterior Deltoid, Corachobrachialis
74. Shoulder Flexion: Innervation? (2) | Axillary, Musculocutaneous
75. Shoulder Extension: Normal ROM? | 0 to 45°
76. Shoulder Extension: Prime Movers? (3) | Latissimus dorsi, Deltoid, Teres major
77. Shoulder Extension: Innervation? (2) | Thoracodorsal, Subscapular
78. Shoulder Abduction: Normal ROM? | 0 to 170°
79. Shoulder Abduction: Prime Movers? (2) | Mid Deltoid, Supraspinatus
80. Shoulder Abduction: Innervation? (2) | Axillary, Suprascapular
81. Shoulder Horizontal Adduction: ROM and Mover? | 130°; Pectoralis major
82. Shoulder External Rotation: Normal ROM? | 0 to 60°
83. Shoulder Internal Rotation: Normal ROM? | 0 to 80°
84. Elbow Flexion: Normal ROM? | 0 to 150°
85. Elbow Extension: Normal ROM? | 150 to 0°
86. Forearm Supination: Normal ROM? | 0 to 80°
87. Forearm Pronation: Prime Movers? (2) | Pronator teres, Pronator quadratus
88. Forearm Pronation: Primary Innervation? | Median nerve
89. Wrist Flexion: Prime Movers? (2) | FCR, FCU
90. Wrist Extension: Normal ROM? | 0 to 70°
91. Hip Flexion: Prime Movers? (2) | Psoas, Iliacus
92. Hip Flexion: Normal ROM? | 0 to 120°
93. Hip Extension: Normal ROM? | 0 to 20°
94. Hip Extension: Innervation? (2) | Inferior Gluteal, Sciatic
95. Hip Abduction: Normal ROM? | 0 to 45°
96. Hip Abduction: Prime Movers? (2) | Gluteus medius, Gluteus minimus
97. Hip Adduction: Normal ROM? | 0 to 15-20°
98. Hip External/Internal Rotation: Normal ROM? | 0 to 45° (both)
99. Hip Internal Rotation: Primary Innervation? | Superior Gluteal
100. Knee Flexion: Normal ROM? | 0 to 135°
101. Knee Extension: Normal ROM? | 135 to 0°
102. Knee Extension: Innervation? | Femoral nerve
103. Ankle Plantarflexion: Normal ROM and Mover? | 45°; Gastrocsoleus
104. Ankle Dorsiflexion/Inversion: Primary Mover? | Tibialis anterior
105. Foot Inversion: Normal ROM and Mover? | 35°; Tibialis posterior
106. Foot Eversion: Normal ROM? | 0 to 25°

Differential Headings and Comparison Points

107. Compare Hinge vs. Pivot Joints: Movement difference | Hinge: flex/ext; Pivot: rotation
108. Compare Condyloid vs. Saddle Joints: Surface shape | Condyloid: ellipsoidal; Saddle: reciprocal
109. Compare Synarthrosis vs. Amphiarthrosis: Mobility | Syn: little/no; Amphi: some
110. Compare Osteokinematics vs. Arthrokinematics: Visibility | Osteo: visible; Arthro: invisible
111. Compare Roll vs. Slide: Points of contact | Roll: new-to-new; Slide: same-to-new
112. Compare Concave vs. Convex Rule: Glide direction | Concave: same; Convex: opposite
113. Compare Open vs. Closed Kinetic Chain: Distal end | OKC: free; CKC: fixed
114. Compare Closed-Packed vs. Loose-Packed: Stability | Closed: Maximum; Loose: Minimal
115. Compare Collagen vs. Elastin: Property | Collagen: strength; Elastin: flexibility
116. Compare Swing vs. Spin: Rotation axis | Swing: distal end; Spin: longitudinal axis
117. Compare Tennis Elbow vs. De Quervain’s: Location | Elbow: lateral epicondyle; DeQ: radial styloid
118. Compare Distraction vs. Compression: Surface movement | Distraction: separate; Compression: meet
119. Compare Stationary vs. Moving Arm: Placement | Stationary: proximal; Moving: distal
120. Which muscle is the prime mover for Wrist Extension? | ECRL, ECRB, ECU

Practical Guide

Summary

text

• For Manual Muscle Testing (MMT), the examination is scored across four 25-point parameters: Proper Positioning of Patient, Proper Positioning of Examiner, Maneuver, and Dexterity (Total = 100 points).
• During Goniometry Placement, the fulcrum must be over the joint axis, the stationary arm aligned with the proximal bone, and the moving arm aligned with the distal bone.
• In MMT Shoulder Flexion, the prime movers are the Anterior Deltoid and Coracobrachialis; resistance is applied to the distal anteromedial surface of the humerus.
• For Shoulder Flexion Gravity Reduced, the patient is positioned in side-lying with the tested arm supported, moving the hand toward the head.
• In MMT Shoulder Extension, prime movers include the Latissimus Dorsi, Posterior Deltoid, and Teres Major; resistance is applied over the posterior surface of the distal humerus.
• To test Shoulder Abduction MMT, the patient sits with the arm slightly externally rotated (thumb up) to 90 degrees.
• The Shoulder Abduction Gravity Reduced position is supine with the arm at the side and the palm facing the ceiling.
• For Shoulder Adduction MMT (Pectoralis Major), the student must test specific fibers: Clavicular head (start at 60° abduction) and Sternal head (start at 120° abduction).
• During Shoulder Internal Rotation MMT, a folded towel should be placed under the humerus in the prone position to maintain a horizontal alignment.
• In Shoulder Internal Rotation MMT, resistance is applied just proximal to the wrist in the direction of external rotation.
• In Shoulder External Rotation MMT, the prime movers are the Infraspinatus and Teres Minor; resistance is applied toward internal rotation.
• If a patient fails to move in the gravity-removed position, the Next MMT Step is to palpate the muscle for contractions to distinguish between Grade 1 and Grade 0.
• To test Scapula Elevation MMT, the patient is seated with the head turned away from the side being tested.
• For Scapular Retraction MMT, the middle trapezius and rhomboids are the prime movers; the patient is prone and lifts the elbow toward the ceiling.
• In Elbow Flexion MMT, the examiner must stabilize the shoulder to prevent the patient from leaning forward (compensating with trunk flexion).
• For Elbow Flexion Gravity Reduced, the patient is seated with the arm abducted to 90 degrees and supported on a table.
• In Elbow Extension MMT, the Supine position with the shoulder flexed to 90 degrees is the standard for Grade 3 and up.
• When testing Elbow Extension MMT, the examiner must be careful to avoid applying resistance to a fully locked or extended elbow joint.
• For Forearm Supination MMT, the stabilization point is at the elbow/olecranon and the medial elbow joint.
• For Forearm Pronation MMT, the stabilization point is at the elbow/olecranon and the lateral elbow joint.
• To bias Flexor Carpi Ulnaris (Wrist Flexion), the patient should flex the wrist leading with the 5th digit; resistance is applied toward radial deviation and extension.
• To bias Flexor Carpi Radialis (Wrist Flexion), the patient should flex the wrist leading with the thumb; resistance is applied toward ulnar deviation and extension.
• To bias Extensor Carpi Radialis (Wrist Extension), the patient should extend the wrist leading with the thumb; resistance is applied toward ulnar deviation and flexion.
• The Hip Flexion MMT (Iliopsoas) gravity-resisted position involves sitting on the edge of a table with legs hanging off.
• For Hip Extension MMT (Gluteus Maximus), the gravity-resisted position is prone with a pillow under the hips.
• In Hip Abduction MMT (Gluteus Medius), the patient is side-lying with the lowermost extremity flexed at the hip and knee for stability.
• To bias Laterally-inserting Hamstrings (Knee Flexion), the examiner should externally rotate the tibia during flexion.
• To bias Medially-inserting Hamstrings (Knee Flexion), the examiner should internally rotate the tibia during flexion.
• In Knee Extension MMT (Quadriceps), resistance is applied through the distal tibia and fibula in the direction of flexion.
• For Ankle Dorsiflexion MMT (Tibialis Anterior), the examiner's resistance hand is cupped over the top of the foot while the other stabilizes the leg proximal to the ankle.
• The Ankle Plantarflexion MMT (Gastrocnemius) involves the patient rising on their toes or pointing their foot against resistance.
• In Ankle Inversion MMT (Tibialis Posterior), the instruction to the patient is "Turn your foot in as far as possible."
• In Goniometry Procedure, it is vital that the patient does not move their body during the assessment to ensure the joint movement is isolated.
• The Fulcrum for Shoulder Abduction is the anterior acromion.
• The Fulcrum for Shoulder Rotation (IR/ER) is the olecranon process.
• The Fulcrum for Forearm Supination is the lateral side of the ulnar styloid.
• The Fulcrum for Forearm Pronation is the medial side of the ulnar styloid.
• The Fulcrum for Wrist Flexion/Extension is the lateral wrist over the triquetrum.
• The Fulcrum for Wrist Deviations (Radial/Ulnar) is the dorsal wrist over the capitate.
• The Fulcrum for Hip Abduction/Adduction is the ASIS (Anterior Superior Iliac Spine) of the side being tested.
• The Fulcrum for Hip Rotation (IR/ER) is the anterior patella.
• The Fulcrum for Ankle Dorsiflexion/Plantarflexion is the lateral malleolus.
• The Fulcrum for Ankle Inversion/Eversion is the anterior ankle between the malleoli.

COMPARING SIMILAR ENTITIES FOR EXAM DIFFERENTIATION

• MMT Grade 2 vs. MMT Grade 3: Grade 2 requires full ROM in a gravity-eliminated (horizontal) plane, whereas Grade 3 requires full ROM against gravity but with zero added resistance.
• MMT Grade 4 vs. MMT Grade 5: Both involve full ROM against gravity and resistance, but Grade 4 is "moderate resistance" while Grade 5 is "maximal resistance."
• Shoulder Flexion vs. Extension (Goniometry Fulcrum): Both use the lateral aspect of the greater tubercle as the fulcrum.
• Shoulder Abduction vs. Adduction (Goniometry Fulcrum): Both use the anterior acromion as the fulcrum.
• Shoulder Rotation (Internal vs. External) Goniometry: Both use the olecranon process as the fulcrum and have the moving arm aligned with the ulna and ulnar styloid.
• Forearm Supination vs. Pronation (Goniometry Fulcrum): Supination uses the LATERAL side of the ulnar styloid; Pronation uses the MEDIAL side of the ulnar styloid.
• Wrist Flexion/Extension vs. Deviations (Goniometry Fulcrum): Flexion and extension use the lateral triquetrum; Radial and ulnar deviation use the dorsal capitate.
• Hip Flexion vs. Hip Extension (Goniometry Fulcrum): Both use the greater trochanter as the fulcrum.
• Hip Abduction vs. Hip Adduction (Goniometry Fulcrum): Both use the ASIS on the side being tested.
• Hip Internal vs. External Rotation (Normal ROM): Both internal and external rotation of the hip have a normal range of 0–45°.
• Shoulder Internal vs. External Rotation (Normal ROM): Shoulder Internal Rotation is 0–70°, while External Rotation is 0–90°.
• Wrist Flexion vs. Extension (Normal ROM): Wrist Flexion (0–80°) generally has 10 degrees more range than Wrist Extension (0–70°).
• Ankle Dorsiflexion vs. Plantarflexion (Normal ROM): Dorsiflexion is only 0–20°, while Plantarflexion is significantly more at 0–50°.
• Ankle Inversion vs. Eversion (Normal ROM): Inversion (0–35°) has more than double the range of Eversion (0–15°).
• Radial vs. Ulnar Deviation (Normal ROM): Radial deviation is 0–20°, while Ulnar deviation is slightly larger at 0–30°.
• Wrist Flexion MMT (FCU vs. FCR Bias): To bias Flexor Carpi Ulnaris, lead with the pinky; to bias Flexor Carpi Radialis, lead with the thumb.
• Knee Flexion MMT (Lateral vs. Medial Hamstrings): To bias lateral muscles (Biceps Femoris), externally rotate the tibia; to bias medial muscles (Semis), internally rotate the tibia.
• Goniometry Stationary vs. Moving Arm: The stationary arm always aligns with the stable, proximal bone; the moving arm always follows the distal, moving bone.
• Goniometry Pronation vs. Supination (Arm Alignment): Pronation measures across the ventral (palm) forearm; Supination measures across the dorsal (back) forearm.
• Hip Flexion vs. Knee Flexion (Normal ROM): Knee flexion (135°) allows for more range than hip flexion (120°).

QA

text

1. Define the criteria and meaning for Grade 0 (Zero) MMT. | No contraction;
   No palpable or visible muscle activity.
2. Define the criteria and meaning for Grade 1 (Trace) MMT. | Flicker or palpable contraction;
   No joint movement occurs.
3. Define the criteria and meaning for Grade 2 (Poor) MMT. | Full ROM with gravity eliminated.
4. Define the criteria and meaning for Grade 3 (Fair) MMT. | Full ROM against gravity only.
5. Define the criteria and meaning for Grade 4 (Good) MMT. | Full ROM against moderate resistance.
6. Define the criteria and meaning for Grade 5 (Normal) MMT. | Full ROM against maximal resistance.
7. What is the maneuver/resistance for Shoulder Flexion MMT? | Lift arm to 90°;
   Resistance at distal anteromedial humerus.
8. What is the maneuver/resistance for Shoulder Extension MMT? | Raise arm off table;
   Resistance at posterior distal humerus.
9. What is the maneuver/resistance for Shoulder Abduction MMT? | Raise arm laterally to 90° (thumb up);
   Resistance proximal to elbow.
10. What is the maneuver/resistance for Shoulder Internal Rotation MMT? | Move forearm backward;
    Resistance proximal to wrist (toward ER).
11. What is the maneuver/resistance for Shoulder External Rotation MMT? | Move forearm forward;
    Resistance proximal to wrist (toward IR).
12. Where is the resistance point for Elbow Flexion MMT? | Proximal to the wrist.
13. Where is the resistance point for Elbow Extension MMT? | Proximal to the wrist.
14. What is the maneuver/resistance for Forearm Supination MMT? | Start in pronation;
    Resist toward pronation at hand/distal forearm.
15. What is the maneuver/resistance for Forearm Pronation MMT? | Start in supination;
    Resist toward supination at hand/distal forearm.
16. Describe the bias technique for Wrist Flexion (Flexor Carpi Ulnaris). | Lead with 5th digit.
17. Describe the bias technique for Wrist Extension (Extensor Carpi Ulnaris). | Lead with 5th digit.
18. Name the prime mover and resistance point for Hip Flexion MMT. | Iliopsoas;
    Distal thigh.
19. Name the prime mover and resistance point for Hip Extension (Gluteus maximus). | Gluteus maximus;
    Posterior distal thigh.
20. Name the prime mover and resistance point for Hip Abduction MMT. | Gluteus medius;
    Lateral distal thigh/knee.
21. Name the prime mover and resistance point for Knee Flexion MMT. | Hamstrings;
    Distal tibia/fibula.
22. Name the prime mover and resistance point for Knee Extension MMT. | Quadriceps;
    Distal tibia/fibula.
23. What is the maneuver and resistance point for Ankle Dorsiflexion MMT? | "Bend foot up";
    Top of foot (proximal to toes).
24. What is the maneuver and resistance point for Ankle Plantarflexion MMT? | "Rise on toes"/"Point foot";
    Bottom of foot.
25. What is the maneuver and resistance point for Ankle Inversion MMT? | "Turn foot in";
    Medial aspect of foot.
26. What is the maneuver and resistance point for Ankle Eversion MMT? | "Turn foot out";
    Lateral aspect of foot.
27. State the fulcrum and normal ROM for Shoulder Flexion Goniometry. | Greater tubercle;
    0–180°.
28. State the fulcrum and normal ROM for Shoulder Abduction Goniometry. | Anterior acromion;
    0–180°.
29. State the fulcrum and normal ROM for Elbow Flexion Goniometry. | Lateral epicondyle;
    0–150°.
30. State the fulcrum and normal ROM for Wrist Flexion Goniometry. | Triquetrum (lateral);
    0–80°.
31. State the fulcrum and normal ROM for Hip Flexion Goniometry. | Greater trochanter;
    0–120°.
32. State the fulcrum and normal ROM for Knee Flexion Goniometry. | Lateral epicondyle;
    0–135°.
33. State the fulcrum and normal ROM for Ankle Dorsiflexion Goniometry. | Lateral malleolus;
    0–20°.
34. List the four 25-point parameters for Manual Muscle Testing (MMT) scoring. (4) | 1) Patient Position
    2) Examiner Position
    3) Maneuver
    4) Dexterity
35. State the alignment rules for Goniometry Placement (Fulcrum, Stationary, Moving). (3) | 1) Fulcrum: Joint axis
    2) Stationary: Proximal bone
    3) Moving: Distal bone
36. Identify the prime movers for MMT Shoulder Flexion. (2) | Anterior Deltoid;
    Coracobrachialis.
37. Where is resistance applied in MMT Shoulder Flexion? | Distal anteromedial humerus.
38. Describe the Shoulder Flexion Gravity Reduced position. | Side-lying;
    Tested arm supported.
39. Identify the prime movers for MMT Shoulder Extension. (3) | Latissimus Dorsi,
    Posterior Deltoid,
    Teres Major.
40. Where is resistance applied in MMT Shoulder Extension? | Posterior surface of distal humerus.
41. Describe the patient position for Shoulder Abduction MMT. | Sitting;
    Arm externally rotated (thumb up) to 90°.
42. Describe the Shoulder Abduction Gravity Reduced position. | Supine;
    Arm at side, palm facing ceiling.
43. What are the starting positions for Shoulder Adduction MMT (Pectoralis Major)? (2) | Clavicular: 60° abduction;
    Sternal: 120° abduction.
44. What requirement is needed for Shoulder Internal Rotation MMT in the prone position? | Folded towel under humerus.
45. In what direction is resistance applied during Shoulder Internal Rotation MMT? | Direction of external rotation.
46. Identify the prime movers for Shoulder External Rotation MMT. (2) | Infraspinatus;
    Teres Minor.
47. If a patient fails to move in gravity-removed position, what is the Next MMT Step? | Palpate the muscle for contractions.
48. What is the patient position for Scapula Elevation MMT? | Seated;
    Head turned away from testing side.
49. Identify the prime movers and maneuver for Scapular Retraction MMT. | Middle trapezius and rhomboids;
    Prone, lift elbow toward ceiling.
50. Why must the examiner stabilize the shoulder in Elbow Flexion MMT? | Prevent trunk flexion compensation.
51. Describe the Elbow Flexion Gravity Reduced position. | Seated;
    Arm abducted to 90° on table.
52. What is the standard position for Elbow Extension MMT (Grade 3 and up)? | Supine;
    Shoulder flexed to 90°.
53. What precaution should be taken during Elbow Extension MMT regarding the joint? | Avoid resistance on fully locked/extended elbow.
54. State the stabilization points for Forearm Supination MMT. (2) | Olecranon;
    Medial elbow joint.
55. State the stabilization points for Forearm Pronation MMT. (2) | Olecranon;
    Lateral elbow joint.
56. How do you bias the Flexor Carpi Ulnaris during wrist flexion? | Lead with 5th digit;
    Resist toward radial deviation/extension.
57. How do you bias the Flexor Carpi Radialis during wrist flexion? | Lead with thumb;
    Resist toward ulnar deviation/extension.
58. How do you bias the Extensor Carpi Radialis during wrist extension? | Lead with thumb;
    Resist toward ulnar deviation/flexion.
59. Describe the gravity-resisted position for Hip Flexion MMT (Iliopsoas). | Sitting;
    Legs hanging off table.
60. Describe the gravity-resisted position for Hip Extension MMT (Gluteus Maximus). | Prone;
    Pillow under hips.
61. Describe the patient position for Hip Abduction MMT (Gluteus Medius). | Side-lying;
    Lowermost extremity flexed for stability.
62. How do you bias the Laterally-inserting Hamstrings during knee flexion? | Externally rotate the tibia.
63. How do you bias the Medially-inserting Hamstrings during knee flexion? | Internally rotate the tibia.
64. In what direction is resistance applied for Knee Extension MMT (Quadriceps)? | Direction of flexion.
65. Describe the hand placement for Ankle Dorsiflexion MMT (Tibialis Anterior). | One hand cupped over top of foot;
    Other stabilizes proximal to ankle.
66. What is the maneuver for Ankle Plantarflexion MMT (Gastrocnemius)? | Rising on toes or pointing foot.
67. What is the specific verbal instruction for Ankle Inversion MMT? | "Turn your foot in as far as possible."
68. What is a vital requirement for the patient during Goniometry Procedure? | Do not move their body (isolate joint).
69. Identify the Fulcrum for Shoulder Abduction. | Anterior acromion.
70. Identify the Fulcrum for Shoulder Rotation (IR/ER). | Olecranon process.
71. Identify the Fulcrum for Forearm Supination. | Lateral side of ulnar styloid.
72. Identify the Fulcrum for Forearm Pronation. | Medial side of ulnar styloid.
73. Identify the Fulcrum for Wrist Flexion/Extension. | Lateral wrist over triquetrum.
74. Identify the Fulcrum for Wrist Deviations. | Dorsal wrist over capitate.
75. Identify the Fulcrum for Hip Abduction/Adduction. | ASIS (of the side being tested).
76. Identify the Fulcrum for Hip Rotation (IR/ER). | Anterior patella.
77. Identify the Fulcrum for Ankle Dorsiflexion/Plantarflexion. | Lateral malleolus.
78. Identify the Fulcrum for Ankle Inversion/Eversion. | Anterior ankle between malleoli.
79. Compare MMT Grade 2 vs. MMT Grade 3 in terms of gravity. | Grade 2: Gravity-eliminated plane.
    Grade 3: Against gravity.
80. Compare MMT Grade 4 vs. MMT Grade 5 in terms of resistance. | Grade 4: Moderate resistance.
    Grade 5: Maximal resistance.
81. Compare the Shoulder Flexion vs. Extension Fulcrum. | Both use the lateral greater tubercle.
82. Compare the Shoulder Abduction vs. Adduction Fulcrum. | Both use the anterior acromion.
83. Compare the Shoulder Rotation (IR/ER) Fulcrum and Moving Arm. | Both use olecranon process;
    Moving arm aligned with ulna/ulnar styloid.
84. Compare Forearm Supination vs. Pronation Fulcrums. | Supination: Lateral ulnar styloid.
    Pronation: Medial ulnar styloid.
85. Compare Wrist Flexion/Extension vs. Deviations Fulcrums. | Flexion/Extension: Lateral triquetrum.
    Deviations: Dorsal capitate.
86. Compare the Hip Flexion vs. Hip Extension Fulcrum. | Both use the greater trochanter.
87. Compare the Hip Abduction vs. Hip Adduction Fulcrum. | Both use the ASIS on testing side.
88. Compare the Hip Internal vs. External Rotation ROM. | Both are 0–45°.
89. Compare the Shoulder Internal vs. External Rotation ROM. | Internal: 0–70°.
    External: 0–90°.
90. Compare Wrist Flexion vs. Extension ROM. | Flexion (80°) has 10° more than Extension (70°).
91. Compare Ankle Dorsiflexion vs. Plantarflexion ROM. | Dorsiflexion: 0–20°.
    Plantarflexion: 0–50°.
92. Compare Ankle Inversion vs. Eversion ROM. | Inversion (35°) has >2x the range of Eversion (15°).
93. Compare Radial vs. Ulnar Deviation ROM. | Radial (20°);
    Ulnar (30°).
94. Compare Wrist Flexion MMT Bias (FCU vs. FCR). | FCU: Lead with pinky.
    FCR: Lead with thumb.
95. Compare Knee Flexion MMT Bias (Lateral vs. Medial Hamstrings). | Lateral: External tibial rotation.
    Medial: Internal tibial rotation.
96. Compare Goniometry Stationary vs. Moving Arm alignment. | Stationary: Stable proximal bone.
    Moving: Distal moving bone.
97. Compare Goniometry Pronation vs. Supination Arm alignment. | Pronation: Across ventral (palm).
    Supination: Across dorsal (back).
98. Compare Hip Flexion vs. Knee Flexion ROM. | Knee flexion (135°) > Hip flexion (120°).
99. What is MMT Dexterity? | One of the four 25-point parameters used for scoring MMT.
100. Where is resistance applied for Internal Rotation of the Shoulder? | Proximal to wrist;
     Applied toward external rotation.
101. What is the stationary arm for Shoulder Flexion Goniometry? | Midaxillary line.
102. Where is the stationary arm for Ankle Dorsiflexion Goniometry? | Lateral midline of fibula.
103. Define the prime mover for Ankle Inversion. | Tibialis posterior.
104. Define the prime mover for Ankle Eversion. | Peroneus longus and brevis.
105. Where is the fulcrum for Hip Rotation (IR/ER)? | Anterior patella.

Guide

List of things

This summary and checklist are designed for your Manual Muscle Testing (MMT) and Goniometry Practical Exam. It follows the scoring criteria and procedural steps outlined in your source text.

I. Practical Exam Scoring Parameters

For every test performed, you will be graded on these four 25-point criteria:

II. MMT Checklist (Muscle Strength)

Use this list to ensure you know the Prime Movers and the switch between Gravity Resisted (Grades 3-5) and Gravity Reduced (Grades 0-2).

Upper Extremity MMT

• Shoulder Flexion: (Anterior Deltoid/Coracobrachialis)
• Shoulder Extension: (Latissimus Dorsi/Posterior Deltoid/Teres Major)
• Shoulder Abduction: (Middle Deltoid/Supraspinatus)
• Shoulder Adduction: (Pectoralis Major - Clavicular vs. Sternal heads)
• Shoulder Internal Rotation: (Subscapularis)
• Shoulder External Rotation: (Infraspinatus/Teres Minor)
• Scapula Elevation: (Upper Trapezius/Levator Scapulae)
• Scapular Retraction: (Middle Trapezius/Rhomboids)
• Elbow Flexion: (Biceps Brachii/Brachialis/Brachioradialis)
• Elbow Extension: (Triceps Brachii)
• Forearm Supination: (Biceps/Supinator)
• Forearm Pronation: (Pronator Teres/Quadratus)
• Wrist Flexion: (Bias: FCU lead with 5th digit; FCR lead with thumb)
• Wrist Extension: (Bias: ECRL/B lead with thumb; ECU lead with 5th digit)

Lower Extremity MMT

• Hip Flexion: (Iliopsoas)
• Hip Extension: (Gluteus Maximus)
• Hip Abduction: (Gluteus Medius)
• Knee Flexion: (Hamstrings - Bias: Lateral vs. Medial rotation)
• Knee Extension: (Quadriceps)
• Ankle Dorsiflexion: (Tibialis Anterior)
• Ankle Plantarflexion: (Gastrocnemius)
• Ankle Inversion: (Tibialis Posterior)
• Ankle Eversion: (Peroneus Longus/Brevis)

III. Goniometry Checklist (Range of Motion)

For these tests, ensure the Fulcrum, Stationary Arm, and Moving Arm are aligned before and after movement.

IV. Critical Grade Definitions

If the instructor asks for the meaning of your assigned grade:

text Grade 5 (Normal): Full ROM against gravity; Maximal resistance. Grade 4 (Good): Full ROM against gravity; Moderate resistance. Grade 3 (Fair): Full ROM against gravity; NO resistance. Grade 2 (Poor): Full ROM; Gravity-eliminated plane. Grade 1 (Trace): Palpable contraction; No joint movement. Grade 0 (Zero): No contraction; No movement.

V. Exam Day Pro-Tips

1. Stabilization: Always stabilize the proximal bone to prevent "compensation" (e.g., don't let the patient lean their trunk during elbow flexion).
2. Instructions: Always give clear commands: "Hold, don't let me move you."
3. Gravity Reduced: If the patient cannot perform the movement against gravity, immediately transition to the side-lying or supported position to test for Grade 2.
4. Palpation: If there is no movement in the gravity-reduced position, palpate the muscle belly to distinguish between Grade 1 and Grade 0.

QA

text

I. Practical Exam Scoring Parameters

1. What is the performance expectation for Patient Position? | Correct starting position.
   (Sitting, Supine, Prone, Side-lying)
2. What is the performance expectation for Examiner Position? | Correct hand placement.
   Stabilization and resistance hands.
3. What is the performance expectation for Maneuver? | Correct instructions and force.
   Verbal commands and direction of force.
4. What is the performance expectation for Dexterity? | Efficiency and bilateral testing.
   Smoothness and R/L testing.

II. MMT Checklist (Muscle Strength)

5. Identify the Prime Movers for Shoulder Flexion. | Anterior Deltoid and Coracobrachialis.
6. Identify the Prime Movers (3) for Shoulder Extension. | Latissimus Dorsi,
   Posterior Deltoid,
   Teres Major.
7. Identify the Prime Movers for Shoulder Abduction. | Middle Deltoid and Supraspinatus.
8. Identify the Prime Movers for Shoulder Adduction. | Pectoralis Major.
   (Clavicular vs. Sternal heads)
9. Identify the Prime Mover for Shoulder Internal Rotation. | Subscapularis.
10. Identify the Prime Movers for Shoulder External Rotation. | Infraspinatus and Teres Minor.
11. Identify the Prime Movers for Scapula Elevation. | Upper Trapezius and Levator Scapulae.
12. Identify the Prime Movers for Scapular Retraction. | Middle Trapezius and Rhomboids.
13. Identify the Prime Movers (3) for Elbow Flexion. | Biceps Brachii,
    Brachialis,
    Brachioradialis.
14. Identify the Prime Mover for Elbow Extension. | Triceps Brachii.
15. Identify the Prime Movers for Forearm Supination. | Biceps and Supinator.
16. Identify the Prime Movers for Forearm Pronation. | Pronator Teres and Quadratus.
17. Describe the bias for FCU and FCR during Wrist Flexion MMT. | FCU: 5th digit; FCR: Thumb.
18. Describe the bias for ECRL/B and ECU during Wrist Extension MMT. | ECRL/B: Thumb; ECU: 5th digit.
19. Identify the Prime Mover for Hip Flexion. | Iliopsoas.
20. Identify the Prime Mover for Hip Extension. | Gluteus Maximus.
21. Identify the Prime Mover for Hip Abduction. | Gluteus Medius.
22. Identify the Prime Movers and bias for Knee Flexion. | Hamstrings.
    (Lateral vs. Medial rotation)
23. Identify the Prime Mover for Knee Extension. | Quadriceps.
24. Identify the Prime Mover for Ankle Dorsiflexion. | Tibialis Anterior.
25. Identify the Prime Mover for Ankle Plantarflexion. | Gastrocnemius.
26. Identify the Prime Mover for Ankle Inversion. | Tibialis Posterior.
27. Identify the Prime Movers for Ankle Eversion. | Peroneus Longus and Brevis.

III. Goniometry Checklist (Range of Motion)

28. What is the Axis and Normal ROM for Shoulder Flexion? | Greater Tubercle; 0–180°.
29. What is the Axis and Normal ROM for Shoulder Abduction? | Anterior Acromion; 0–180°.
30. What is the Axis and Normal ROM for Shoulder IR / ER? | Olecranon Process;
    IR: 70° / ER: 90°.
31. What is the Axis and Normal ROM for Elbow Flexion? | Lateral Epicondyle (Humerus); 0–150°.
32. What is the Axis and Normal ROM for Forearm Sup/Pro? | Ulnar Styloid; 0–90°.
33. What is the Axis and Normal ROM for Wrist Flex/Ext? | Triquetrum;
    Flex: 80° / Ext: 70°.
34. What is the Axis and Normal ROM for Wrist Rad/Uln Dev? | Capitate (Dorsal);
    Rad: 20° / Uln: 30°.
35. What is the Axis and Normal ROM for Hip Flexion? | Greater Trochanter; 0–120°.
36. What is the Axis and Normal ROM for Hip Abd/Add? | ASIS;
    Abd: 45° / Add: 30°.
37. What is the Axis and Normal ROM for Hip IR / ER? | Anterior Patella; 0–45°.
38. What is the Axis and Normal ROM for Knee Flexion? | Lateral Epicondyle (Femur); 0–135°.
39. What is the Axis and Normal ROM for Ankle DF / PF? | Lateral Malleolus;
    DF: 20° / PF: 50°.
40. What is the Axis and Normal ROM for Ankle Inv / Ev? | Between malleoli;
    Inv: 35° / Ev: 15°.

IV. Critical Grade Definitions

41. Define MMT Grade 5 (Normal). | Full ROM; Maximal resistance.
42. Define MMT Grade 4 (Good). | Full ROM; Moderate resistance.
43. Define MMT Grade 3 (Fair). | Full ROM; NO resistance.
44. Define MMT Grade 2 (Poor). | Full ROM; Gravity-eliminated plane.
45. Define MMT Grade 1 (Trace). | Palpable contraction; no movement.
46. Define MMT Grade 0 (Zero). | No contraction; no movement.

V. Exam Day Pro-Tips

47. Why is Stabilization of the proximal bone necessary? | Prevent compensation.
48. What is the required verbal command for Instructions? | "Hold, don't let me move you."
49. When do you transition to a Gravity Reduced position? | Cannot perform against gravity.
50. What is the purpose of Palpation in the gravity-reduced position? | Distinguish Grade 1 from 0.

4 - Exercise Prescription

Summary

text

SITUATION & EPIDEMIOLOGY (FILIPINO CONTEXT)

• In the Philippines, Non-Communicable Diseases (NCDs) or lifestyle-related diseases are the most common cause of morbidity and mortality as of 2020.
• Physical inactivity is the most prevalent risk factor for NCDs in the Philippines, affecting 60.5% of the population.
• Heart disease, cancer, and stroke currently represent the top three leading causes of death, replacing the infectious diseases prominent in the 1900s.
• Hypertension and Diseases of the Heart are the top two leading causes of morbidity in the Philippines.
• Metabolic syndrome increases the risk for coronary artery disease and is identified via abdominal circumference, lipid profile, blood pressure, and glucose levels.

THE THREE LEVELS OF PREVENTION

• Primary Prevention (Topic: Prevention) aims at preventing a target problem or condition in an individual or community at risk (e.g., exercise, vaccination).
• Secondary Prevention (Topic: Prevention) focuses on decreasing the duration and severity of a disease once it has occurred.
• Tertiary Prevention (Topic: Prevention) involves rehabilitation and decreasing the degree of disability for individuals with chronic or irreversible diseases.
• Rehabilitation (Topic: Prevention) is specifically classified as a tertiary prevention measure.

EXERCISE PHYSIOLOGY & ENERGY SYSTEMS

• Muscle contraction (Topic: Exercise Physiology) requires ATP for actin and myosin to glide over each other, a process facilitated by Myosin ATPase.
• Stored ATP (Topic: Energy Sources) in the muscle is limited (about 4-6 ATPs), providing only enough energy for initial anaerobic bursts like sprinting.
• Lactic acidosis (Topic: Metabolism) occurs when pyruvate cannot be converted into Acetyl Coenzyme A (due to O2 lack) and is instead converted into lactate, causing muscle soreness.
• Isocapnic buffering (Topic: Metabolism) is the point during exercise where lactate is buffered by bicarbonate (HCO3-), resulting in exhaled CO2.
• Respiratory Compensation Point (RCP) (Topic: Metabolism) is reached when bicarbonate stores are exhausted, leading to increased acidity and the inability to continue exercise.
• Aerobic Metabolism (Topic: Metabolism) substrates are utilized in the following order: Carbohydrates first, then Fats, and Proteins last.

MUSCLE FIBER TYPE CHARACTERISTICS

• Slow-Twitch (Type I/ST) fibers are oxidative, have high capillary/mitochondrial density, high resistance to fatigue, and are used primarily for aerobic activities.
• Fast-Twitch B (Type IIB/FT-B) fibers are glycolytic, have very fast contraction times, low resistance to fatigue, and are used for short-term anaerobic activity (sprinting).
• Fast-Twitch A (Type IIA/FT-A) fibers are intermediate, used for long-term anaerobic activities, and possess intermediate resistance to fatigue.
• Marathoners (Topic: Muscle Training) typically develop Type I (Slow-twitch) lean muscles, whereas sprinters develop bulky Type II (Fast-twitch) muscles.

CLINICAL SCREENING & THE PAR-Q

• Sudden Cardiac Death (SCD) (Topic: Exercise Risk) risk increases transiently and acutely in individuals with diagnosed or occult cardiovascular disease during vigorous exercise.
• The Physical Activity Readiness Questionnaire (PAR-Q) (Topic: Screening) is a 7-item screening tool where an answer of "YES" to any question requires seeing an EIM certified specialist.
• PAR-Q Questions (Topic: Screening) include:
  1. Heart condition diagnosis/doctor restriction.
  2. Current meds for BP or heart.
  3. Chest/neck/jaw pain during activity or rest.
  4. Shortness of breath with mild exertion.
  5. Frequent fatigue/drowsiness without activity.
  6. Rapid weight loss without extreme hunger.
  7. Bone/joint pain increasing with movement.
  8. Other known reasons not to exercise.
• Common findings against ischemic origin chest pain (Topic: Cardiac S/Sx) include sharp, knifelike, or stabbing pain, or pain occurring after the completion of exercise rather than during.
• Common findings favoring ischemic origin chest pain (Topic: Cardiac S/Sx) include constricting/burning sensations located substernally and provoked by exertion or stress.
• Intermittent claudication (Topic: Vascular S/Sx) is muscle pain (usually calf) occurring during exercise due to inadequate blood supply (atherosclerosis), which disappears within 1-2 mins of rest.

ACSM RISK STRATIFICATION

• CAD Positive Risk Factors (Topic: Risk Stratification):
  • Age: Men ≥45, Women ≥55.
  • Family History: MI/SCD in male first-degree relative <55 y/o or female <65 y/o.
  • Smoking: Current or quit within last 6 months.
  • Sedentary: <30 mins moderate exercise, 3 days/week, for 3 months.
  • Obesity: BMI ≥27.5 or WC ≥90cm (M) / ≥80cm (W) [Asia-Pacific].
  • Hypertension: ≥140/90 mmHg or on meds.
  • Hypercholesterolemia: TC ≥5.2 mmol/L, LDL ≥3.4 mmol/L, or HDL <1.0 mmol/L.
  • Prediabetes: Fasting glucose ≥6.1 mmol/L.
• Negative Risk Factor (Topic: Risk Stratification): High serum HDL (≥1.6 mmol/L) allows the subtraction of one risk factor from the total score.
• Low Risk Category (Topic: ACSM Classification): Individuals with <2 risk factors and no signs/symptoms/diagnosed disease; they can start any intensity without supervision.
• Moderate Risk Category (Topic: ACSM Classification): Individuals with ≥2 risk factors but no signs/symptoms; safe for light/moderate exercise, but medical clearance is needed for vigorous exercise.
• High Risk Category (Topic: ACSM Classification): Individuals with ≥1 sign/symptom or diagnosed cardiovascular, pulmonary, or metabolic disease; requires medical clearance and clinical supervision for any intensity.

EXERCISE PRESCRIPTION (FITT-P)

• Frequency (Topic: Aerobics) should be 5x a week for aerobics (150-300 mins total).
• Target Heart Rate (Karvonen) (Topic: Intensity): Target HR = [(220 - Age - Resting HR) x %Intensity] + Resting HR.
• Borg Rating of Perceived Exertion (RPE) (Topic: Intensity) correlates with heart rate; "Somewhat Hard" (12-14) is moderate, while "Hard" (15-16) and above is high intensity.
• The Talk Test (Topic: Intensity) defines moderate intensity as being able to talk but not sing during the activity.
• Metabolic Equivalent (MET) (Topic: Intensity) defines 1 MET as 3.5 mL/kg/min O2 uptake or 1 kcal/kg/hour (sitting quietly).
• Progression (Topic: FITT-P) typically follows a 4-to-6-week cycle where intensity or duration is adjusted.
• Reversibility (Topic: Exercise Principles) states that benefits are lost if exercise stops for 2 weeks; the individual may become heavier than before.
• Hypertension Contraindication (Topic: Exercise Safety): Patients with resting SBP ≥200 mmHg or DBP ≥110 mmHg should NOT undergo exercise testing or exercise until blood pressure is controlled.

STRENGTHENING PARAMETERS

• Strength Training (Topic: Muscle Goals) focuses on high load (>85% of 1RM), low repetitions (1-5 reps), and long recovery (3-5 mins).
• Hypertrophy Training (Topic: Muscle Goals) focuses on moderate weight (67-85% of 1RM), moderate reps (6-12), and 1-2 mins recovery.
• Endurance Training (Topic: Muscle Goals) focuses on low load (<67% of 1RM), high repetitions (12+), and short recovery (30-60 seconds).
• 10-Repetition Maximum (10RM) (Topic: Strengthening) is the maximum weight a patient can lift exactly 10 times with proper form, commonly used in rehabilitation.

DIFFERENTIATING DISEASE ENTITIES AND CONCEPTS

1. Aerobic vs. Anaerobic Thresholds: Aerobic threshold (VT/Lactate threshold) is the upper limit for light intensity where the patient can talk/sing; Anaerobic threshold (RCP) is the point of lactic acidosis where the patient must stop due to breathlessness and acidity.
2. Type I vs. Type IIB Muscle Fibers: Type I (Slow-twitch) is designed for endurance/marathons with high mitochondrial density and low fatigue; Type IIB (Fast-twitch) is designed for power/sprinting with high glycolytic capacity and low capillary density.
3. Moderate vs. High ACSM Risk: Moderate risk is defined solely by having 2+ risk factors with no symptoms; High risk is defined by the presence of at least one symptom OR a known diagnosed disease (even if well-controlled).
4. Ischemic vs. Non-Ischemic Chest Pain: Ischemic pain feels like "heaviness" or "burning" and occurs during exertion; Non-ischemic pain feels "knifelike" or "stabbing" and often occurs after exercise or with specific body movements.
5. Orthopnea vs. Paroxysmal Nocturnal Dyspnea (PND): Orthopnea happens immediately upon lying down and is relieved by sitting; PND begins 2-5 hours after sleep onset and may be caused by LV dysfunction or COPD (COPD-related PND is relieved by clearing secretions).
6. Bilateral vs. Unilateral Ankle Edema: Bilateral edema is characteristic of heart failure or venous insufficiency; Unilateral edema suggests venous thrombosis or lymphatic blockage.
7. HIIT vs. Constant Workload Training: HIIT involves short stimulus phases (seconds/minutes) followed by recovery phases at lower intensities; Constant workload is continuous aerobic activity at a steady pace for 20-30 minutes.
8. Strengthening vs. Endurance Recovery: Strength training requires long recovery (3-5 mins) to replenish ATP; Endurance training requires short recovery (30-60 secs) to keep the muscle challenged.
9. METs vs. VO2: METs is the "language of cardiologists" expressing energy cost relative to sitting; VO2 is the "language of pulmonologists" expressing O2 uptake per minute.
10. Primary vs. Tertiary Prevention: Primary prevention (like vaccination or initial exercise) happens before disease; Tertiary prevention (rehab) happens after a chronic or irreversible disease is established to limit disability.
11. Isocapnic Buffering vs. Respiratory Compensation: Isocapnic buffering (Stage II) is when hyperventilation successfully maintains pH by blowing off CO2; Respiratory Compensation (Stage III) is when buffering fails and pH begins to fall.
12. 1RM vs. 10RM: 1RM (Repetition Maximum) is the max weight for 1 lift (powerlifting focus); 10RM is the max weight for 10 lifts with form (rehab focus) to avoid injury.
13. VO2 Linear vs. VCO2 Steep Rise: VO2 (Oxygen consumption) remains linear because aerobic metabolism continues; VCO2 (CO2 production) rises steeply after the lactate threshold due to the combined CO2 from aerobic metabolism and bicarbonate buffering.
14. Metabolic Syndrome WC: Men vs. Women: For men, WC >102cm is the general cutoff; for women, WC >88cm is the cutoff (note: Asia-Pacific guidelines used in other tables define it as 90cm for M and 80cm for W).
15. Fast-Twitch A vs. Fast-Twitch B: Type IIA (FT-A) is "intermediate" with high oxidative capacity; Type IIB (FT-B) is "purely" glycolytic with low oxidative capacity and the fastest contraction time.

QA