AT1 - PHYSICAL EXAM SKILLS

Question 1

CLINICAL DECISION MAKING: What indicates a specific serious pathology?

Answer 1

• Presence of red flags
• Sleep disturbance (cannot continue sleeping, wakes often, difficult to get to sleep)
• Widespread neurological signs
• Very high pain reports (9/10 or 10/10 pain)

Question 2

CLINICAL DECISION MAKING: What are some examples of red flags?

Answer 2

• Unwell
• Recent unexplained weight loss
• Structural deformities
• Hx of cancer, steroids, drug abuse, HIV
• CONSTANT PAIN
• Non-mechanical pain
• Trauma for injury
• S&S of inflammatory disorders (i.e. morning stiffness)
• Family Hx of inflammatory disorders

Question 3

CLINICAL DECISION MAKING: What are some red flags for cauda equina syndrome?

Answer 3

• Urinary retention
• Incontinence
• Saddle area numbness
• Neurological signs in lower limbs
• Gait abnormality
• Lax sphincter

Question 4

CLINICAL DECISION MAKING: What indicates a spinal nerve/root pathology?

Answer 4

Neurological symptoms of shooting/electric pain, or weakness, numbness, pins and needles, or reduced reflexes

Question 5

CLINICAL DECISION MAKING: What indicates radiculopathy - and what are contraindications for this?

Answer 5

Neurological symptoms of numbness, weakness or reduced reflexes, caused by blocked axon conduction from disc herniation or foraminal stenosis

Question 6

CLINICAL DECISION MAKING: What indicates radicular pain - and what are contraindications for this?

Answer 6

Shooting/electric pain, band-like in distribution, irritation of spinal nerve or roots caused by inflammation from nuclear disc material or mechanical compression.
If this is indicated, you cannot perform PAIVMs

Question 7

CLINICAL DECISION MAKING: What indicates non-specific low back pain (NSLBP)?

Answer 7

If the other two presentations are ruled out, then it will be NSLBP

Question 8

CLINICAL DECISION MAKING: When is pain expected in a patient response during examination?

Answer 8

Pain is expected when:
- The patient is irritable (we do not want to provoke pain)
- The patient is moving into positions which were identified as painful in Hx
- The patient is stiff and we are moving into stiffness (we DO want to provoke pain here)

Question 9

CLINICAL DECISION MAKING: What are appropriate follow up tests?

Answer 9

Any tests that have not been contraindicated by the Hx, as well as giving us useful information for a diagnosis, based on the Hx

Question 10

CLINICAL DECISION MAKING: What are appropriate follow up measures?

Answer 10

Measures for reassessment should be the most affected movement (in terms of pain or range loss), measured in a way that can be reproduced

Question 11

CLINICAL DECISION MAKING: How do we know if a patient is irritable?

Answer 11

This will be identified in the Hx, by pain levels above 6/10, and pain that is either brought on quickly, or settles very slowly (e.g. 1 squat brings on 8/10 pain that takes 5 min to settle, or 5 mins of squats brings on 8/10 pain and takes 30mins to settle)

Question 12

CLINICAL DECISION MAKING: What can/can’t we do if a patient is irritable?

Answer 12

We can still perform observation, AROM, PROM, etc. BUT we need to give sensible pain limits (P1) to onset of pain to prevent the examination from getting pain throughout. We do not want to bring on high levels of pain as this will change the effectiveness of our assessments

Question 13

CLINICAL DECISION MAKING: When is a cerebral artery or vertebral artery test indicated?

Answer 13

When symptoms of 5D and 3N are present in Hx (diplopia, dizziness, drop attacks, dysarthria, dysphagia, ataxia, nausea, numbness and nystagmus)

Question 14

PHYSICAL EXAM PERFORMANCE: How do we choose the exam procedures to perform?

Answer 14

This is based on the Hx, pt irritability, and what will give us the best information to diagnose their condition and inform treatment possibilities

Question 15

PHYSICAL EXAM PERFORMANCE: How can we reduce risk of harm to physio during PE?

Answer 15

• Using line of force to ensure physio is in good position for power moves
• Putting patient at mechanical disadvantage or physio in mechanical advantage to reduce power needed for a movement
• Infection control
• Correct techniques (particularly for hands as these fatigue easily)

Question 16

PHYSICAL EXAM PERFORMANCE: What is important to do before, during and after assessments?

Answer 16

• Get consent before performing a movement
• Ensure patient understanding of what is going to happen, what is expected in this movement
• PAIN LEVELS!! Check resting pain, pain during movement, and if any pain was brought on, that it settles after movement is completed

Question 17

PHYSICAL EXAM PERFORMANCE: What is important to measure for reassessment later?

Answer 17

Measures for reassessment should be the most affected movement (in terms of pain or range loss), measured in a way that can be reproduced

Question 18

PHYSICAL EXAM PERFORMANCE: What are the three most important steps of PE?

Answer 18

Observation - always used.
AROM - almost always used
PPIVM/PAIVM - can assess if this would be useful Rx
Ruling in or out neurological exam, stressful procedures and behavioural functional movements also useful
NOTE: you will have to document findings now

Question 19

PHYSICAL EXAM PERFORMANCE: What is the purpose of observation?

Answer 19

To hone focus on what positions or activities aggravate the condition, as well as introducing possibility of easing positions (combined movements), looking for functional movement abnormalities also

Question 20

PHYSICAL EXAM PERFORMANCE: What is the purpose of neurological testing (and when is this indicated)?

Answer 20

Neurological testing is used to determine if a patient has spinal nerve/root involvement in their pain (indicated by pain radiating below the shoulder or buttocks)

Question 21

PHYSICAL EXAM PERFORMANCE: What is the purpose of neurodynamic testing (and when is this indicated)?

Answer 21

Neurodynamic testing is used to see if a patient has any neural tension (problems with nerves not sliding correctly with muscle movements). It is indicated when in the Hx the patient states that the positions that bring on pain/tingling are the same as neurodynamic positions

Question 22

PHYSICAL EXAM PERFORMANCE: What is the purpose of active movement assessment?

Answer 22

Active movement assessment is to find any affected movements/ranges (either by pain or stiffness). It tests all movements available at the joint (back) and measures the most affected for reassessment. We are looking to reproduce and understand the relationship between movements and our patient’s pain.

Question 23

PHYSICAL EXAM PERFORMANCE: What is the purpose of passive movement assessment?

Answer 23

Passive movement testing is used to identify possible treatment methods (either PAIVM or PPIVM), as well as localise where the issue is coming from (a specific level of vertebrae).

Question 24

PHYSICAL EXAM PERFORMANCE: What is the purpose of palpation?

Answer 24

Palpation is used for feeling for pain/tenderness, heat/sweating, abnormalities (bony or muscular), muscle spasms, hyperalgesia (less useful in spine for specific diagnoses, but good for fractures)

Question 25

PHYSICAL EXAM PERFORMANCE: What is the purpose of stressful procedures (and when are they indicated)?

Answer 25

Stressful procedures are used when either 1) AROM did not reproduce the patient’s symptoms or 2) we are looking for possible treatment procedures. They use combined, repeated, sustained, or overpressure movements to increase the stress at the joint to reproduce or relieve symptoms

Question 26

PHYSICAL EXAM PERFORMANCE: What is the purpose of SIJ tests (and when are they indicated)?

Answer 26

SIJ tests (distraction, Gaenslens, sacral shear, thigh thrust, and compression) are used to determine if the patient’s pain is coming from the SIJ area - indicated in the Hx by recent trauma or pregnancy, and from the PE by pain below S1 and worse pain in single leg standing

Question 27

PHYSICAL EXAM PERFORMANCE: What is the purpose of behavioural experiments with functional movements (and when are these indicated)?

Answer 27

The purpose of these is to try and change the patient’s outlook on their pain and it’s relationship with their movements. This is done through functional movement experiments, where we assess their expectations of pain during a movement, offer postural change suggestions, and ask them how their pain actually was compared to their expectations. These are indicated when the patient has a defeatist outlook on their pain or are extremely kinesiophobic

Question 28

PHYSICAL EXAM PERFORMANCE: What are three important things to do/say to a patient before starting a physical assessment?

Answer 28

• Perform infection control (sanitise)
• Seek consent for touch and shirt removal (offer draping!)
• Ensure patient understands why you are doing things