Chapter Five - MSK Assessment Principles and Concepts

Question 1

What is the purpose of a musculoskeletal assessment? What is the difference between a symptom and a sign?

Answer 1

• Understand the patient’s problem
• Design a treatment program

Symptom: what the patient complains of

Ex: pain tingling, crepitus, numbness

Sign: what the therapist sees and feels (observable, measurable findings)

Ex: warmth, swelling, …

Question 2

What is an initial assessment?

Answer 2

the first encounter with the patient that should be quiet, private and distraction free

Question 3

How do you create a proper environment for the initial assessment?

Answer 3

Introduce yourself, establish and maintain eye contact
Do not assume the right to call a person by their first name Make the patient feel welcome
Ensure that the patient understands the PT roles as well their own

You and your treatment area should be neat, clean and tidy Appear cool and talk calmly; appear confident
Care about the patient’s problem and them as a person
Be reassuring

Always give the impression that the patient’s problem is the most important thing that you have to deal with and nothing else matters.

Question 4

What are some good tips for taking a history?

Answer 4

Use an orderly sequence with your questions; minimize wandering

Use lay terminology; but do not degrade the patient’s levelof intelligence

Rephrase your questions if this is required

Ensure you understand the patient’s explanation

• If necessary, repeat what you heard back to the patient

Use open-ended questions; minimize yes/no questions

Take a complete medical history and document accurately in detail

• Supports the management of your patient
• Important for legal purposes
• Ensures reliability of what you are documenting

Question 5

What are some personal factors that could be helpful during the subjective part of an assessment?

Answer 5

PERSONAL FACTORS

• Age (e.g., Osgoode-Schlatter’s disease)• Occupation
• Type of work?
• Hours of work?
• E.g., part-time, full-time, casual, shift work
• How long has the patient done this particular job?
• E.g., too much too soon
• E.g., too much too long
• Language, gender, activity history (current and past), insurance, culture
• Psychological Factors
• Hand dominance
• Personality characteristics (e.g., motivation, comprehension)

Question 6

What are some environmental/social factors that could be helpful during the subjective part of an assessment?

Answer 6

• Living arrangements (e.g., stairs, transportation, housing)

• Family and friend support
• Culture
• Work/School environment
• Team/coach/trainer environment

Question 7

What are some questions to ask for the history of the present illness (HPI)?

Answer 7

• When did the problem start?
• How long has the patient had the problem?
• What was the mechanism of injury (MOI)?
• What happened? How did it start?
• Slow versus traumatic onset

Question 8

During the initial subjective assessment, how can you map out the site of the injury?

Answer 8

• Map out the exact area and boundaries of the pain
• Get the patient to point to the area “Where exactly are your symptoms?”
• When several painful areas exist, identify the top painful areas to manage first

Question 9

Describe the four components of a subjective assessment: radiation, nature, periodicity, and duration of the pain.

Answer 9

Radiation

• Is the pain localized or does it spread?
• Does the pain follow a dermatomal or segmental reference nature of pain

• Extra-segmental pain (dura – red flag)

Nature

• Worse in the morning but gets better as the day goes on
• E.g., fluid in the disc with ongoing weight-bearing positions

Periodicity

• Constant or intermittent (even if the intermittent is only 5 minutes long)

Duration of the Pain

• How long does the pain last?

Question 10

How can you assess the intensity of the pain during the subjective assessment?

Answer 10

• Using a 0-10 pain index or a visual analog scale
• Anobjective, subjective index

Question 11

What are some characteristics that describe pain’s “quality”

Answer 11

Burning

Sharp

Boring

Shooting

Dull

Aching

Question 12

What is a referred pain? What is it generated by? Secondary pain results from what? Secondary hyperalgesia results from what?

Answer 12

• Symptoms that have their origin at a site other than where the patient feels the pain

Generated by:

• Convergence of sensory input from separate parts of the body to the same dorsal horn neuron via primary sensory fibers (e.g. heart attack felt in left arm)
• Secondary pain resulting from a myofascial trigger point
• Secondary hyperalgesia from inflammation

Question 13

What are aggravating activities? When should we include these? Give examples. What are some easing activities? Give examples. The location, characteristics and behavior of symptoms are helpful in determining what?

Answer 13

Aggravating Activities

Movements that increase symptoms
Include these movements toward the end of the assessment E.g., positions, activities, time of day

Easing Activities

Movements that improve symptoms
What activity or position makes the patient feel better? E.g., medications (anti-inflammatories), modalities

The location, characteristics and behavior of symptoms are helpful in determining the pain mechanisms involved

Question 14

What does SOCRATES stand for?

Answer 14

Question 15

There is more that just pain to consider. Whats else?

Answer 15

Question 16

What do we have to consider regarding the activities of daily living (ADL) of the patient?

Answer 16

• How long has this problem affected your:

• Everyday activities?
• Occupation?
• Recreational activities?

• Is there anything that is difficult or impossible for your to do now since the onset of this problem?

Helps create patient centric goals and what the patient would want to accomplish

Question 17

What does morning pain vs morning stiffness indicate?

Answer 17

• Morning pain

Ligamentous injury

Inflammatory disease (E.g., rheumatoid arthritis – chemical build up

overnight)

• Morning stiffness
• Degenerative joint disease (E.g., osteoarthritis)
• Lose lubrication while sleeping – can reduce stiffness with hot shower• Could be inflammatory if lasting longer than 1 hour

Question 18

What is there to consider regarding night pain? What would be concerning?

Answer 18

• Do their symptoms ever keep the patient awake? If yes, how frequently?

• Does the pain ever awaken the patient? If yes, how frequently?
• What does the patient do to relieve symptoms?
• Can the patient lie on the affected side?

Night pain that is not relieved by anything is concerning!

Question 19

What are the two possible causes of night pain and their characteristics? Which one is a red flag for PTs?

Answer 19

Chemical Causes

• A “RED FLAG” for the physiotherapy
• Neither movement nor change in position will affect the pain• Comes on roughly the same time each night
• The patient will often “walk the floor”
• Possible cause could be cancer

Refer back to family physician for further tests, if absolutely nothing makes it feel better

Mechanical Causes

• Improves with a change in position or with movement

Question 20

What is there to consider while taking the previous medical history (PMHx)?

Answer 20

• Has the problem occurred before (i.e., first occurrence or reoccurrence)?

• Was pervious treatment effective?
• What was the outcome?
• Any residual findings?

• Was the patient satisfied with the results?

Question 21

What do you ask regarding previous surgeries?

Answer 21

• Where?
• When?
• Surgeon?

• What was the outcome? – depends on who you ask *caution*

• Surgeon versus patient satisfaction
• E.g., return to sport in youth athlete

Question 22

What questions can you ask regarding general health?

Answer 22

What treatments have been tried?

ER visit, family physician, trainer,

medication, massage therapist, osteopath,

chiropractor, another PT

What was the result?

Neurological, cardiovascular, pulmonary, skin, urogenital, endocrine, rheumatology, psychological

Signs and symptoms versus diagnosis

Can relate to (red) flag questions

Question 23

What do you consider regarding radiographs.

Answer 23

When

Where

Outcomes (don’t assume that no news is good news)

Other imaging or diagnostic investigations?

E.g., MRI, CT scan, bone scan, bone density, blood

work, EMG
• Can be requested with the patient’s consent

Question 24

Which aspects are helpful to know regarding patient’s current medication? Which one would be a yellow flag?

Answer 24

For current condition and/or other conditions

• Type, dosage and length of time on a medication
• Purpose for taking medication
• Response, compliance and side effects of medication
• Known allergies to medication
• Insurance coverage
• Anti-coagulants? (e.g., Warfarin, Cumafin) – YELLOW FLAG
• High risk of bleeding
• Important implications for treatment (e.g., rigor)
• Chemotherapy and radiation therapy can also lead to high fracture risk
• When did they last take their medication (e.g., 10 min versus 8 hours)
• Need to be able to reproduce symptoms to assess

Question 25

What are the possible long-term effects of corticosteroid use?

Answer 25

Debate on detrimental long-term effects of corticosteroid use * Osteoporosis proximal muscle weakness * Generalized weakness * Generalized tissue swelling * Thin, fragile skin (no deep tissue treatment) * Increased pain threshold * Precaution when using manual techniques * High fracture risk * Limited modality use

Question 26

How are red flags important? What are some global system questions?

Answer 26

To identify any serious underlying pathology E.g. cancer, vascular compromise, neurological signs, infections, fractures Global System Questions: • Any unexplained alteration in energy level? • Does the pain consistently wake you from your sleep? * Have you experienced night sweats? * Any unexplained weight loss?

Question 27

What's the difference between urgency and emergency?

Answer 27

Indicating need for medical consultation: URGENCY (You want to manage it right away) versus EMERGENCY (More life-threatning, needs medical intervention)

Question 28

Give some red flag examples.

Answer 28

Severe, constant unremitting pain, night pain or spasm No history of injury, unaffected by medication or position Spinal Cord symptoms: paraesthesia or numbness in 2 or 4 limbs Vertebral Artery symptoms: dizziness, difficulty swallowing (dysphagia), double vision (diplopia), difficulty articulating words (dysarthria), drop attack (fall to floor but no loss of consciousness), nausea, nystagmus (Difficulty keeping your eyes in one direction) (Know all our Five Ds) Cauda Equina symptoms: numbness in the saddle area, loss of sexual function Bowel/Bladder dysfunction: loss of bowel control It’s always a matter of ruling out, instead of ruling in

Question 29

What are some possible red flag sources?

Answer 29

Cancer Heart Upper motor neuron disorder Joint infection Other infection Vertebral artery compromise Internal carotid artery issue Fracture Upper cervical spine instability

Question 30

Other than red, what are some other types of flags? What do they represent?

Answer 30

YELLOW FLAGS Psychological/behavioral factors BLUE FLAGS Social and economic factors BLACK FLAGS Occupational factor

Question 31

Which three main factors are to consider when assessing the level of irritability? Describe them. Are they proportional of inversely proportional with irritability?

Answer 31

Clinical reasoning and decision making to determine your patient’s condition, and isdependent using three main factors: [1] VIGOUR of the activity needed to reproduce the patient’s symptoms • Inversely proportional with irritability (more vigour needed, less irritable) [2] DURATION of the patient’s symptoms • Proportional with irritability (longer lasting symptoms, more irritable) [3] INTENSITY of the patient’s symptoms after onset (depends on pain experience) • Proportional to the level of irritability (more intense, more irritable)

Question 32

Describe what a mild/low, a moderate, and a severe level of irritability indicate. Which implications does that have for your objective assessment?

Answer 32

The level of irritability will have implications for your objective assessment * How aggressive should the objective exam be? * What components of the objective exam will you include? Mild/Low: Not easily provoked and symptoms return to baseline once the source has been removed Moderate: Symptoms are proportionate to the source and the symptoms gradually return to baseline Severe: Easily provoked and may remain elevated for while

Question 33

After your subjective history, you should be able to:

Answer 33

After your subjective history, you should be able to: [1] Describe a clinical hypothesis/hypotheses [2] Determine if appropriate and safe to continue [3] Determine the irritability ofthe patient’s condition

Question 34

What are the three steps to objective examination?

Answer 34

1. Observation 2. Upper and lower quadrant scans 3. Regional objective exams Don't forget to keep in mind the ICF model

Question 35

Give some examples of upper/lower quadrant scans

Answer 35

* Observation * Active ROM (with overpressure) * Myotomes * Dermatomes * Reflexes * Motor Neuron Reflexes * Neurodynamic Tests * Pulses * Provocative Tests / Palpation

Question 36

Give some examples of regional objective exams.

Answer 36

* Observation * Active ROM * Passive ROM * Resisted testing – muscle strength * Stress tests (stability) * Mobility tests * Joint glides * Muscle length * Neurodynamic * Special tests * Functional/Performance testing• Palpation

Question 37

During observation, start by checking the alignment of the body. Why is the alignment important?

Answer 37

* Appropriate exposure * Always look first at the overall picture then narrow your focus ALIGNMENT (includes posture) As with any other mechanical system, alignment is important Ideal alignment facilitates optimal movement If alignment is ideal, there is less chance of causing microtrauma to the joint and its supporting structures

Question 38

What are the key aspects to a good postural scan?

Answer 38

* The “looking phase”, but always describe to the patientwhat you are looking at * Complete in standing, sitting, and supine (modify for age/condition as needed) * Consider anterior, posterior and both lateral perspectives * Despite asymmetry, we need to be convinced that it is related to the presenting symptoms

Question 39

Give some of the most important aspects to check for during observation.

Answer 39

POSTURE BRUISING SWELLING SOFT TISSUE CONTOURS SKIN CONDITION BONY CONTOURS PATIENT BEHAVIOURS

Question 40

Name some functional movements that you can ask your patient to do during observation.

Answer 40

* Functional movements combining elements of the objective exam * E.g., ROM, strength, balance * Quick gait assessment * Walk on heels and toes * Squat * Twist • One leg standing * Shoulder shrug * Hand behind back • Hand behind head

Question 41

Why is functional assessment testing? What are three aspects to consider, that could possibly be affected by the injury?

Answer 41

• To determine how injury is affecting the patient’s ADLs Daily self-care activities: • E.g., grooming, walking, eating, dressing Recreational activities: • E.g., driving, gardening, meal preparation, laundry Patient specific/injury specific tests: • E.g., running, squatting, hand dexterity, transfers, throwing

Question 42

What aspects are you looking at during a GAIT assessment?

Answer 42

Balance Stride length Coordination Limp Rhythm Assistive devices Distribution of weight

Question 43

What are the main principles of examination? What do you start with? After that?

Answer 43

• Tell the patient what you are doing and test the unaffected side first * AROM→PROM→resisted isometric movements (most painful are last) * For PROM and ligament testing, the quality of movement and quality of end-feel are important * Apply overpressure (OP) with care to test the end-feel * Repeated movements or sustained postures and positions * Resisted isometric movements (resting position→resist on stretch)

Question 44

What are active range of motion movements (AROM)? What are they used for (2)? What can they tell you (3)?

Answer 44

* Movements under the patient’s volitional control * Can be normal, limited or excessive * Painful active movements implicate both contractile and inert structures * Used to determine: * Patient’s willingness to move * Available joint ROM (quality and quantity of movement) • How gentle or vigorous the subsequent objective examination should be * If the patient has the muscle power to perform the movement * The region where symptoms are located and which tissue to test in detail * When in AROM does pain occur and where is the pain? * Does the movement make the pain better, worse, or the same?• The pattern of movement and quality of movement * Amount of restriction * Movement of associated joints * Willingness of patient to move

Question 45

What is the goal of passive range of motion (PROM)? What are the two different types? Gives examples

Answer 45

* Tests inert structures and places passive tension on the antagonist contractile unit * Findings: reproduction or alteration of pain or other symptoms, ROM and pattern of limitation, end-feel Types • Passive physiological movements (PPM) * Movements that occur normally at the joint * Performed under volitional control or performed passively * ex: flexion (PPF), extension (PPE), abduction (PPABD) * Passive accessory movements (PAM) ex: posterior-anterior (PA), anterior-posterior (AP), longitudinal movements

Question 46

What are the two types of passive range of motion movements? (hint: we also saw those in Movement and Exercise Science)

Answer 46

OSTEOKINEMATICS * Rotary movement of the bony lever in space during physiological joint motion * Physiological (PPM) ARTHROKINEMATICS * Occurs during osteokinematics * One segment is relatively stable and the other segment moves on that stable base • Accessory (PAM)

Question 47

What are passive accessory movements? What are the three types of joint mobility? What are some abnormal types of end-feels?

Answer 47

* Movement not under volitional control * Necessary (with physiological movements) to function • “Joint Play Movement” = passive accessory movements * Joint mobility: normal, hypomobile, hypermobile * The amount or free play of a given joint (neutral zone) * Oscillatory versus Sustained * End-feel: painful, resistance, spasm (and the relationship between them)

Question 48

What are some aspects to look for in PROM testing?

Answer 48

* When in PROM does pain occur and where is the pain? * Does the movement make the pain better, worse, or the same? * The pattern of movement and quality of the end-feel * Amount of restriction * Movement of associated joints

Question 49

Name some of the different types of endfeel and an example for each.

Answer 49

ENDFEEL EXAMPLE Normal: bone to bone Elbow extension Soft tissue approximation Elbow flexion Tissue stretch Ankle dorsiflexion Abnormal: early muscle spasm Protective spasm following injury Late muscle spasm Spasm due to instability Hard capsular Frozen shoulder Soft capsular Synovitis, edema, ligament laxity Bone to bone Osteophyte formation Empty Acute bursitis Springy block Meniscus tear

Question 50

LAG describes what type of phenomenon? What are some possible causes for that?

Answer 50

PROM \> AROM Possible causes of muscle weakness: * Muscle strain * Pain/reflex inhibition * Peripheral nerve injury * Nerve root lesion * Tendon pathology * Avulsion * Psychological Factors

Question 51

What does resisted ROM test? What can it help find? There are two ways to find that ROM...?

Answer 51

* Tests contractile structures by active tension * Findings: pattern of pain and weakness Test in neutral – the muscle position to generate maximum force Test the muscle in its stretched position –to maximize tension through contractile tissues (e.g., muscle belly, tendon, tendon- periosteal junction)

Question 52

Elements to look for in resisted ROM.

Answer 52

* Does the contraction cause pain. If so, how much, where? * How strong is the contraction? * What type (isometric, concentric, eccentric) of contraction caused the pain? • Did the contraction start strong but with sustained maximal effort (5-6 seconds), did the contraction become weak (fatigable weakness = neurological = nerve palsy)

Question 53

What do these resisted ROM test findings indicate? * Strong and pain free in all positions = ? * Relatively strong but some pain = ? * Weak and painful = ? * Weak and painless = ?

Answer 53

* Strong and pain free in all positions = normal * Relatively strong but some pain = mild strain of contractile structure * Weak and painful = moderate to severe strain of contractile structure * Weak and painless = complete tear or rupture of the contractile structure

Question 54

What are some examples of abnormal sensations?

Answer 54

* Crepitus * Clicking * Snapping * Grating * Creaking * Popping

Question 55

What can special joint tests indicate? What do we have to watch out for with these?

Answer 55

* Specific tests of a joint or particular structure * Suggestive of a particular problem involving those structures (not conclusive) * Do NOT diagnose based on a single test! * Results depend largely on the skill level of the therapist * Do NOT do all tests for every joint! * Only the best test for an individual – selected based on the mechanism of injury

Question 56

Reflexes: a loss or abnormal conduction will lead to (3)?

Answer 56

* Usually performed during the scan exam * A loss or abnormal of conduction will lead to: * Hyporeflexia: A reduced deep tendon reflex (DTR) * Areflexia: A loss or absence of DTR • Hyperreflexia: An increased DTR Assess peripheral nerve or dermatomal distribution around joint being examined

Question 57

What information can palpation give you?

Answer 57

* Discriminate differences in tissue tension * Muscle tone, spasticity, flaccidity (know what every tissue feels like) * Discriminate difference in tissue texture * Identify shape, structures, tissue type, thickness – normal versus abnormal

Question 58

Other than feeling tissues, palpation can be helpful to determine (3)...

Answer 58

* Pulses * Local temperature • Swelling