Clinical Assessment Flashcards
what does soap stand for?
-subjective, objective, assessment, plan
symptoms:
- symptoms are described by the patient
- severe headache, muscle pain, stiff neck, dislike bright lights, etc
signs:
- can be noted by examiner
- vomiting, fever, blotchy skin, confusion, convulsions, drowsy/dizzy
subjective; tips for conducting good clinical history
- smile
- eye contact
- ask open-ended questions (allows them to elaborate)
- empathize
- show competence without arrogance
- use clear language (minimize jargon/science talk)
- ensure privacy
- create space for question
- establish expectations (what assessments will look like)
- summarize what they told you (show you have been actively listening)
Elements of Subjective Assessment: History of Current Condition
- when it happened, how long has it been, what was MOI
Elements of Subjective Assessment: past history of current history
- have you had this before?
- have you had any lower extremity injuries?, etc…
Elements of Subjective Assessment: Past Medical/Surgical History
- have they had any previous surgery or imaging done in this area
Elements of Subjective Assessment: Medications
- have you taken any meds such as anti-inflammatories what would clear inflammation?
Elements of Subjective Assessment: Diagnostic tests
- any imaging? what does report say? what was the diagnosis?
Elements of Subjective Assessment: social habits
- what do they like to do for fun?
- work?
- this gives sense for types of movements in terms of repetition and load
Elements of Subjective Assessment: social history
- suggests what position they are in outside of sports or work,
- they may be a grandparent and lifting kids up
- they may be a gardener, etc
Elements of Subjective Assessment: family history
-example; x ray suggests OA, do you have a family history of OA?
Elements of Subjective Assessment: living environment
- post surgical and on crutched; how many stairs are in your house? do you have easy access to bathroom?, is bathroom same level as bedroom?
- do you need modification such as raise toilet or shower seat
- what social supports do they have that can help do activities at home? PSW?
Elements of Subjective Assessment: Occupation
- what does demands of job look like
Elements of Subjective Assessment: functional status/activity level
most important
- if we know their functional status before an injury we have a goal to work back to
- if person was an elite runner, we can ask if their goal is to return back to that level
- cannot assume someone is active, if we assume they are but they are actually sedentary, then we might prescribe exercises that are outside of their capabilities
Biopsychosocial Factors: Yellow Flag
- yellow refers to psychological or behavioural risk factors for prolonged disability (anxiety, lack of coping strategies)
- we want to refer or identify these risks that prolong ability
- if we can identify yellow flags we can refer to people who specialize in treating those flags such as someone who can help decrease anxiety, or stress that will have a positive output on bettering symptoms
Biopsychosocial Factors: Blue Flags
- conditions in the workplace that may inhibit recovery (poor relations with co workers or boss, high work demands)
- this will effect whether someone has a positive outlook to recover to return to work
- injury at workplace; number one predictor if they will recover and return to work is if they like their boss.
- psychological factor
- get people to talk through feelings about work
Biopsychosocial Factors: Black Flags
- organizational issues (workers comp, attitudes towards the sick worker)
- does person feel pressure to go to work early
- do they feel supported?
- if there is a case where someone is suing; may take longer to recover because they think outcome will be better
Red Flags
- need to screen for serious pathology to determine whether urgent transfer to emergency room is necessary
- asking closed-ended questions to be efficient
- be very explicit and clear, especially when assessing for a fracture
- ask if they feel they have a concern for something serious that may need referral
General Red Flag Screening: Cancer
- potential cause of pain with any assessment
- general malaise (fatigue) unlike normal
- unexplained fever
- unexplained weight loss (>5kg in 2 weeks)
- personal and/or family history of cancer
- unrelenting pain (particularly at night) independent and doesn’t matter what posture you are in
General Red Flag Screening: Infection
- redness, heat, change in function
- pain at rest or at night (inflammation)
- movement-independent pain; at rest do you have pain or only with movement? pain at rest is more nociceptive inflammatory pain
- fever
- general malaise
- night sweats
General Red Flag Screening: Fractures
- traumatic MOI
- identify fracture and educate them to take weight off it
- if not improving; even with rest, people can have pain every time they weight bear even after 2 weeks of rest
- severe pain; pain at night, unrelenting
- history of corticosteroid use?? decreases bone density
Region Specific (Neck) Red Flag Screening Vertebral-Basilar Insufficiency
- 5 D’s and 3 N’s
- dizziness
- diplopia (double vison)
- dysphagia (trouble swallowing)
- drop attacks (fainting spells)
- dysarthria (trouble speaking)
- numbness (more so around mouth)
- nystagmus- uncontrolled eye movement
- nausea
Objective Assessment
- look at observations (posture, asymmetries, impaired function)
- neuro exam (if applicable); assess nerves, dermatome, myotomes, reflexes and ROM (active > passive)
- strength testing (isometric MRC)
- joint stability; helps rule out ligamentous injuries
- special tests; rule in or out remaining conditions left
- palpation- poke areas we suspect are culprits
- least aggravating to most
Differentiating Inert and Contractile Tissue Injuries: Inert
- can’t move under own volition: it would include joint-joint capsule ligament
- painful when stretched
Differentiating Inert and Contractile Tissue Injuries: contractile
- what can contract
- muscle, tendon, musculotendinous junction
painful with:
- active contraction (AROM and isometric testing of agonist)
- passive stretching (AROM, PROM through antagonist)-if you hurt bicep and passively stretch it, it will still hurt
Inert: AROM
- pain in parts of ROM where ligament is stretched (closed-pack position)
- point in ROM where joint is locked (2 ends of bones are brought together and all structures around it are most stressed from inert standpoint)
- closed-pack is most stable, open pack is joint is open and inert structures are more relaxed
Inert: PROM
- pain in parts of the ROM where the ligament is stretched (closed-pack position)
Inert: Resisted Isometric
- no pain; isometric means not moving and since joints aren’t moving and stretching ligaments there is no pain
Contractile: AROM
- pain with agonist contraction, weakness
- possibly pain with antagonist AROM–> from stretching it
Contractile: PROM
- no pain with agonist (PROM) -slackened; Biceps, if you passively bring it into flexion, bicep isn’t activated so it is slackened
- possibly pain with antagonist PROM (stretch)
Contractile: Resisted Isometric
- pain and weakness with agonist contraction; if we turn on injured muscles it will hurt
- no pain with antagonist isometric
MCL sprain: flexion- AROM
- MCL is being slackened (knee flexion)
MCL sprain: flexion- PROM
- MCL is being slackened
MCL sprain: flexion- resisted isometric
- turning on hamstrings will not put tension through MCL if joint isn’t moving (no pain)
MCL sprain: extension-AROM
- pain at end-range extension (ligament is stressed at end range extension)
MCL sprain: extension- PROM
- pain at end rage extension (stretched)
MCL sprain: extension
no pain, turning on quads at mid-range won’t put tension through MCL if joint isn’t moving
Medical Research Council (MRC) Strength Grades -Grade Zero
- no signs of contraction (visible or palpable)
Medical Research Council (MRC) Strength Grades - Grade One
- flicker or trace of contraction
Medical Research Council (MRC) Strength Grades - Grade Two
- full active range of motion with gravity eliminated
Medical Research Council (MRC) Strength Grades -Grade Three
- full active range of motion against gravity without additional resistance from the examiner
Medical Research Council (MRC) Strength Grades - Grade Four
- full active range of motion against gravity PLUS moderate resistance from examiner
Medical Research Council (MRC) Strength Grades - Grade 5
- normal strength- full active range of motion against gravity PLUS maximal resistance from examiner
Objective Assessment Joint Stability; active subsystem
- force closure (muscles)
- use of force of muscles to stabilize joint in socket,
- how effective muscles work
Objective Assessment Joint Stability; passive subsystem
- form closure (joint, inert)
- the congruency of joint itself as well as inert structures helping stabilize, anatomy itself and inherent stability comes with that
Objective Assessment Joint Stability; neural control subsystem
- motor control
- proprioception
- rely on nervous system, to supply stability,
- these all work together to coordinate time and force of active subsystem
Ankle Joint Stability: Active Subsystem
- intrinsic foot muscles (local stabilizers) - originate and insert on foot itself n
- extrinsic foot muscles (global movers) - originate outside of ankle and go into foot
Ankle Joint Stability: Passive Subsystem
- bones of the arches
- plantar fascia
- ligaments
Ankle Joint Stability: Neural Control System
- musculotendinous receptors
- ligamentous receptors
Joint Neutral Zone
- part of the range where motion is produced with minimal resistance
Loose Joint
- active and neural subsystems of stability have to compensate for inadequate passive stability to prevent instability
- larger ROM, more mobility,
2/3 subsystems have to work harder so it doesn’t dislocate
Stiff Joint
- joint mobilizations/manipulations can help increase neutral zone and available joint ROM to reduce the burden on the active system to pull joint through ROM
- benefit from joint mobilizations or manipulations
- passive subsystem is working too hard, we have a narrow joint so active subsystem has to work hard to pull joint through ROM
Compressed Joint
- need to stretch the active subsystem (muscles) and/or passive (ligaments) subsystem.
- could be like frozen shoulder, even though joint is normal, the structures around it will which and tightly hold ball in socket, therefore we have to work hard to loosen that part
Motor Control Deficit Joint
- need to strengthen and work on joint position sense (proprioception) to keep the joint centre. motor control deficit, head of humerus or ball would be just pinging around in area with no control.
- may need brace due to excessive movement
Passive Accessory Motions
- once we move a joint past its neutral zone, we begin the sense resistance to the motion
- when we have exhausted all available passive ROM, examiner can feel empty end-feel
- presence of an abnormal end-feel may indicate injury to the joint
Anatomical Barrier
- joint capsule/ligament sprains occur when the joint is stretched and forced past its anatomical barrier (dislocations)
- if you go beyond this you are in plastic region and you would stress or sprain passive subsystem
End-Feel: Soft Tissue Approx
- joint cannot be pushed further because of engagement against another part of the body
- elbow flexion or knee flexion
End-Feel: firm
- muscular stretch
- capsular stretch
- ligamentous stretch
examples;
- straight leg raise, MCP extension, ligamentous stress test
End-Feel: Bony
- bone contacting bone
- elbow test
- or due to loose body
Abnormal End Feel: Empty
- complete rupture of soft tissue (grade III ligament tear)
- example; Lachman’s test for ACL tear
- nothing stopping ROM
Abnormal End Feel: Bony
- osteophyte formation, or loose body within joint, fracture
- example; loose body within knee felt during flexion
- you may feel bony end feel where you wouldn’t expect to
Abnormal End Feel: Boggy
- significant joint effusion, hemarthrosis
- so much swelling
- example; astute ankle sprain
- joint feels squishy and sloshing around
Abnormal End Feel: Springy
- rebound movement due to internal derangement
- example; torn meniscus
- can have flap tears that block ROM
What are special tests?
- typically pain-provocation tests
- usually performed near the end of the objective assessment
- to limit the number of special tests needed
- used to narrow down the differential diagnosis list by ruling in or out tentative diagnoses
- can be particularly aggravating as they often test specific structures at fault
- narrow down test by research
Sensitivity
- SnNOUT
- sensitivity, negative test rules out
- when sensitivity of a test is high, negative test rules out a condition
- 80% or higher is good
Specificity
- spPIN
- when specificity is high, a positive test will rule IN a condition
Highly-Sensitive Test: Ottawa Ankle Rule
- sensitivity: 96.4-99.0%
- specificity - 78%
- reduces number of unnecessary x rays by 30-40%
- if patient has no pain within the palpation areas and they are able to bear weight than it is considered a negative test and rules out fracture
Palpation Point for Ottawa Ankle Rule
A; posterior edge or tip of lateral malleolus
B: posterior edge or tip of medial malleolus
C: base of 5th metacarpal
D: navicular
Highly Specific Test: X ray
- specificity -98%
- sensitivity- 98%
- not perfect, fractures can be missed if they are very small
- since x rays are hight specific, they can rule in a fracture, and since they are sensitive they can rule out fractures with no evidence
Outcome Measure
- a tool used to asses a patients current status
test will provide
- a score
- interpretation of results (mild, mod, severe)
- risk categorization (prognosis)
- ex; pain scale,
Types of Outcome Measures: Self-Report
- questionnaires
- seems subjective but self-report measures objectify a patient’s perception
- LEFS, UEFI
Types of Outcome Measures: Performance Based
- require the patient to perform a set of movements or tasks and asses their movements
- scores can be based on either an objective measure (time) or qualitative assessment that is assigned a score (normal or abnormal mechanics)
- ex; vertical hop (metres)
- or beep test for endurance
Types of Outcome Measures: Clinical-Reported
- the professional used clinical judgement and reports on patient behaviours or signs that are observed by the professional
- Glasgow coma scale
Why do we use outcome measure?
- identify the impact of the disorder on an individual
- establish a baseline measure form which to monitor changes overtime
- evaluate the impact of an intervention
- evaluate the need for referral
What are outcome measures intending to measure?
- impairment of body structure and function (stiff joint at 140 degrees)
- activity limitations (sitting to standing,
- participation restrictions (has to do with work)
- ## quality of life
Psychometric Properties
- psychometric properties are the intrinsic properties of an outcome measure
- want to choose outcome measure that have been well validated in the literature
include:
- validity
- inter-rater reliability and intra-rater reliability
- minimal detectable chances (MDC); amount of change required to be reasonable certain that true changes has occurred and too due to error
Assessment: Diagnosis
- making a diagnosis is a controlled act available to only a select few health care providers can roster for (PT< MD< NP< DC)
- registered kinesiologists can work under clinical suspicions or from the diagnosis made by another clinician
Problem list
- after making a diagnosis make the list
- collection of body structures/function impairments, activity limitations and participation restrictions gathered from the subjective history
- to consider how contextual factors will either help or hinder recovery
- to organize into ICF model
SMART goals; short term
- short term: regain full knee flexion (130 degrees) within 4 weeks of surgery as measured by goniometer
SMART goals; intermediate term
- to be able to being running at 5mph without compensation on the treadmill for 10 mins by 4.5 months post-op
SMART goals; long term
- return to play 30 mins within varsity game within 14 months of surgery
Plan; treatment
- considerations for selecting the most appropriate treatment
- is it within the patients expectations and addresses their problems list/goals
- supported by the literature to treat the condition/disorder you have diagnosed
- is it within your scope of practice
- you have received accredited training to perform the act
- you have rostered to perform the act with your College
- the benefits outweigh the risks of treatment
- you get INFORMED CONSENT from the patient
Imaging
- x ray is quick and easy, looks at bones,
- ct scan is more expensive and riskier, more radiation
- MRI is looking at soft tissues, pricey, some may be claustrophobic
- ultrasound- quick and easy but limitations of quality of tissue
referral to another physician
- emergency physician- could not clear red flag
- family physician - diagnostic testing, blood work
- sports medicine physician - assess and treat musculoskeletal injuries
- orthopaedic surgeon- structural issues, ACL rupture
- psychology, psychiatry, social work, psychotherapy; yellow flags
- dietician
- chiropractor
- massage therapy
