E1-MSK Exam/Eval Flashcards
what is the process of taking a proper hx
open ended questions initially for a narrative
narrow to more specific questions
no leading questions
what are the key components of a hx
symptoms and behavior
onset/prior to injury
symptom impact/function
imaging and diagnostic tests
patient prospective
past medical hx/meds
S&S of severe MSK or non-MSK conditions (RED FLAGS)
what are key questions for symptoms and behavior
location
duration
changes
irritability
type
why is knowing the duration of the symptoms imporatant
can help with stages of tissue healing
not all tissues are in a stage of healing
why are not all tissues in a stage of healing
there may not be real damage to the tissue, it may just be irritated or inflamed
what are the questions needed to be asked when asking about the changes in symptoms
intensity (set boundary)
frequency
location
improving, worsening, or stay the same
when asking about the irritability of a symptom, what are we looking for
aggravating or easing factors
mechanical or non-mechanical
immediate or delayed symptoms upon activity
how can we differentiate types of symptoms
questionnaires
may indicate tissue involved or the condition of tissues
paresthesias may indicate
spinal nerve or nerve root
numbness may indicated
peripheral n
deep ache may indicate
joint pain
sharp pain may indicate
inflammation
why is onset questions important to discuss
timing- whether gradual or traumatic
circumstances and severity
T/F: imaging tests should be used in isolation
false
they should be compared with clinical findings.
should a patient with high sensitivity have imaging done
yes, it is better at ruling out
should a patient with low specificity have imaging done
no, not as good at ruling in
why is it so important to have the patients perspective and goals
+/- toward their condition and PT
does it match with their condition
what information is important in past medical hx
personal, immediate family, and allergies
influence on present condition
influence on prognosis
what topics need to be questioned on social hx
smoking
alcohol
drugs
with type, frequency, and duration
what is a suspicious MSK S&S red flag
neck splinting with lack of side bending could indicate a dens fracture after trauma
what is a suspicious Non-MSK S&S red flag
chest and shoulder pain only on exertion could indicate cardiovascular issue
when does observation start
from the moment you are introduced to the patient
what does observation consist of
conversation- slurred speech, hoarseness
structural- body type, skin markings, posture, orthotics, etc
functional
guarding
facial grimaces
mental
what is a rigid body type
flatter spine with tighter hips and genu and calcaneal varus
more propulsive
what is a flexible body type
excessive spinal curves with hypermobile hips and genu and calcaneal valgus
more absorbing
can the body have normal dominance asymmetries, if so, what are they
yes
ipsilateral shoulder depression, more hyperextended knee, and flatter foot
what are the parts to tests and measures
scans- general assessment
biomechanical exam- greater detailed assessment from scan findings
what are the purpose of scans
further assessing red flag S&S
neurological status
determine if symptoms are referred or radicular
severity of condition
identify need for more in-depth biomechanical exam
what are the certain situations you will do a scan
w/o recent trauma start with a spinal scan, ESPECIALLY with past hx of spinal P!, then cont to extremity
with recent trauma start with involved area then surrounding
always check neuro status
what is a selective tissue tension test
A/PROM with overpressure
combined motions
resisted testing
discerning contractile from non-contractile tissue intergrity
what is WNL
within normal limits= full, pain free, coordinated, smooth movements
if ROM is limited and painful in multiple planes, what is indicated
more severe injury
if ROM is aberrant, what is indicated
joint hypermobility/instability
if ROM has sharp curves or fulcrums, what is indicated for the joint
joint hypomobility
if ROM is lacking, but it is not a mechanical restriction or joint hypomobility, what is indicated and how can we fix it
misalignment—- manipulation plus stability exercises
what are essential ADLs
walking
squatting
reaching
bending
turning
what are higher level ADLs
jumping
throwing
lifting
running
what can an AROM test indicate
willingness to move
unwillingness to move or splint= red flag
may be deferred if too limited
uniplanar motions
might also assess response to repitions
if improved pain and function is found in repetitive AROM test, what is possible
inhibited muscle
regional interdependence or disc injury
if worse pain and function is found in repetitive AROM test, what is possible
acute injury
if pain occurs in the same direction of AROM and PROM, what is indicated
non contractile tissue is the problem
if PROM is similarly restricted as AROM in the same plane, what is indicated
joint hypomobility or protective guarding
what is the end feel like?
if PROM is significantly greater than AROM in the same direction, what is indicated for the joint
joint hypermobility/instability
Pt was tested in WB and NWB motions and was found to be limited. What is the likely cause and general Rx
fused, fixated or hypomobile joint
improve joint mobility
Pt was tested in WB and NWB motions, WB was limited but NWB was WNL. What is the likely cause and general Rx
joint hypermobility/instability paired with impaired neuromuscular control
improve neuromuscular control
what characteristics describe capsular restriction
loss of motion due to capsular restrictions= firm end feels
varies among joints
what causes a firm end feel in capsular restriction
arthritis, adhesions, prolong disuse/immobilizations
why use combined motion if uniplanar motion is inneffective
applies greater stress and challenges on the joint
a Pt has a consistent block when performing combined motion, what does this mean
differing paths to the same point indicates hypomobility
follow up with accessory motions
a Pt has an inconsistent block when performing combined motions, what does this indicate
hypermobility/instability
follow up with stability tests
how long should you hold resisted testing
3 secs
what does resisted testing indicate
general integrity of contractile tissue and severity of condition
if resisted testing results come back painful but strong, what is indicated
mild injury
only painful in lengthened range
if resisted testing results are painful and weak, what is indicated
acute
moderate to severe injury
if resisted testing results are painless but weak, what is indicated
neurological damage or chronic contractile rupture
if the same pain is produced in one direction of AROM and/or resisted testing and is opposite direction of PROM, what tissue would cause the problem
contractile tissue
if symptoms are reproduced upon release during resisted testing, what is the problem
non contractile tissue as glide is released when muscle relaxes
if one joint is weak at multiple planes during resisted testing, what is the problem
possible acute or severe injury
if multiple joints are weak during resisted testing, what is indicated
possible CNS issues
if there is weakness throughout a range and not just midrange during resisted testing, what might be the issue
possible pathology
if improved pain and function is found in resisted testing, what is possible
inhibited muscle
regional interdependence
if decreased force is found with repetitive resisted testing, what is possible
n palsy
if consistent weak force is found with repetitive resisted testing, what is possible
deconditioned/torn muscle
if pain and function are worse with repetitive resisted testing, what is possible
acute condition
what is a stress test testing
non contractile tissue: location of P! and severity
how do you perform a stress test
apply a rapid but shallow force
If P! happens in a stress test, what is indicated
acute conidtion
if no P! happens in a stress test, what is the next step
apply a slower, larger, and deeper force and hold for 10 secs
if a 10 sec hold causes pain in a stress test, what condition is indicated
hypermobility/instability
what are the symptoms of joint hypermobility/instability when doing a stress test
late, empty/soft end feels
click, clunk/spasm
Pt has increased pain with the distraction stress test, what tissue is possibly damaged
capsule, ligament, annulus
Pt has decreased pain with distraction stress testing, what tissue might be the issue
cartilage, disc, bone, spinal n
are both compression and distraction stress test indications the same
no, they are opposites
if the capsule is the issue, distraction would tighten the injured tissue making it more painful, whereas compression puts the tissue on slack decreasing the pain
Pt describes increased pain with compression stress test, what tissue is the problem
cartilage, disc, bone, spinal n
Pt describes a decrease in pain with compression stress test, what tissue is the issue
capsule, ligament, annulus
if both distraction and compression stress testing produce pain, what is indicated
acute condition
how do you perform a sensory test
assess light touch without moving the skin
light touch is lost first
check sharp with pinprick
what happens next if sensation is diminished in a sensory test
repeat to find if it is either a spinal n or peripheral n
if both light and sharp touch are WNL in the presence of paresthesia, what should happen next
use a pinwheel to check for hyperesthesia due to nociplastic pain
what proceeds if the pt has lost fine touch in sensory testing
check vibration
2 pt. discrimination
proprioception for possible dorsal column issue
what proceeds if the pt has lost sharp touch in sensory testing
check temperature and crude touch for possible spinothalamic tract issue
what is the scale for sensory testing
0= absent
1= diminished
2= WNL
3= hyperesthesia
what is DTR or myotatic reflex
loop from muscle spindle afferents to ventral horn efferents
how do you perform a DTR
brisk tap 3 times
how would you distract a pt to successful perform a DTR
jendrassik maneuver or teeth clinching
what is the scale for DTR
0= absent
1+= hyporeflexive
2+= WNL
3+= hyperreflexive
4+= clonus
what does 1+ mean on the DTR scale
hyporeflexive- LMN condition
what does 3+ mean on the DTR scale
hyperreflexive- large arc with normal dampening; UMN condition or nociplastic pain
what does 4+ mean on the DTR scale
clonus- >3 beats when dampening; UMN condition
what is pathological reflexes
assess for normal reflexive suppression by UMN system
what are abnormal findings of pathological reflexes
release of primitive reflex indicating UMN impairment
how do you perform a pathological reflex test
hoffman or babinski
3x
what is myotome testing
key m or group of mm innervated by a single spinal n
what are we looking for when testing myotomes
fatiguing weakness during a 10 sec hold
what is dural mobility
sequential/progressive assessment of neural mechanosensitivity
what is tension restriction
inelasticity
pain or symptoms increases from both ends
what is gliding restrictions
adhesions
pain or symptoms increase from one end and relieved from the other
what might inelasticity or inflammation of a nerve produce
reproduction of achy or sharp symptoms or paresthesia
what indicates the need to perform an accessory motion test
limited ROM and/or consistent block in combined motions
is accessory motion testing better at picking up on hypo or hypermobility and why
hypo
it is much easier to compare the affected side to the unaffected side, so it is easier to see if the affected side has limited range
what is PPM in accessory motion
passive physiological mobility
assessing glides with extremity osteokinematics
what is PAM in accessory motion
passive accessory mobility
assessing glides without osteokinematics
more common in extremities
what is PPIVM in accessory motion
passive physiologic intervertebral mobility
assessing glides with spinal osteokinematics
more commonly performed in spine
what is PPAIVM in accessory motion
passive physiologic accessory intervertebral mobility
assessing glides without osteokinematics
in the accessory motion scale, what would a 0 grade mean
fused joint- no accessory motion
fibrosed capsule or bony bridge
in the accessory motion scale, what would the grade 1-2 mean
joint hypomobility
joint fixation, articular, capsule/ligamentous shortening
in the accessory motion scale, what would the grade 4-5 mean
joint hypermobility
capsule/ligamentous laxity, local muscle insufficiency
in the accessory motion scale, what would the grade 6 mean
pathologically unstable joint
tissue rupture, unable to stabilize with neuromuscular function
if a joint has reduced accessory motion, what is indicated
hypomobility
if a joint has increased accessory motion, what is indicated
hypermobility/instability
if the accessory motion and ROM is limited, what is the restriction
articular- capsular shortening or cartilage
if the accessory motion is WNL but ROM is limited, what is the restriction
extraarticular- muscular shortening, guarding, hypermobility
what does abnormalities of accessory motion mean
indicates improper axis of joint motion and puts excessive stress on adjacent tissue (noncontractile)
what is a normal axis of motion
should never be on articular surfaces
should always be changing due to gliding and rolling
what is an abnormal axis of motion
indicates excessive compression and friction forces with limited gliding
what are the consequences of abnormal axis of motion
decrease in synovial fluid leads to degenerating noncontractile tissue of the joint
what can special tests help indicate
identify more specific tissue
the integrity
assess progress
what is a provocative test
identify tissues by the reproduction of symptoms during the test
what info is given from stability tests
integrity of noncontractile tissues
provocation
laxity with late, soft, or empty end feels
segmental play
what is segmental play
assessing for excessive linear shearing of vertebra
what is the indication to perform a stability test
excessive ROM or inconsistent block in combined motions
what do you do if no symptoms are reproduced in a stability test
hold for 10 secs like stress test
if a pt reports pain and /or laxity during a stability test, what happens next
retest with m activation, correct posture, closed packed position or external support
after retesting a pt for a stability test, they report improved pain and/or laxity, what does this indicate
confirmation of a hypermobile joint with instability and a better prognosis
what is a muscle length test
a special test testing the passive flexibility of muscles
what is an anthropometric test
a special test testing body dimensions with a tape measure
what is MMT and how do you perform it
attempting specific m testing and grading
midrange muscle test
what does a fully lengthened muscle correlate to in strength testing
passive insufficiency
tightens inert component of muscle
tests for muscle tears with minimal force
what does a midrange lengthened muscle correlate to in strength testing
muscle in strongest position
full strength power
what does a fully shortened muscle correlate to in strength testing
muscle in weakest point
used to detect palsies, especially an eccentric contraction
why hold a MMT for 3 secs and what are we looking for
better assess neuromuscular adaptation capacity and not maximal strength
smooth, exponential increase to linear force
what are the cons to MMT
not good at finding smaller deficits
not reliable or valid
subjective to scoring
overestimate strength
can not predict function
very objective
what are the differences between resisted testing and MMT
resisted testing is testing a group of muscle where as MMT is testing a specific muscle for function
what can we assess with palpation
temperature
turgor and possible pain
swelling
muscle function
hypertonicity of a msucle
what might be indicated by the presence of a red flag
a severe condition that is not appropriate for physical therapy
how is an end feel described
PROM with overpressure
A patient presents directly to an outpatient physical therapy clinic without seeing a physician and with a gradual onset of multiple segment weaknesses and multiple segments with decreased sensation. What should be your next action?
refer pt to physician
These findings indicate an upper motor neuron lesion (brain/spinal cord), is inappropriate for out-patient physical therapy and should be referred for differential diagnosis.
if statistics are high, indicates a special test is better at ruling in a condition if the test is positive?
specificity
