Extremities Course Introduction & Basic Principles Flashcards
During which of the 6 basic steps of the physiotherapeutic process do you begin to form a hypothesis?
Step 2: History-taking
List the 6 fundamental steps of the whole physiotherapeutic process
- Screening
- History-taking (including forming a hypothesis)
- Basic Assessment (Observation/Posture Analysis, Functional Assessment, Range of Motion, Manual Muscle Testing)
- Special Testing (including Clinimetrics)
- Treatment
- Re-Assessment to evaluate the treatment
What is the first of the 6 steps of the physiotherapeutic process?
Screening
What is the second of the 6 steps of the physiotherapeutic process?
History-taking (including formation of a hypothesis)
What is the third of the 6 steps of the physiotherapeutic process?
Basic Assessment (Observation/Posture Analysis, Functional Assessment, Range of Motion, Manual Muscle Testing)
What is the fourth of the 6 steps of the physiotherapeutic process?
Special Testing (including Clinimetrics)
What is the fifth of the 6 steps of the physiotherapeutic process?
Treatment
What is the last of the 6 steps of the physiotherapeutic process?
Re-Assessment to evaluate the treatment
What are 4 components that make up the Basic Assessment stage of the physiotherapeutic process?
- Observation/Posture Analysis
- Functional Assessment
- Range of Motion
- Manual Muscle Testing
True or False: During the Screening stage of the physiotherapeutic process, it’s better to ask closed-ended, “yes”/”no” questions.
True
What is the purpose of the Screening stage of the physiotherapeutic process?
to look for patterns that might show a severe pathology that falls outside of the physical therapy scope of practice and/or requires urgent referral to a physician (a.k.a “Red Flags”)
What are the 7 steps of a good, thorough screening process?
- Health-Seeking Question
- General Red Flags
- Specific Red Flags
- Tract Anamnesis
- Normal or Abnormal Course?
- Is the Pain Mechanical / Movement-Dependent?
- Your Conclusion
What is meant by a “health-seeking question” in the physiotherapy screening process?
the patient is asked to briefly (in a few sentences) sum up why they are seeking your help
What is the first of the 7 steps of a good, thorough screening process?
determining the patient’s health-seeking question
What is the second of the 7 steps of a good, thorough screening process?
look for the presence of general red flags
What is the third of the 7 steps of a good, thorough screening process?
look for the presence of specific red flags
What is the fourth of the 7 steps of a good, thorough screening process?
determine if symptoms might be due to tract anamnesis
What is the fifth of the 7 steps of a good, thorough screening process?
determine if this condition is following a normal or abnormal course
What is the sixth of the 7 steps of a good, thorough screening process?
determine if the symptoms are mechanical / movement-related
What is the last of the 7 steps of a good, thorough screening process?
your conclusion that the person is or is not appropriate for physiotherapy treatment and/or referral to a physician
What are 11 questions to detect the presence of general red flags during the screening process?
- Do you feel generally unwell at the moment?
- Have you recently had an unexplained fever? (~2 weeks?)
- Have you lost more than 10lbs in the past 2 weeks?
- Have you ever had cancer?
- Have you ever used corticosteroids for a prolonged period? (e.g. prednisone, cortisone)
- Have you experienced physical trauma that led to your symptoms?
- Do you have pain at night?
- Do you experience widespread changes in sensation in your arms or legs?
- Do you experience dizziness?
- Do you experience problems with balance?
- Do you experience problems with vision?
Why, while screening for general red flags during a thorough screening process, should you ask the person if they feel generally unwell at the moment?
general malaise can indicate chronic inflammation, possibly due to infection or other systemic diseases
Why, while screening for general red flags during a good screening process, should you ask the person about recent unexplained fever?
this can indicate chronic inflammation, possibly due to infection or other systemic diseases
Why, while screening for general red flags during a thorough screening process, should you ask the person if they’ve lost more than 10 lbs in the past 2 weeks?
a tumor can consume a high amount of energy in order to sustain its growth, so people with cancer can lose weight quickly and unexpectedly
Why, while screening for general red flags during a thorough screening process, should you ask the person if they’ve ever had cancer?
a history of cancer is the strongest predictor of future development of cancer
Why, while screening for general red flags during a thorough screening process, should you ask the person if they’ve ever used corticosteroids for a prolonged period?
prolonged use of medications like Cortisone or Prednisone weakens soft tissue structures and bone, which can make them more prone to fracture or ligamentous injuries
Why, while screening for general red flags during a thorough screening process, should you ask the person if they experienced any physical trauma?
mainly for screening for fracture risk
Why, while screening for general red flags during a thorough screening process, should you ask the person if they have pain at night?
- pain at rest indicates non-musculoskeletal pathology
- this is only concerning if they aren’t talking about a specific position that is uncomfortable (ex. sidelying on a painful hip or shoulder)
What 4 serious pathologies are you trying to detect during the General Red Flags stage of a good, thorough screening process?
- Cancer
- Infection
- Fracture
- Central Neurologic Problems
Why, while screening for general red flags during a thorough screening process, should you ask the person if they experience widespread sensation changes in their arms or legs?
central nervous system pathology can cause bilateral sensory changes in the extremities
While screening for General Red Flags during a good, thorough screening process, why should you ask the person if they experience dizziness?
central nervous system pathology can cause dizziness
Why, while screening for general red flags during a thorough screening process, should you ask the person if they have problems with balance?
central nervous system pathology can cause balance issues
Why, while screening for general red flags during a thorough screening process, should you ask the person if they have problems with vision?
central nervous system pathology can cause vision issues
What are 5 things that may be general red flags for cancer?
- cancer in the person’s past
- pain at night
- non-mechanical pain
- general discomfort/unease
- unexplained weight loss (more than 10 lbs in 2 weeks)
What are 5 things that may be general red flags for infection?
- night pain
- non-mechanical pain
- fever (greater than 100°)
- night sweating
- general discomfort/unease
What are 4 things that may be general red flags for a fracture?
- prolonged corticosteroid use (1 month or more, depending on the dose)
- trauma
- severe pain that does not reduce following the onset
- night pain
What are 4 things that may be general red flags for central nervous system pathology?
- widespread sensation changes in the arms or legs
- dizziness
- problems with balance
- problems with vision
There are several “tracts” - or systems of body parts and organs - that can cause peripheral symptoms. List 5 of the major tracts to consider when performing a good, thorough screening process.
- cardiovascular tract
- respiratory tract
- digestive tract
- urogenital tract
- locomotor tract
When screening for Tract Anamnesis, what are 4 areas of the body that may be painful due to issues in the cardiovascular tract?
ischemic heart problems can cause pain in the:
1. left shoulder
2. left arm
3. anterior neck
4. cervicothoracic spine
When screening for Tract Anamnesis, radiating medial arm pain can be caused by which underlying pathology? List 4 other signs/symptoms that may indicate this serious issue.
- A Pancoast Tumor (growth in the apex of the lung, above the 1st rib)
1. unusual coughing
2. changes in color, consistency, or blood in the phlegm/mucus
3. existing lung disease
4. shortness of breath / wheezing
What serious underlying condition should be screened for / ruled out if someone presents with radiating medial arm pain?
respiratory tract anamnesis, specifically a Pancoast Tumor
Unusual coughing, changes in the color/consistency of mucus, existing lung disease, and/or shortness of breath/wheezing are all red flags for which serious underlying pathology? How might this condition present similarly to a musculoskeletal issue?
- a Pancoast Tumor (growth in the apex of the lung, above the 1st rib)
- Pancoast tumors can present clinically as radiating medial arm pain
When screening for Tract Anamnesis, what are 2 organs of the digestive tract can cause low back and/or groin pain?
- the appendix
- the small intestine
When screening for Tract Anamnesis, what are 4 organs of the digestive tract can cause shoulder pain?
- the liver
- the gallbladder
- the pancreas
- the spleen
When screening for Tract Anamnesis, which organ of the urogenital tract can cause low back or groin pain?
- the kidney(s)
When screening for Tract Anamnesis, what are two rheumatic diseases of the locomotor tract can cause multiple different symptoms that mimic musculoskeletal pain?
- ankylosing spondylitis
- rheumatoid arthritis
When screening for tract anamnesis, pain in which 3 body parts might indicate screening for digestive tract pathology? List 5 things you should ask about during screening.
- low back pain
- groin pain
- shoulder pain
- stomach aches
- food intolerances
- nausea
- bowel movements
- pain after eating
List 4 organs/tissues that are innervated by the Phrenic Nerve (C3-C5) and can therefore cause referred shoulder pain
- the liver
- the diaphragm
- the pericardium
- the gallbladder
List 4 organs/tissues that are innervated by the Phrenic Nerve (C3-C5) and can therefore cause referred neck pain
- the liver
- the diaphragm
- the pericardium
- the gallbladder
Which nerve innervates the liver and can therefore cause referred shoulder pain? Which 3 nerve root levels contribute to this nerve?
Right phrenic nerve (C3-C5)
Which nerve innervates the liver and can therefore cause referred neck pain? Which 3 nerve root levels contribute to this nerve?
Right phrenic nerve (C3-C5)
Which nerve innervates the diaphragm and can therefore cause referred shoulder pain? Which 3 nerve root levels contribute to this nerve?
Phrenic nerves (C3-C5)
Which nerve innervates the diaphragm and can therefore cause referred neck pain? Which 3 nerve root levels contribute to this nerve?
Phrenic nerves (C3-C5)
Which nerve innervates the pericardium and can therefore cause referred shoulder pain? Which 3 nerve root levels contribute to this nerve?
Phrenic nerves (C3-C5)
Which nerve innervates the pericardium and can therefore cause referred neck pain? Which 3 nerve root levels contribute to this nerve?
Phrenic nerve (C3-C5)
Which nerve innervates the gallbladder and can therefore cause referred neck pain? Which 3 nerve root levels contribute to this nerve?
Right phrenic nerve (C3-C5)
Which nerve innervates the gallbladder and can therefore cause referred neck pain? Which 3 nerve root levels contribute to this nerve?
Right phrenic nerve (C3-C5)
The gallbladder shares afferent innervation (Phrenic nerve) with which 2 body parts?
- the right shoulder
- the right neck
The liver shares afferent innervation (Phrenic nerve) with which 2 body parts?
- the right shoulder
- the right neck
The diaphragm shares afferent innervation (Phrenic nerve) with which 2 body parts?
- the shoulders
- the neck
The pericardium shares afferent innervation (Phrenic nerve) with which 2 body parts?
- the left shoulder/arm
- the neck
Which 2 organs/tissues are innervated by the Greater Splanchnic Nerve (T6-T9) and can therefore cause referred scapular pain?
- the stomach
- the pancreas
Which 2 organs/tissues are innervated by the Greater Splanchnic Nerve (T6-T9) and can therefore cause referred mid-back pain?
- the stomach
- the pancreas
Which nerve innervates the stomach and can therefore cause referred mid-back pain? Which 4 nerve root levels contribute to this nerve?
Greater Splanchnic Nerve (T6-T9)
Which nerve innervates the stomach and can therefore cause referred scapular pain? Which 4 nerve root levels contribute to this nerve?
Greater Splanchnic Nerve (T6-T9)
Which nerve innervates the pancreas and can therefore cause referred mid-back pain? Which 4 nerve root levels contribute to this nerve?
Greater Splanchnic Nerve (T6-T9)
Which nerve innervates the pancreas and can therefore cause referred scapular pain? Which 4 nerve root levels contribute to this nerve?
Greater splanchnic nerve (T6-T9)
The stomach shares afferent innervation (Greater splanchnic nerve) with which 2 body parts?
- the mid-back
- the scapular region
The pancreas shares afferent innervation (Greater splanchnic nerve) with which 2 body parts?
- the mid-back
- the left scapula
Which 2 organs/tissues are innervated by the Lesser Splanchnic Nerve (T10-T11) and can therefore cause referred mid-back pain?
- the small intestine
- the appendix
Which nerve innervates the small intestine and can therefore cause referred mid-back pain? Which 2 nerve root levels contribute to this nerve?
Lesser Splanchnic Nerve (T10-T11)
Which nerve innervates the appendix and can therefore cause referred mid-back pain? Which 2 nerve root levels contribute to this nerve?
the Lesser splanchnic nerve (T10-T11)
The small intestine shares afferent innervation (Lesser splanchnic nerve) with which part of the body?
the mid-back
The appendix shares afferent innervation (Lesser splanchnic nerve) with which part of the body?
the right mid-back
Which organ is innervated by the Lesser and Lumbar splanchnic nerves (T10-L3) and can therefore cause referred pelvis pain?
the Colon
Which organ is innervated by the Lesser and Lumbar splanchnic nerves (T10-L3) and can therefore cause referred low back pain?
the Colon
Which 2 nerves innervate the colon and can therefore cause referred pelvis pain? Which 5 nerve root levels contribute to these nerve?
Lesser splanchnic & Lumbar splanchnic nerves (T10-T11 & L1-L3)
Which 2 nerves innervate the colon and can therefore cause referred low back pain? Which 6 nerve root levels contribute to these nerves?
Lesser splanchnic & Lumbar splanchnic nerves (T10-L3)
The colon shares afferent innervation (Lesser & Lumbar splanchnic nerves) with which 2 parts of the body?
- the pelvis
- the low back
Which 2 organs/tissues are innervated by the Pelvic splanchnic nerves (S2-S4) and can therefore cause referred pelvis pain
- the sigmoid colon
- pelvic viscera
Which 2 organs/tissues are innervated by the Pelvic splanchnic nerves (S2-S4) and can therefore cause referred low back pain
- the sigmoid colon
- pelvic viscera
Which 2 organs/tissues are innervated by the Pelvic splanchnic nerves (S2-S4) and can therefore cause referred sacrum pain
- the sigmoid colon
- pelvic viscera
Which nerves innervate the sigmoid colon and can therefore cause referred pelvis pain? Which 3 nerve root levels contribute to these nerves?
the Pelvic splanchnic nerves (S2-S4)
Which nerves innervate the sigmoid colon and can therefore cause referred low back pain? Which 3 nerve root levels contribute to these nerves?
the Pelvic splanchnic nerves (S2-S4)
Which nerves innervate the sigmoid colon and can therefore cause referred sacrum pain? Which 3 nerve root levels contribute to these nerves?
the Pelvic splanchnic nerves (S2-S4)
Which nerves innervate the pelvic viscera and can therefore cause referred pelvis pain? Which 3 nerve root levels contribute to these nerves?
the Pelvic splanchnic nerves (S2-S4)
Which nerves innervate the pelvic viscera and can therefore cause referred sacrum pain? Which 3 nerve root levels contribute to these nerves?
the Pelvic splanchnic nerves (S2-S4)
The sigmoid colon shares afferent innervation (Pelvic splanchnic nerves) with which 3 parts of the body?
- the pelvis
- the low back
- the sacrum
The pelvic viscera share afferent innervation (Pelvic splanchnic nerves) with which 3 parts of the body?
- the pelvis
- the low back
- sacrum
Which organ is innervated by the Pudendal nerve (S2-S4) and can therefore cause referred low back pain?
the rectum
Which organ is innervated by the Pudendal nerve (S2-S4) and can therefore cause referred sacrum pain?
the rectum
Which organ is innervated by the Pudendal nerve (S2-S4) and can therefore cause referred gluteal pain?
the rectum
Which nerve innervates the Rectum and can therefore cause referred low back pain? Which 3 nerve root levels contribute to this nerve?
the Pudendal nerve (S2-S4)
Which nerve innervates the Rectum and can therefore cause referred sacrum pain? Which 3 nerve root levels contribute to this nerve?
the Pudendal nerve (S2-S4)
Which nerve innervates the Rectum and can therefore cause referred gluteal pain? Which 3 nerve root levels contribute to this nerve?
the Pudendal nerve (S2-S4)
The rectum shares afferent innervation (Pudendal nerve) with which 3 parts of the body?
(usually left-sided)
1. the low back
2. the sacrum
3. the gluteal areas
Which 2 organs/tissues are innervated by the Lesser, Lumbar, and Pelvic Splanchnic nerves (T10-S4) and can therefore cause referred low back pain?
- the ureters
- the testes
Which 2 organs/tissues are innervated by the Lesser, Lumbar, and Pelvic Splanchnic nerves (T10-S4) and can therefore cause referred upper thigh pain?
- the ureters
- the testes
Which organ/tissue is innervated by the Lesser, Lumbar, and Pelvic Splanchnic nerves (T10-S4) and can therefore cause referred genital pain?
the ureters
Which organ/tissue is innervated by the Lesser, Lumbar, and Pelvic Splanchnic nerves (T10-S4) and can therefore cause referred sacrum pain?
the testes
Which 3 nerves innervate the ureters and can therefore cause referred low back pain? Which 12 nerve root levels contribute to this nerve?
the Lesser splanchnic, Lumbar splanchnic, and Pelvic splanchnic nerves (T10-S4)
Which 3 nerves innervate the ureters and can therefore cause referred upper thigh pain? Which 12 nerve root levels contribute to these nerves?
the Lesser splanchnic, Lumbar splanchnic, and Pelvic splanchnic nerves (T10-S4)
Which 3 nerves innervate the ureters and can therefore cause referred genital pain? Which 12 nerve root levels contribute to this nerve?
the Lesser splanchnic, Lumbar splanchnic, and Pelvic splanchnic nerves (T10-S4)
Which 3 nerves innervate the testes and can therefore cause referred low back pain? Which 12 nerve root levels contribute to this nerve?
the Lesser splanchnic, Lumbar splanchnic, and Pelvic splanchnic nerves (T10-S4)
Which 3 nerves innervate the testes and can therefore cause referred sacrum pain? Which 12 nerve root levels contribute to this nerve?
the Lesser splanchnic, Lumbar splanchnic, and Pelvic splanchnic nerves (T10-S4)
The ureters share afferent innervation (Lesser, Lumbar, and Pelvic Splanchnic nerves) with which 3 areas of the body?
- the low back
- the upper thigh
- the genitalia
The testes share afferent innervation (Lesser, Lumbar, and Pelvic Splanchnic nerves) with which 2 areas of the body?
- the low back
- the sacrum
During the 5th stage of a good, thorough screening process, ask yourself: “Is this person’s pain following a normal course?”. As a general rule of thumb, nearly musculoskeletal all injuries heal within how many weeks?
12 weeks (or around 3 months)
During the 5th stage of a good, thorough screening process, ask yourself: “Is this person’s pain following a normal course?”. Within 12 weeks (or around 3 months) of most injuries, what 2 changes in the person’s recovery would you expect to see?
during that time frame, we should expect to see
- pain decrease
- activity levels increase
For most injuries, decreased pain and increased activity levels should occur within the first 12 weeks (or about 3 months). If not, what should next be explored?
What are the negative prognostic factors that have delayed / prevented recovery?
During the 5th stage of a good, thorough screening process, what might be considered a red flag?
If pain and activity levels don’t improve within 3 months (for most injuries) & there are also no significant negative prognostic factors present
(rare cases)
During the 6th stage of a good, thorough screening process, what is meant by calling pain “movement-dependent”
the person’s complaint can be aggravated or eased by movement and/or repositioning
During the 6th stage of a good, thorough screening process, “non-mechanical” pain is common in which 2 pathologies?
- infection
- cancer
Infection and cancer commonly cause “non-mechanical” pain that is constant. Musculoskeletal pain can also be constant. When differentiating between the two during a good, thorough screening process, what might be a way to tell the difference?
Even if that person’s musculoskeletal pain is constant, there should be certain movements that clearly aggravate or at least reduce their pain.
Define “non-mechanical” pain
pain with an absence of a movement-dependent component
During the 7th and final stage of a good, thorough screening process, it can be helpful to perform what mental exercise before proceeding?
Summarize your findings from the first 6 stages
During the 7th and final stage of a good, thorough screening process, what is the fundamental question that you are trying to answer?
“Is this person appropriate for me to treat?”
If you conclude your good, thorough screening process and the person is appropriate for you to treat, what next step should you take?
start History-taking
If you conclude your good, thorough screening process that there are multiple different red flags, what next step should you take?
perform orthopaedic or neurologic screening tests to investigate specific red flags further
During the second of the 6 steps of the physiotherapeutic process, the patient’s history is taken. What are 3 general goals of this step?
- form a hypothesis about the person’s pathology
- identify what the person’s impairments are
- identify what negative prognostic factors that physiotherapy can influence
What tool does Physiotutors recommend to help guide your history-taking process?
the Rehabilitation Problem-Solving (RPS) Form
During the patient history-taking stage of the physiotherapeutic process, what are the first 2 general questions that you want to ask?
- What happened to cause their issue?
- What do they want to regain from physiotherapy treatment?
During the patient history-taking stage of the physiotherapeutic process, what is the primary reason that you should have the patient elaborate on the mechanism of injury?
you want to be able to picture which structures might be affected
During the patient history-taking stage of the physiotherapeutic process, it’s important to ask about signs of local inflammation. List 5 things to ask about specific to the affected body part.
- redness
- swelling
- warmth
- pain
- impairment in function
During the patient history-taking stage of the physiotherapeutic process, you might ask the person to choose and rate at least 3 specific activities that are difficult or problematic due to their complaint. How do you know whether or not the activity should be considered an activity vs a participation impairment?
if an impaired activity has a social component, it is considered a participation impairment
During the patient history-taking stage of the physiotherapeutic process, what are 2 important reasons to ask about a patient’s current medications?
Medications can give you an idea of
- comorbidities that might affect your treatment process
- the person’s coping skills/strategies for dealing with their condition
During the patient history-taking stage of the physiotherapeutic process, you’re looking for both personal and environmental factors that might affect the treatment process. Explain the difference between the two & give a few examples of each.
- personal factors: inside of us; can’t be taken away (marital status, coping strategy, stress)
- environmental factors: outside of us; may have a good or bad influence on rehab (single-point cane, 3rd floor apartment with elevator)
During the patient history-taking stage of the physiotherapeutic process, you should always ask about body functions, activities, participation, current medications, and personal/environmental factors around their complaint. List 3 other general things outside of their specific complaint that you should probably have information on.
- any earlier pathologies
- any earlier injuries
- any co-morbidities
During the patient history-taking stage of the physiotherapeutic process, there are several pain-specific questions that you should ask to help you form your diagnosis. List 8 particular aspects of someone’s pain that can give you valuable information and guide your hypothesis formation.
- quality of pain (stabbing, throbbing, dull, fatigue, tensioning, burning, aching)
- location (clearly limited / focal, diffuse, radiating)
- timing of pain (24-hour behavior, on-and-off phases, how sx have behaved since onset)
- onset of pain (increased training, workload, or cognitive/emotional stress; lifestyle changes)
- intensity (severity at worst, best, and average)
- behavior / “relation” (aggs/eases)
- duration (brief, long, subchronical)
- medications that may or may not help (NSAIDs, antieplieptics, antidepressants)
During the patient history-taking stage of the physiotherapeutic process, you should ask pain-specific questions. Give 7 examples of pain “qualities” that may help you form your hypothesis. Which pain types are most often associated with these qualities?
- stabbing (mechanical nociceptive)
- pulsing/throbbing (inflammatory nociceptive)
- dull (inflammatory nociceptive)
- fatigue (ischemic nociceptive)
- tensioning (ischemic nociceptive)
- burning (peripheral neurogenic)
- aching/”toothache” (peripheral neurogenic)
During the patient history-taking stage of the physiotherapeutic process, you should ask pain-specific questions. List 3 different ways that patients may describe the location of their symptoms and give examples of some types of pain associated with them.
- focal / clearly limited (mechanical nociceptive and peripheral neurogenic pain)
- diffuse (central nervous system pain, output - sympathetic nervous system pain)
- radiating (peripheral neurogenic pain)
During the patient history-taking stage of the physiotherapeutic process, you should ask pain-specific questions, including the initial onset of their pain. What are 4 common changes in a person’s life that may be associated with the initial onset of pain?
- increased training
- increased workload
- increased cognitive/emotional stress
- lifestyle changes
During the patient history-taking stage of the physiotherapeutic process, you should ask pain-specific questions. Which 3 aspects of pain intensity/severity should you know to help form your hypothesis?
pain at worst, best, and on average
During the patient history-taking stage of the physiotherapeutic process, you should ask pain-specific questions.
What is meant by the “behavior” of pain?
what improves the pain & which movements or activities aggravate it?
During the patient history-taking stage of the physiotherapeutic process, you should ask pain-specific questions. What are 3 different durations of pain that someone might describe, and which pain types are most closely associated with each?
- brief (mechanical nociceptive, inflammatory nociceptive pain)
- subchronical / repeats over a relatively short period (peripheral neurogenic pain)
- long (ischemic nociceptive, central nervous system, output - sympathetic nervous system pain)
During the patient history-taking stage of the physiotherapeutic process, you should ask pain-specific questions. Which medications have or have not reduced pain can help guide your hypothesis. List 3 types of pain medication and give examples of types of pain that are improved by each.
- anti-inflammatories (maybe somewhat for mechanical & ischemic nociceptive pain, but most effective for inflammatory nociceptive pain)
- antiepileptics (peripheral neurogenic & central nervous system pain)
- antidepressants (central nervous system pain)
During the patient history-taking stage of the physiotherapeutic process, you should ask pain-specific questions. List 3 aspects of the timing of pain that can guide your hypothesis.
- 24-hour behavior
- on-and-off phases
- how sx have behaved since onset
During the patient history-taking stage of the physiotherapeutic process, the person may describe a subchronical duration of their pain. Describe what is meant by “subchronical”.
pain that is episodic or that repeats over a relatively short period of time (6 weeks to 3 months)
During the patient history-taking stage of the physiotherapeutic process, it’s very important to try to categorize someone’s pain, but very difficult. List the 6 different pain mechanisms described by Physiotutors.
- Mechanical Nociceptive
- Inflammatory Nociceptive
- Ischemic Nociceptive
- Peripheral Neurogenic
- Central
- Output - Sympathetic Nervous System
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 2 of the most common characteristics associated with the quality of Mechanical Nociceptive pain
- stabbing
- focal / localized to one area
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 2 of the most common characteristics associated with the quality of Inflammatory Nociceptive pain
- pulsating/throbbing
- dull
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 of the most common characteristics associated with the quality of Ischemic Nociceptive pain
- fatigue
- tensioning
- feeling of “breaking” or “pulling” apart
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 of the most common qualities of Peripheral Neurogenic pain
- burning
- radiating
- aching (“toothache”)
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 5 common qualities of Central Nervous System pain
- diffuse pain
- changes location / behavior (“does what it wants”, “has a mind of its own”)
- Multiple locations (“Everything hurts”)
- extensive pain (spread over large area)
- “mirror” pain (bilateral)
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 of the most common qualities of Output - Sympathetic Nervous System pain
- swelling (or the sensation of swelling)
- sweating
- hot/cold sensations
(trophic changes)
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is associated with qualities such as stabbing, focal pain that is clearly limited to one area?
Mechanical Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is associated with pulsating, throbbing, and/or dull qualities?
Inflammatory Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is associated with the qualities of fatigue and tensioning?
Ischemic Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is associated with the qualities of burning, radiating, or a “toothache” that is limited to a specific area?
Peripheral Neurogenic pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type is associated with the qualities of diffuse/extensive pain that “has a mind of its own”? What other qualitative phenomenon may also occur with this type of pain?
- Central Nervous System pain (Nociplastic)
- Mirror pain (pain occurs in the same location contralaterally)
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is associated with trophic changes like swelling, sweating, and hot/cold sensations?
Output - Sympathetic Nervous System pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 behaviors most commonly associated with Mechanical Nociceptive pain
- clear, on/off behavior
- occurs with certain movements
- rest improves pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 behaviors most commonly associated with Inflammatory Nociceptive pain
- pain at rest
- pain at night
- careful movement / avoidance behaviors
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 behaviors most commonly associated with Ischemic Nociceptive pain
- posture-dependent
- worse with sustained positions
- improved with movement
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 behaviors most commonly associated with Central Nervous System pain
- unpredictable
- possibly dependent on stress/emotional state
- changes day-to-day
Physiotutors describes multiple different types of pain mechanisms and their attributes. List the pain behavior most commonly associated with Output - Sympathetic Nervous System pain
pain may be connected to stress / emotional state
Physiotutors describes multiple different types of pain mechanisms and their attributes. List the 2 types of pain that generally have a relatively short duration
- Mechanical Nociceptive pain
- Inflammatory Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. List the 3 types of pain that generally have a longer duration
- Ischemic Nociceptive pain
- Central Nervous System pain
- Output - Sympathetic Nervous System pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain generally presents as “subchronical” pain that repeats over relatively short periods (6-12 weeks)
Peripheral Neurogenic
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the duration of Mechanical Nociceptive pain?
usually a shorter duration of symptoms
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the duration of Inflammatory Nociceptive pain?
usually a shorter duration of symptoms
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the duration of Ischemic Nociceptive pain?
longer duration of symptoms
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the duration of Peripheral Neurogenic pain?
episodic / “subchronical” (repeating over a relatively short period of time)
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the duration of Central Nervous System pain?
longer duration of pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the duration of Output - Sympathetic Nervous System pain?
longer duration of pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the relationship between medication and Mechanical Nociceptive pain?
medication isn’t always very effective in reducing pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the relationship between medication and Inflammatory Nociceptive pain?
NSAIDs tend to help
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the relationship between medication and Ischemic Nociceptive pain?
medications don’t tend to help very much
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the relationship between medication and Peripheral Neurogenic pain?
CNS-inhibiting medications such as anti-epileptics (Gabapentin) reduce pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the relationship between medication and Central Nervous System pain?
CNS-inhibiting medications such as anti-epileptics (Gabapentin) as well as anti-depressants reduce pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the relationship between medication and Output - Sympathetic Nervous System pain?
hardly any influence on pain (Calcitonin was taken off the market due to cancer risk)
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what 2 types of pain have the best prognosis for rehabilitation?
- Mechanical Nociceptive pain
- Inflammatory Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. What type of pain has a generally good prognosis if the person is able to address their movement/postural habits?
Ischemic Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what type of pain has a good, but months-long, prognosis for rehabilitation?
Peripheral Neurogenic pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what 2 types of pain have the worst prognosis for rehabilitation?
- Central Nervous System pain
- Output - Sympathetic Nervous System pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the prognosis for rehabilitating Mechanical Nociceptive pain?
generally good
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the prognosis for rehabilitating Inflammatory Nociceptive pain?
generally good
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the prognosis for rehabilitating Ischemic Nociceptive pain?
generally good, but requires habit changes
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the prognosis for rehabilitating Peripheral Neurogenic pain?
generally good, though it may take months
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the prognosis for rehabilitating Central Nervous System pain?
generally bad, especially if the “cause” is not identified
Physiotutors describes multiple different types of pain mechanisms and their attributes. Generally, what is the prognosis for rehabilitating Output - Sympathetic Nervous System pain
generally bad, especially if the “cause” is not identified
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain should be treated with manual therapy?
Mechanical Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain should be treated with medication, immobilization, physiotherapy, and/or load removal?
Inflammatory Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain should be treated by identifying causal factors / postural habits?
Ischemic Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain should be treated with decompression and neurodynamic mobilization?
Peripheral Neurogenic pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain should be treated with education, information, addressing cognitive-affective components, and multi-professional rehab?
Central Nervous System pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain should be treated with relaxation/breathing exercises, thoracic mobilization, stress management, and lymphatic drainage?
Output - Sympathetic Nervous System pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 2 of the best treatment approaches for Mechanical Nociceptive pain
- mechanical treatment (increase ROM & strengthen)
- manual therapy
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 4 treatments for Inflammatory Nociceptive pain
- medications
- immobilization
- physiotherapy/exercise
- load reduction/removal
Physiotutors describes multiple different types of pain mechanisms and their attributes. What is the primary treatment for Ischemic Nociceptive pain?
identifying causal factors / postural habits
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 2 treatments for Peripheral Neurogenic pain
- decompression
- neurodynamic mobilization
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 treatments for Central Nervous System pain.
- patient education/information
- identifying cognitive-affective components
- multi-professional rehab
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 4 treatments for Output - Sympathetic Nervous System pain
- relaxation/breathing exercises
- stress management
- thoracic mobilization
- lymphatic drainage
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain would be most likely to occur due to a restriction in joint motion?
Mechanical Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain would be most likely to occur due to trauma or tendonitis?
Inflammatory Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain would be most likely to occur due to ergonomics or hypermobility?
Ischemic Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain would be most likely to occur due to carpal tunnel syndrome, thoracic outlet syndrome, radiculopathy, or piriformis syndrome?
Peripheral Neurogenic pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain would be most likely to occur due to chronic low back pain or whiplash disorder?
Central Nervous System pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain would be most likely to occur due to chronic regional pain syndrome, T4 Syndrome, and possibly lateral epicondylalgia?
Output - Sympathetic Nervous System pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 2 of the most common injuries/conditions associated with Inflammatory Nociceptive pain
- trauma
- tendonitis
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 2 of the most common injuries/conditions associated with Ischemic Nociceptive pain
- posture
- hypermobility
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 4 examples of common injuries/conditions associated with Peripheral Neurogenic pain
- carpal tunnel syndrome
- thoracic outlet syndrome
- radiculopathies (cervical / lumbar)
- piriformis syndrome
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 3 examples of common injuries/conditions associated with Central Nervous System pain
- chronic low back pain
- whiplash-associated disorder
- fibromyalgia
(really, all chronic musculoskeletal complaints)
Physiotutors describes multiple different types of pain mechanisms and their attributes. List 2 examples of common injuries/conditions associated with Output - Sympathetic Nervous System pain. What additional condition may also be associated with a similar mechanism?
- chronic regional pain syndrome
- T4 syndrome
- possibly lateral epicondylalgia
Physiotutors describes multiple different types of pain mechanisms and their attributes. What type of pain is caused by hip osetoarthritis?
Mechanical Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is caused by systemic diseases like Bechterew’s Disease (Ankylosing Spondylitis)?
Inflammatory Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is caused by arteriosclerosis and/or peripheral artery disease (PAD)?
Ischemic Nociceptive pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is caused by polyneuropathies and/or amputations?
Peripheral neurogenic pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is caused by chronic functional problems of the inner organs?
Central Nervous System pain
Physiotutors describes multiple different types of pain mechanisms and their attributes. Which type of pain is most closely associated with burnout / chronic fatigue syndrome?
Output - Sympathetic Nervous System pain
During the second of the 6 steps of the physiotherapeutic process, the patient’s history is taken and hypotheses are formed. What are the 2 types of hypotheses that should be considered?
- a hypothesis of the person’s pathology
- a hypothesis of the person’s impairments that are negatively impacting their recovery
During the second of the 6 steps of the physiotherapeutic process, the patient’s history is taken and hypotheses are formed. Why is it important to distinguish between hypotheses about pathology vs those about impairments?
While it’s important to try to establish a hypothesis about the pathology (e.g. diagnosis), it’s important to realize that it’s very often not treatable.
This is why we as physios pay more attention to the impairments (on ICF level) that focus on things like pain, ROM, mobility, strength, endurance, and coordination that ARE treatable by physiotherapy.
What does ICD stand for and how does this relate to hypothesis formation during the second of the 6 steps of the physiotherapeutic process?
International Classification of Disease
ICD is a system for coding disease, illness, and injury. It pertains to a specific diagnosis or a musculoskeletal pathology or condition. (often not directly treatable by a physiotherapist)
What does ICF stand for and how does this relate to hypothesis formation during the second of the 6 steps of the physiotherapeutic process?
International Classification of Functioning, Disability, and Health
Forming hypotheses about impairments (rather than pathology) allows us to focus on things like pain, ROM, mobility, strength, endurance, and coordination, which negatively impact the ability to recover. (and are directly treatable with physiotherapy)
During the second of the 6 steps of the physiotherapeutic process, the patient’s history is taken and hypotheses about impairments are formed (ICF). In addition to factors such as pain, ROM, mobility, strength, endurance, and coordination, what are 2 other factors that are also described and classified by the ICF?
- environmental factors
- personal factors
During the physiotherapeutic process, what is the goal of the physical assessment as it relates to your hypothesis formation?
the goal of the physical assessment is to confirm (or reject) your hypothesis(es)
if your hypothesis is rejected, move to your next likely hypothesis
Form and describe 4 hypotheses about the following case example:
A person has limited active knee extension due to an ACL tear. They experience severe limitations in ADLs and participation and suffers from a fear of movement as a result. Give examples of tools that might be associated with each one.
- ACL tear (ICD)
- test: Lachman test - limited active knee extension ROM (ICF)
- tool: goniometer - severe limitations in ADLs and participation (ICF)
- tool: Knee Injury and Osteoarthritis and Outcome Score (KOOS) - fear of movement (ICF)
- tool: Tampa Scale of Kinesiophobia
Roughly, how long can Lateral Epicondylalgia (Tennis Elbow) last?
anywhere from 6 - 18 months (about 90% of people achieve resolution of symptoms)
Roughly, how long can Plantar Heel Pain last?
13-24 months on average
Roughly, how long can Patellofemoral Pain last?
2-8 years (half of people never experience complete resolution of symptoms; no longer considered self-limiting)
Roughly, how long can Frozen Shoulder last?
1-3.5 years, with an average of 2.5 years (mild to moderate pain and/or disability may still persist)
Roughly, how long can Cervical Radiculopathy last?
substantial improvement in 4-6 months, with 83% of people completely recovering within 2-3 years
Roughly, how long can Acute Low Back Pain last?
substantial improvement in pain and disability within 6 weeks, though improvement starts to slow (most people still have minimal, but still present, pain by 1 year)
Roughly, how long can Ankle Sprains last?
rapid improvement in pain by 2 weeks, but many continue to have pain, recurrent sprains, and/or instability in the following 1-4 years
Roughly, how long can Acute Neck Pain / Whiplash-Associated Disorder last?
about half of people will experience decreased pain and disability by 6 weeks, but anywhere from 50%-80% of people will still have some level of symptoms 1 year later
Roughly, how long can Achilles Tendinopathy last?
3-12 months (most patients recover, but 23%-37% of people will still have symptoms at 10 years)
most of the improvement comes within the first year, which means that we shouldn’t take a wait-and-see approach
Roughly, how long can Patellar Tendinopathy last?
6+ months (progress is slow and can often take longer)
Roughly, how long can Rotator Cuff Related Shoulder Pain last?
half of people will recover within 6 months, but progress often plateaus within the first year (30% of people experience some level of symptoms by 1 year)
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and wide-spread pain, specifically?
there is a strong association between wide-spread pain and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and high disability, specifically?
there is a strong association between high disability and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and somatization, specifically?
there is a strong association between somatization and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and high pain intensity/severity, specifically?
there is a moderately strong association between high pain intensity/severity and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and long pain duration, specifically?
there is a moderately strong association between long pain duration and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and depression, specifically?
there is a moderately strong association between depression and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and anxiety, specifically?
there is a moderately strong association between anxiety and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and previous pain episodes, specifically?
there is a weak association between previous pain episodes and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and poor coping strategies, specifically?
there is a weak association between poor coping strategies and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and movement restriction, specifically?
there is a weak association between movement restriction and poorer recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and level of education, specifically?
there is strong evidence showing no significant association between level of education and recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and use of pain medication, specifically?
there is moderately strong evidence showing no significant association between use of pain medication and recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and older age, specifically?
there is weak evidence showing no significant association between older age and recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and biological sex, specifically?
there is weak evidence showing no significant association between biological sex and recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and social support, specifically?
evidence is inconclusive about the association between someone’s social support and recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. What is the relationship (and degree of association) between recovery and heavy lifting, specifically?
evidence is inconclusive about the association between heavy lifting and recovery
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. List 3 prognostic factors that have strong evidence associating them with whether someone will recover from a musculoskeletal condition.
- the presence of wide-spread pain
- high levels of disability
- somatization
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. List 4 prognostic factors that have moderately strong evidence associating them with whether someone will recover from a musculoskeletal condition.
- high pain intensity/severity
- a long duration of pain (3+ months)
- depression
- anxiety
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. List 3 prognostic factors that have weak evidence associating them with whether someone will recover from a musculoskeletal condition.
- poor coping strategies
- previous episodes of pain
- movement restriction
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. List a prognostic factor that has strong evidence showing no significant association with whether someone will recover from a musculoskeletal condition.
level of education
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. List a prognostic factor that has moderate evidence showing no significant association with whether someone will recover from a musculoskeletal condition.
use of pain medication
Understanding generic prognostic factors is important when setting someone’s expectations and creating a plan of care. List 2 prognostic factors that have weak evidence showing no significant association with whether someone will recover from a musculoskeletal condition.
- older age
- female gender
During the third step of the physiotherapeutic process, you begin your basic physical assessment with your hypothesis(es) in mind. What is always the first part of your physical assessment? What is the goal of this part?
- Observation/posture analysis in standing
- the goal is to examine the person’s posture and compare bony landmarks (look for structural abnormalities that you might link to your patient’s complain)
During the third step of the physiotherapeutic process, you begin your basic physical assessment with your hypothesis(es) in mind. How should you prepare the patient in order to perform the typical observation/posture analysis in standing?
- in order to see specific landmarks, Physiotutors recommends asking the person to remove their shirt & shoes
- ask them to stand upright, looking straight ahead; relax the shoulders and leg the arms hang by the sides
During the third step of the physiotherapeutic process, you should first perform your observation/posture analysis in standing. From what 3 positions should you perform you observations?
- Frontal plane anterior
- Sagittal plane
- Front plane posterior
During the third step of the physiotherapeutic process, you should first perform your observation/posture analysis in standing. List 11 things you should look for when observing someone in the anterior frontal plane.
- is head rotated or leaning? (imagine a line from the tip of the nose to the chin to the manubrium of the sternum)
- compare the heights of the AC joints
- compare the angles of the clavicles
- compare the heights of the nipples
- compare the heights of the iliac crests
- compare the heights of the ASISs
- compare the spaces between the trunk and each arm
- compare arm length by observing the levels of the fingertips
- compare the apices of the patellae (inferior point)
- are the knees valgus or varus? (caved or bow-legged)
- compare the heights of the medial malleoli
During the third step of the physiotherapeutic process, you should first perform your observation/posture analysis in standing. List 7 things you should look for when observing someone in the sagittal plane.
- use the lateral plumb line to see if the head is positioned excessively anteriorly or posteriorly (line runs from earlobe through the humeral head)
- are the shoulders protracted or retracted?
- any abnormalities of the cervical lordosis?
- any abnormalities of the thoracic kyphosis?
- any abnormalities of the lumbar lordosis?
- is there about a 15° angle between the PSIS and ASIS? (PSIS is higher)
- are the knees hyper-extended?
During the third step of the physiotherapeutic process, you should first perform your observation/posture analysis in standing. List 12 things you should look for when observing someone in the posterior frontal plane.
- see if the head is rotated or leaning to one side
- look for scoliotic curvature of the spine (named after the convex side) - this may be an opportunity to check for McKenzie’s “lateral shift”
- compare the heights of the acromions
- compare the heights of the spines of the scapulae
- compare the heights of the inferior angles of the scapulae
- look to see if either medial border of the scapulae are raised from the spine/ribcage
- compare the heights of the iliac crests
- compare the heights of the PSISs
- compare the gluteal folds (optional)
- are the knees valgus or varus? (caved or bow-legged)
- compare the heights of the medial malleoli
- look to see the number of toes that are visible from behind (more than 2 toes or any asymmetries should be noted)
What is the Postural-Structural-Biomechanical (PSB) model of orthopaedic medicine? What are its limitations currently?
- things like deviations of posture from “normal”, body asymmetries, and pathomechanics are either predisposing and/or maintaining factors for musculoskeletal conditions
- a lot of these PSB factors haven’t been able to show an association with pain, nor shown to cause musculoskeletal pain in the first place
In 2009, Van Nieuwenhuyse et al investigated the relationship between physical exam findings and the development of low back pain over the following year in young healthcare or distribution workers (avg age 26). What did they find?
although obese people were more than twice as likely to develop low back pain, if someone had no low back pain during the physical exam, then the exam was “not useful to predict workers at risk for the development of low back disorders one year later”
In 2008, Christensen et al performed a systematic review of 54 studies investigating the relationship between sagittal spine curvatures (lordosis/kyphosis) and health (including spinal pain). What did the authors find?
- study quality was low, generally
- there was a moderate association between sagittal spinal curvatures and things like TMD, pelvic organ prolapse, daily function, and death (but “these associations are unlikely to be causal”)
- “evidence from epidemiological studies does not support an association between sagittal spinal curves and health, including spinal pain”
In 2005, Knutson et al performed a review of leg length discrepancy and it’s clinical significance. What did they conclude?
- on x-ray, 90% of people have a measurable leg length discrepancy
- the average leg length difference was about 5mm (1/4 thumb’s width)
- leg length difference doesn’t appear to be clinically relevant until about 2 cm (1 thumb’s width, or 3/4 inch)
- “anatomic leg length inequality is near universal, but the average magnitude is small and not likely to be clinically significant”
According to Knutson et al (2005), when is leg length discrepancy is likely to be more clinically relevant? What is one way of estimating this in the clinic?
- when there is at least 2 cm (3/4 inch) difference between the two legs
- this is about 1 thumb’s width
What is the Weber Barstow Maneuver? How is it performed?
- a technique for estimating leg length discrepancy
- have the patient lie in supine
- apply gentle traction to both legs
- palpate the inferior medial malleoli with your thumbs
- guide the patient’s legs into hooklying
- have the patient perform one repetition of a bridge, then relax
- straighten the legs and bring them together so that your thumbs are almost touching
- compare the heights of the malleoli using your thumbs
(the average person can have anywhere up to 1/2 a thumb’s difference - if there’s no overlap between thumbs, it may be more significant)
During the third step of the physiotherapeutic process, you perform your basic physical assessment with your hypothesis(es) in mind. What should follow your observation/postural assessment?
a functional assessment
During the third step of the physiotherapeutic process, you perform your basic physical assessment with your hypothesis(es) in mind. What is the general goal of performing a functional assessment, specifically?
to get a quick idea of which movements the person is having trouble with
During the third step of the physiotherapeutic process, a functional assessment is performed. How do you choose which movements to assess?
- the movements should already be familiar from history-taking
- it’s important to choose activities that are part of that person’s familiar routine / ADLs
During the third step of the physiotherapeutic process, a functional assessment is performed. Give 3 common examples of functional movements and the biomechanics that you’d investigate with each.
- walking (gait analysis)
- picking something up from the floor (forward bending, squatting)
- reaching overhead (shoulder flexion)
During the third step of the physiotherapeutic process, a functional assessment is performed. List 4 things that you should be looking for when the patient demonstrates the movement that they’re having trouble with.
- the quality of the movement
- pain and in what range of the movement
- how far they can go (AROM)
- how strong the movement is (and/or how stable are they)
During the third step of the physiotherapeutic process, a functional assessment is performed. The word “functional” is thrown around a lot. What are the definitions of the terms “functional” and “function”?
- functional: affecting bodily functions, but not structure; designed or developed chiefly from the point of view of use
- function: the natural or proper action of a bodily part in a living thing; the particular purpose for which a person or thing exists; any group of related actions contributing to a larger action
During the third step of the physiotherapeutic process, a functional assessment is performed. Physiotutors gives an example of watching someone stand from sitting. As the person stands up, what information can you get from watching their hips, knees, and ankles, respectively?
- hip joint: AROM (110° flexion to 0° extension), strength (glute max / hip extensor strength of at least 3/5)
- knee joint: AROM (100° flexion to 0° extension), strength (quads/knee extensors at least 3/5)
- ankle joint: AROM (~10° dorsiflexion to 0° plantarflexion), strength (gastroc-soleus/plantarflexors at least 3/5)
What clinical tool do Physiotutors recommend to use when performing a gait analysis
The Nijmegen (“nay-may-hun”) Gait Analysis form
According to the Nijmegen gait analysis form, what 6 areas of observation should you note while assessing someone’s walking gait?
- general movement
- the trunk
- the pelvis
- both hips
- both knees
- both ankles
According to the Nijmegen gait analysis form, what are the 11 items to be observed while assessing someone’s gait?
- shortened stance phase on either leg
- trunk position relative to hips
- trunk lateral flexion
- trunk stiffness / arm swing
- pelvis rotation
- hip extension
- knee extension
- knee flexion - absent?(“stiff knee”)
- knee flexion - reduced?
- knee extension absent in stance
- ankle plantarflexion in late stance
According to the Nijmegen gait analysis form, what is the first and most general item that should be assessed when observing someone’s walking?
is a shortened stance present on either leg?
According to the Nijmegen gait analysis form, what 3 things about the trunk should be assessed when observing someone’s walking?
- what is the trunk position relative to the hip? (should be above or just slightly anterior to the pelvis)
- is the trunk laterally flexed? (should only be slight flexion toward the stance leg)
- is arm swing reduced? (a way of assessing trunk rotation)
According to the Nijmegen gait analysis form, what about the pelvis should be assessed when observing someone’s walking?
is there any noticeable rotation of the pelvis? (normally, it only rotates 5° forward & backward, so you shouldn’t be able to see it)
According to the Nijmegen gait analysis form, what about the hip should be assessed when observing someone’s walking?
is hip extension reduced? (should be extended 10° by contralateral heel strike)
According to the Nijmegen gait analysis form, what 4 things about the knee should be assessed when observing someone’s walking?
- is knee extension in late swing reduced? (should be 0° by initial contact)
- is the knee flexion movement absent? (should flex to 25° when first weight-bearing)
- is the amount of knee flexion reduced? (less than 25°)
- is knee extension in stance reduced? (should be 0° in mid-stance)
According to the Nijmegen gait analysis form, what about the ankle should be assessed when observing someone’s walking?
is plantarflexion during late stance reduced? (should be 20° by contralateral initial contact)
What is the difference between step length and stride length?
- step: initial contact of one foot to initial contact of the other foot
- stride: initial contact of one foot to the initial contact of the same foot
(1 stride = 2 steps)
Define step length
the distance between the initial contact of one foot to the initial contact of the contralateral foot
Define stride length
the distance between the initial contact of one foot and the next initial contact of the same foot
(1 stride = 2 steps)
What are the two phases of the gait cycle? What percentage does each phase make up?
- Stance phase (60%)
- Swing phase (40%)
During the stance phase of the gait cycle, the foot is always in contact with the ground. List 3 tasks that the stance leg has to complete during this phase.
- accept the weight of the body
- move from absorbing impact to propelling the body forward
- shift the weight of the body onto the contralateral leg to begin weight acceptance on the other side
During the normal gait cycle, what is the “loading response”?
the period of stance that starts with initial contact with the ground and ends when the opposite foot lifts off of the ground to begin it’s swing phase
During a gait analysis, what are the 4 parts of the stance phase that you should observe?
- loading response
- mid-stance
- terminal stance
- pre-swing
During a gait analysis, what are the 3 parts of the stance phase that you should observe?
- initial swing
- mid-swing
- terminal swing
During a gait analysis, what makes up the terminal stance portion of the stance phase?
the heel leaves the floor while the opposite foot makes initial contact
During normal gait, what is the main task of the leg during the swing phase?
to bring our leg forward to accept body weight on it again
During normal gait, what part of the gait cycle occurs when the opposite leg is in its loading response?
pre-swing (toe off marks the end of the loading response on the other side)
During normal gait, how is the initial swing defined?
from toe off to the point when the feet are next to each other
During normal gait, how is the mid-swing defined?
the short period between the feet being next to each other to the point where the tibia is vertical
During normal gait, how is terminal swing defined?
the short period between the point where the tibia is vertical and the initial contact of the foot on the ground
During the gait cycle, what is the first of the 4 stages of stance phase?
initial contact / loading response
During the gait cycle, what is the second of the 4 stages of stance phase?
mid-stance
During the gait cycle, what is the third of the 4 stages of stance phase?
terminal stance
During the gait cycle, what is the last and 4th stage of stance phase?
pre-swing / toe-off
During the gait cycle, what is the first of the 3 stages of swing phase?
initial swing
During the gait cycle, what is the second of the 3 stages of swing phase?
mid-swing / “tibia vertical”
During the gait cycle, what is the last and 3rd stage of swing phase?
terminal swing
What is normal shoulder flexion AROM? What is considered “functional” AROM?
180°, ~120°
What is normal shoulder extension AROM? What is considered “functional” AROM?
45°-60°, 45°
What is normal shoulder external rotation AROM? What is considered “functional” AROM?
90°, 70°
What is normal shoulder abduction AROM? What is considered “functional” AROM?
150°-180°, 130°
What is normal shoulder internal rotation AROM? What is considered “functional” AROM?
70°-90°, 30°-50°
What is normal shoulder horizontal adduction AROM? What is considered “functional” AROM?
130°, 115°
What is normal elbow flexion AROM? What is considered “functional” AROM?
145°, 130°
What is normal elbow extension AROM? What is considered “functional” AROM?
0°, 30°
What is normal wrist flexion AROM? What is considered “functional” AROM?
70°, 5°
What is normal wrist extension AROM? What is considered “functional” AROM?
70°-80°, 30°
What is normal finger (MCP) flexion AROM? What is considered “functional” AROM?
90°-100°, 60°
What is normal finger (MCP) extension AROM? What is considered “functional” AROM?
30°-45°, 10°-30°
What is normal trunk flexion AROM? What is considered “functional” AROM?
70°-90°, 40°-60°
What is normal trunk extension AROM? What is considered “functional” AROM? (Bonus points for thoracic/lumbar ROM, specifically)
25°-35° (~10° thoracic, ~25° lumbar), 20°-30°
What is normal trunk rotation AROM? What is considered “functional” AROM? (Bonus points for thoracic/lumbar ROM, specifically)
40°-70° (~45° thoracic, ~10° lumbar), 30°-40°
What is normal trunk lateral flexion AROM? What is considered “functional” AROM?
30°-60°, 20°-30°
What is normal hip flexion AROM? What is considered “functional” AROM?
110°-120°, 115°-120°
What is normal hip extension AROM? What is considered “functional” AROM?
10°-15°, 10°
What is normal hip abduction AROM? What is considered “functional” AROM?
30°-50°, 40°-50°
What is normal hip adduction AROM? What is considered “functional” AROM?
30°, 15°-30°
What is normal hip external rotation AROM? What is considered “functional” AROM?
40°-60°, 40°-60°
What is normal hip internal rotation AROM? What is considered “functional” AROM?
30°-40°, 30°-40°
What is normal knee flexion AROM? What is considered “functional” AROM?
130°, 90°-120°
What is normal knee extension AROM? What is considered “functional” AROM?
-0° (up to 10°-15° hyperextension is common), 0°
What is normal ankle dorsiflexion AROM? What is considered “functional” AROM?
20°, 10° (for walking) - 35° (for squatting)
What is normal ankle plantarflexion AROM? What is considered “functional” AROM?
50°, 20°
During the third step of the physiotherapeutic process, you should assess passive and active range of motion to confirm/rule out your hypothesis. What are 3 reasons that a joint’s PROM is normal, but AROM is limited?
- pain
- muscle weakness
- active insufficiency
What is “active insufficiency” and how does this concept relate to your ROM assessment during examination of a joint?
- when a multi-joint muscle actively shortens across all joints simultaneously, reducing its ability to generate optimal tension/force
- active insufficiency should be suspected if PROM is full, but the person is unable to move through the full range actively
During the third step of the physiotherapeutic process, you should assess passive and active range of motion to confirm/rule out your hypothesis. What are 6 reasons that both a joint’s PROM and AROM are equally limited?
- capsule is limiting motion (arthrogenic)
- bone-to-bone (arthrogenic)
- muscle spasm (myogenic)
- contracture (myogenic)
- shortened muscle (myogenic)
- passive insufficiency
What is “passive insufficiency” and how does this concept relate to your ROM assessment during examination of a joint?
- when a multi-joint muscle is stretched across all joints simultaneously, limiting how far the joint can move
- during the examination, passive insufficiency should be suspected with the AROM and PROM are equally limited
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What are the 3 normal types of end-feel? Give an example of each.
- bone-to-bone (elbow extension)
- soft tissue approximation (knee flexion)
- tissue stretch (ankle dorsiflexion, shoulder external rotation)
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What are the 9 abnormal types of end-feel? Give reasons/examples for each.
- early muscle spasm (protective response following injury)
- late muscle spasm (more often due to shortened soft tissue stretching)
- tissue stretch (tight muscle)
- spasticity (upper motor neuron lesion)
- hard capsular (ex. frozen shoulder)
- soft capsular (ex. synovitis, soft tissue swelling)
- bone-to-bone (ex. osteophyte formation)
- empty (pain, ex. acute subacromial bursitis)
- springy block (ex. mensicus tear)
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What is meant by a “capsular” end-feel? How should this feel? Give an example.
- indicates that the joint capsule is limiting the range of motion
- feels like stretching a leather belt
- ex. knee extension
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What is meant by a “ligamentous” end-feel? How should this feel? Give an example.
- indicates that ligament tightness is limiting the ROM
- feels like stretching a leather belt
- ex. wrist radial deviation
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What is meant by a “bony” end-feel? How should this feel? Give an example.
- indicates that bone touching bone is limiting the ROM
- feels like pushing two wooden surfaces together
- ex. elbow extension
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What is meant by a “muscle stretch” end-feel? How should this feel? Give an example.
- indicates that muscle tightness is limiting the ROM
- feels like stretching a bicycle tire inner-tube
- ex. hip flexion with a straight knee
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What is meant by a “soft tissue approximation” end-feel? How should this feel? Give an example.
- indicates that subcutaneous tissue (muscle bulk, fat) are pushing against each other and limit the ROM
- feels like squeezing two balloons together
- ex. knee flexion
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What is meant by a “springy” end-feel? How should this feel? Give an example.
- indicates that a loose body is limiting the ROM
- feels “bouncy”, like you are compressing a spring
- ex. torn meniscus limiting knee extension
During the third step of the physiotherapeutic process, you should assess passive range of motion to confirm/rule out your hypothesis. What is meant by a “empty” end-feel? How should this feel to the examiner?
- indicates that you didn’t reach the end-feel (usually the person is not willing to allow motion due to pain or apprehension)
- feels like the joint has more range, but the person is purposefully stopping you
In 1943, the Medical Research Council created which orthopaedic system as a practical tool for clinicians during World War II to diagnose and manage peripheral nerve injuries sustained in combat?
the MRC Muscle Strength Grading system
What are the 6 grades of the MRC muscle strength grading system?
0: no muscle activation
1: trace/flicker of muscle without joint movement
2: movement only with gravity eliminated
3: movement through gravity only
4: movement through moderate resistance
5: movement through strong resistance
Which MRC muscle strength grade is described as: no muscle activation
Grade 0
Which MRC muscle strength grade is described as: muscle activation without movement of the joint
Grade 1
Which MRC muscle strength grade is described as: movement only if gravity is eliminated
Grade 2
Which MRC muscle strength grade is described as: movement against gravity only
Grade 3
Which MRC muscle strength grade is described as: movement through full range against moderate resistance
Grade 4
Which MRC muscle strength grade is described as: movement through full range against strong resistance
Grade 5
Define the Medical Research Council’s muscle strength grade 0.
no muscle activation/movement
Define the Medical Research Council’s muscle strength grade 1.
the person can activate the muscle, but can’t move the joint at all (“muscle activation with trace/flicker of movement”)
Define the Medical Research Council’s muscle strength grade 2.
the person can only move through the full range of motion if gravity is eliminated
Define the Medical Research Council’s muscle strength grade 3.
the person can move the joint through the full range of motion against gravity, but not against any resistance
Define the Medical Research Council’s muscle strength grade 4.
(a.k.a. “weakness with resistance”, the person can move the joint through the full range of motion with moderate resistance
Define the Medical Research Council’s muscle strength grade 5.
(a.k.a. “full strength”), the person can move through the full range of motion against strong resistance
What does the literature currently say about our ability to distinguish between muscle strength grades?
- Reliability is probably limited, and it can be difficult to distinguish between grades.
- There was an attempt to establish a Grade 4+ to describe “near-normal” strength, but clinicians just had a harder time agreeing on that
In 2017 Nagatomi et al performed a case control study of 53 people with rotator cuff tears. Muscle strength grading was performed and compared with dynamometry. What did they find about our ability to reliably determine muscle strength during manual testing of the shoulder?
- (at least in the shoulder…) we can reliably feel a 60% strength difference between the two shoulders manually
- any difference smaller than 60% and we can’t all seem to reliably agree on how good/bad it is compared to the other side
What is the role of special orthopaedic testing during the physiotherapeutic process? What should special testing NOT be used for? Why?
- Special tests can help guide your physical exam and rule in / out a hypothesis about pathology or impairment
- Special tests should not be our main source of information about the person’s condition
- Most special orthopaedic tests just aren’t that reliable in detecting specific pathology or causes of pain, even if the underlying tissue mechanism makes intuitive sense to us
During the 4th step of the physiotherapeutic process special orthopaedic tests are utilized, but how might previous steps of the process also be considered “special tests”?
Both the screening and patient history can be considered “special testing” in their own way. During these parts of the physiotherapeutic process, each question makes your hypothesis more or less likely. Orthopaedic special tests work the same way.
True or False: Most orthopaedic special tests are designed to assess for a specific ICD pathology.
True
Why are orthopaedic special tests helpful?
- In a lot of cases, people are going to present with very similar signs/symptoms that occur in multiple different pathologies, and it can be difficult to have a hypothesis among many conflicting possibilities
- Special tests can help you rule in/out some options for your hypothesis
Most orthopaedic special tests are focused on diagnosis/pathology. Why is it important to remember the difference between pathology vs. impairment (ICD vs ICF) when performing your special testing?
- It’s the job of the physio to pau much more attention to the impairments
- Pathology is very often not directly treatable
- Focus on pain, mobility, range of motion, strength, endurance, coordination, and environmental/personal factors that can delay/prevent recovery
Which are the two main statistical concepts that are most important to focus on when assessing the efficacy of a special orthopaedic test?
- Reproducibility
- Validity
Define “clinimetrics”
the science of clinical measurements (“clini-“ = observation of the actual patient, outside of theory or the lab. + “-metric” = a system or standard of measurement)
The goals of using clinimetrics (e.g. the goal of measuring someone’s clinical presentation) can usually be described as falling into which 3 different categories?
- Diagnosing/Discriminating (discriminating between ‘sick’ vs health subjects)
- Evaluating (did your treatment lead to a better outcome?)
- Predicting (is there an increased chance of chronicity?)
List 8 things that you want to ask yourself when considering orthopaedic special tests for use in the clinic?
- What exactly is this trying to measure?
- What is the goal of measuring it?
- What instrument do you want to use?
- How do you find the instrument (ex. on Pubmed)
- Is this test feasible? (cost, time, easy for the pt to understand, physical/cognitive demands)
- How good is the ‘methodological quality’ of the measurement instrument? (how well can it avoid errors/bias?)
- How are you going to analyze the data the test gives you?
- How to you interpret and report the outcomes?
It’s very important that our findings from tests and measurements are reproducible - either by ourselves or between us and another therapist. What are the two fundamental questions that are addressed when assessing a tests reproducibility?
- If you’re taking several measurements on one person: “Has my treatment produced a real change?”
- If you and a colleague conduct the same measurement: “Does another clinician have the same result that I do?”
Define reproducibility. What other two statistical measures are included under the umbrella of reproducibility?
- the degree to which a test or a measurement is free from measurement errors (in other words, the degrees to which repeated measures produce the same results)
- reliability and agreement are both aspects of reproducibility
The terms ‘reproducibility’, ‘reliability’, and ‘agreement’ are frequently confused and used interchangeably when assessing clinical tests & measures. Define ‘reliability’ and give an example. (What is another term for reliability?)
- reliability is the ability of a test to produce similar results under the same conditions
- ex. measuring someone’s height or weight is very reliable, even with multiple people over multiple measurements
- (reliability = “precision”)
What are the 2 forms of reliability that are commonly used? What are two statistics that are used to measure them?
- Intra-rater & Inter-rater reliability
- Kappa K (for “yes”/”no” tests) & Intra-Class Correlation Coefficient (for something on a continuum like blood pressure, weight, or ROM)
What is a Kappa K?
- a statical measurement of either inter-rater or intra-rater reliability
(it takes into account that you might get the same measurement again by shear dumb luck, so it shows you the results that are less likely to be by chance)
On what scale is a Kappa K statistic measured?
on a scale from 0 (not reliable) to 1.0 (perfectly reliable
The Kappa K statistic is used to measure reliability. What does a score of less than 0.2 denote?
the test or measurement method is, at best, only slightly reliable
The Kappa K statistic is used to measure reliability. What does a score of 0.2-0.4 denote?
the test or measurement method has fair reliability
The Kappa K statistic is used to measure reliability. What does a score of 0.4-0.6 denote?
the test or measurement method is moderately reliable
The Kappa K statistic is used to measure reliability. What does a score of 0.6-0.8 denote?
the test or measurement method is substantially reliable
The Kappa K statistic is used to measure reliability. What does a score of greater than 0.8 denote?
the test or measurement method has excellent reliability
The Kappa K statistic is used to measure reliability. What does a score of 1.0 denote?
the test or measurement method is perfectly reliable
What Kappa K score denotes that a test or measurement is only slightly reliable?
K = less than 0.2
What Kappa K score denotes that a test or measurement has only fair reliability?
K = 0.2-0.4
What Kappa K score denotes that a test or measurement is moderately reliable?
K = 0.4-0.6
What Kappa K score denotes that a test or measurement is substantially reliable?
K = 0.6-0.8
What Kappa K score denotes that a test or measurement has excellent reliability?
K = greater than 0.8
In statistics, what does ICC stand for?
Intra-class Correlation Coefficient
What is an Intra-class Correlation Coefficient?
- a statical measurement of either inter-rater or intra-rater reliability, specifically when the test or measurement doesn’t have a “yes/no” answer
(like a Kappa K, it takes into account that you might get the same measurement again by shear dumb luck, so it shows you the results that are less likely to be by chance)
On what scale is an Intra-class Correlation Coefficient measured?
on a scale from 0 (not reliable) to 1.0 (perfectly reliable
The Intra-class Correlation Coefficient statistic is used to measure reliability. What does a score of less than 0.2 denote?
the test or measurement method is, at best, only slightly reliable
The Intra-class Correlation Coefficient statistic is used to measure reliability. What does a score of 0.2-0.4 denote?
the test or measurement method has only fair reliability
The Intra-class Correlation Coefficient statistic is used to measure reliability. What does a score of 0.4-0.6 denote?
the test or measurement method is moderately reliable
The Intra-class Correlation Coefficient statistic is used to measure reliability. What does a score of 0.6-0.8 denote?
the test or measurement method has substantial reliability
The Intra-class Correlation Coefficient statistic is used to measure reliability. What does a score of greater than 0.8 denote?
the test or measurement method has excellent reliability
The Intra-class Correlation Coefficient statistic is used to measure reliability. What does a score of 1.0 denote?
the test or measurement method is perfectly reliable
What Intra-class Correlation Coefficient score denotes that a test or measurement is only slightly reliable?
ICC = less than 0.2
What Intra-class Correlation Coefficient score denotes that a test or measurement has only fair reliability?
ICC = 0.2-0.4
What Intra-class Correlation Coefficient score denotes that a test or measurement is moderately reliable?
ICC = 0.4-0.6
What Intra-class Correlation Coefficient score denotes that a test or measurement is substantially reliable?
ICC = 0.6-0.8
What Intra-class Correlation Coefficient score denotes that a test or measurement has excellent reliability?
ICC = greater than 0.8
In general, what is considered an acceptable Kappa K or Inter-class Correlation Coefficient when measuring inter-rater reliability?
0.75 or greater
In general, what is considered an acceptable Kappa K or Inter-class Correlation Coefficient when measuring intra-rater reliability?
0.9 or greater
Intra- and Inter-rater reliability are both measured using either Kappa K or Inter-class Correlation Coefficient statistics, but the two have different values that are considered ‘acceptable’. What is the difference?
- an inter-rater reliability is considered acceptable if Kappa K or ICC = 0.75 or greater
- intra-rater reliability needs to meet a higher threshold, at Kappa K or ICC = 0.9 or greater to be considered acceptable
We want to keep pretty high standards when we conduct and assess our research. So, in general, an intra-rater reliability (ICC or Kappa K) of greater than 0.9 and an inter-rater reliability of greater than 0.75 are considered ‘acceptable’. Put this is common language.
Your test or measurement is considered acceptable if its reliability is good enough that at more than 75% of the time, you’d agree with your colleague and more than 90% of the time, you’d agree with yourself.
In the clinic, you may have several goals or reasons for why you’d select a particular test or measurement. List 3.
- discrimination (who has a condition vs who is ‘healthy’)
- evaluation (did a treatment have an effect)
- prediction (can the test predict a certain outcome - ex. developing chronic pain)
Briefly explain how it is that a test or measurement’s reliability is influenced by the concepts of variability and measurement error. If we were to write out this relationship as a more formal equation, what would that look like?
- reliability always depends upon variability and measurement error: variability among the people being tested and the measurement error of the tool you’re using to test them
- variability means that some of the people being tested are going to be healthy and some are going to be sick - this is also known as the variance; a test is only reliable in that it can distinguish between these two consistently
- measurement error affects the precision of your test to determine difference between sick and healthy people
- variability of people / (variability of people + measurement error) = reliability
When reading a study about a test or measurement’s reliability, why is it important to be aware of the specific group of participants being studied? How does this affect whether reliability will be higher/lower?
- if the group of participants is very similar (a.k.a homogenous) - for example, a group of health people - reliability values will be a lot lower, since it’s much harder to distinguish between them
- if the people being studied are very different (a.k.a. heterogenous) - for example, including both really sick AND really health people - reliability values will be a lot higher than in real-life practice
What is the relationship between ‘agreement’ and measurement error?
agreement assesses how close the results of repeated measurements are - it estimates the measurement error during repeated measurements, and is thus a more ‘pure’ characteristic of the tool you’re using
The aim of a research question can determine whether reliability parameters vs agreement parameters are of greater interest. What might be the difference that would make this distinction?
- if the research question concerns discriminating between people, reliability parameters are more important to consider
- if the aim of the research is to measure a change in health status in an individual, agreement is more appropriate to use (this is going to be more common in clinical practice, since agreement assesses the results of repeated measurements)
True or False: reliability parameters are a pure measure of the measurement instrument itself & not dependent on the variability between the subjects to be measured.
False: this describes agreement, not reliability (agreement is an assessment of the results of repeated measurements)
What are the two types of measurement error?
- systematic measurement error
- random measurement error
What is the relationship between the statistical concept of agreement and a standard deviation statistic? (Apply to an example of someone weighing themself on a scale over several days)
- the standard deviation REPRESENTS the agreement parameter of the scale as a measurement tool - it answers the question “How good is the agreement between repeated measurements?”
- someone’s weight might fluctuate day-to-day, and there will be a “standard deviation” from the average weight on any given day (ex. give or take 1.0-1.5 lbs)
Define a ‘systematic’ measurement error. (Give an example of this when taking someone’s bodyweight over the course of several days)
- error due to (mis)handling of the instrument
- maybe I put the scale on different surfaces on different days
Define a ‘random’ measurement error. (Give an example of this when taking someone’s bodyweight over the course of several days)
- chance fluctuations in the subject being measured
- body water fluctuations that are uncontrolled / unpredictable
Obviously, in the clinic, we want to choose tests that have a smaller measurement error. How small? On what does this depend?
- it depends on the size of the improvement/worsening of the person’s condition that you’re trying to detect
- the measurement error needs to be smaller than the change that you’re trying to detect
- if the error is too large, then you won’t be able to distinguish small - but real - changes in the person’s condition vs. just measurement errors
If the measurement error of a test is too large, we won’t be able to use it to distinguish between small - but real - changes in a person’s condition vs just measurement errors. Explain this using an example of someone trying to lose weight and measuring themselves on a scale over several days.
- we take the weight over several days, knowing that there is some degree of error that’s always going to be present
- we try to minimize the systematic errors by staying consistent with our methods
- we remember that random error is always going to be a thing to some degree
- if the measurement error is BIGGER than the difference between measurements, then we can’t really tell if the person has lost/gained weight
- if the measurement error is SMALLER than the difference between those measurements, we can be more confident that some meaningful change has occurred
- (ex. someone is 2.6 lbs lighter over the course of a week, and the scale has a measurement error of 0.8 lbs, we can be pretty sure that we’re not just seeing random fluctuations and they actually lost weight)
The “limits of agreement” is a method used to calculate what statistic?
measurement error
Define the concept of a “standard deviation”. Give an example of someone taking multiple measures of their bodyweight and how standard deviation of the scale measurements might be considered.
the measure of the spreading of the difference around the average
- (a.k.a. “give or take”: if the standard deviation of a scale during weigh-ins is SD = 1.13 lbs, then our average weight [ex. 157 lbs] can be expressed as 157 ± 1.13, or 157 lbs “give or take” 1.13 lbs)
If I were trying to figure out the size of the measurement error of a scale when measuring bodyweight, how might I go about it using “limits of agreement” on a Bland-Altman plot?
- take two measurements for every person you put on the scale
- the two measurements might not be exactly the same (ex. 1st time weighs 156 lbs, the second time weighs 158 lbs)
- take the difference between those measurements (2 lbs) and plot it out compared to the average weight (157 lbs)
- do this for everybody in the group, weighing everybody twice
- you’ll end up with a scatter plot
- look at what the average difference between each person’s 1st and 2nd measurements and draw a “D-line” through it on the plot
- how close or how far away from this D-line any measurement is will represent how small or how large the measurement error is
- the space that we consider acceptable on either side of the line is delineated by the “limits” of agreement
Define the “smallest detectable change” as it relates to the limits of agreement (ex. when plotting out multiple data points on a chart)
- smallest detectable change (SDC) is the “space” between the limits of agreement on either end of the average difference in measurements (D-line on Blan-Altman scatter plot)
Imagine that someone is weighing themselves regularly on a scale every day. They understand that there is some degree of measurement error on the scale and that this particular scale sucks. It’s smallest detectable change is 0.5 lbs. If they weight themselves on two different days, what does this mean when they’re trying to determine if they’ve lost weight?
- if they weigh less on day 2, but the weight loss is less than 1.5 lbs, we can probably just chalk this up to measurement error (SDC is greater than weight change)
- if they weigh less on day two, but the weight change is greater than 0.5 lbs, we can be pretty confident (95% “confidence interval”) that - at least on this scale - a real change has occurred (weight change is greater than SDC)
What are two statistical terms that we use to refer to “clinically relevant” changes on a test or measurement?
- Minimal Important Change (MICs)
- Minimally Clinically Important Difference (MCIDs)
When using a particular test or instrument to take multiple measurements over time, how do we use the concepts of MICs/MCIDs along with SDCs to determine if it is trustworthy?
if the smallest detectable change (SDC) is less than the minimal important change (MIC) / minimal clinically important difference (MCID), then our instrument is probably sensitive enough to tell us that a clinically relevant change occurred
How does standardization impact measurement error. List two different ways
- making sure that all measurements are taken the same way by one or multiple testers (by using things like training and protocols) can cancel out variations in (1) the use of the instrument and (2) environmental factors that might influence the outcome
When using a measurement tool in the clinic, we might have different goals (ex. discrimination, evaluation, prediction). Which of these goals concerns reliability parameters more so than agreement parameters?
discrimination (who has a condition vs who doesn’t)
When using a measurement tool in the clinic, we might have different goals (ex. discrimination, evaluation, prediction). Which of these goals concerns agreement parameters more so than reliability parameters?
evaluation (did a treatment have an effect?)
