General exam scheme Flashcards
traditional exam flow
listen
look
feel
move
Listen
Let the pt. talk: pts need ~120s to voice complaints Active listening throughout encounter Open ended questions "What else?" History taking
History
Keep in mind:
- pain is usually the reason pt is there
- emotional overlay
- pts forget details and context
- “musculoskeletal” pain may come from other sources
pain scale?
what makes pain better? worse?
What if pain never changes?
could mean it is NOT musculoskeletal
MS should at least vary with different positions
what should you do after listening?
pause and reflect: “Does this patient belong here??”
Look
Posture/alignment Swelling/edema/girth Muscle hypertrophy/atrophy Skin/nail changes Splinting, spasm, guarding Willingness to move Facial expressions Use of adaptive/supportive devices
How gentle must I be in the exam??
SINSS
S=severity: relates to function effected: mild, moderate, severe
I=irritability: relates to stimulus needed to irritate, time to baseline: mild, mod, severe
N=nature of the problem: in pt’s view, what is wrong?
S=stability: is the problem getting worse, better, same?
S=stage: acute, subacute, chronic
Feel
Work superficial to deep
Dermal & subdermal flexibility, density/edema, tenderness, temperature
Muscle spasm, trigger points, tender points
Fascial tightness, tenderness
Joint line and boney prominences
Move
*good source for objective asterisks (used to gauge progress- make a problem list) Clearing tests Movement tests Muscle strength neurological special tests functional tests
Clearing tests
2 joint rule: “clear” at least 1 joint above and 1 below area of complaint
usually want to clear spine also
AROM/PROM with overpressure
rigorous break tests
Movement testing
AROM->PROM -> Resisted isometric
normal=PROM>AROM (endfeel painfree)
- Selective Tissue Tension (Cyriax)
- Irritability
- Arthrokinematic motion (joint play) (0-6 scale: 0=anklyosed, 6=hypermobile)
- Location & type of pain elicited (^ pain w/ w/load? repetitions?)
- Compare to contralateral side
Selective tissue tension (cyriax)
separate contractile from inert lesions
Inert= pain from AROM & PROM in the same direction
Contractile= pain from AROM & PROM in opposite directions
Irritability
determined by sequence of pain and movement barrier
pain BEFORE barrier- acute= Take it easy
pain AT barrier- subacute = more aggressive
pain AFTER BARRIER- chronic = aggressive
If pain with AROM AND PROM:
problem is probably not muscle but joint
If pain with PROM AND Isometric
probably muscle
Muscle strength tests
MMT:
- is pain elicited?
- Bilateral comparison
- watch for compensatory movements
ISOKINETICS
PLYOMETRICS/ FUNCTIONAL TASKS
Neruological Tests
Sensation/light touch/ temp/ vibration
DTR: know the nerve root levels
Proprioception
Peripheral nerve provocation: tinel, neurodynamics
Special tests
must follow pathological based model
most have no or little research support
some have to be used in clusters
Functional tests
- hand behind back/head
- squat: 1/4, 1/2, 3/4, full
- stand on 1 leg
- hop on both legs, then one
measures of function:
- gait/transfers
- ADLS
- Get up and go, hop test, etc.
the eval process
Exam Eval Diagnosis Prognosis Intervention Outcomes (re eval)
*for every intervention there has to be a goal and an impairment. for each goal you have a tx
musculoskeletal therapy assessment
numerous models exist
- cyriax
- kaltenborn
- maitland
- mckenzie
- mennell
- osteopathic
philosophical approaches:
1: biomechanical
2: patient response model
3: mixed
biomechanical/ pathological model
ex: concave/convex rule applied to adhesive capsulitis
patient response model
use of pain production/reduction methods applied to adhesive capsulitis
mixed model
one model applied to assessment the other applied to treatment
both models applied to both assessment and treatment
all musculoskeletal therapy assessment models use what systematic process?
Clinical examination
Treatment
Re-examination
*should result in a generation of a diagnostic label
diagnostic labels
1: pathology based
2: impairment based
pathology based diagnostic label
- traditional medical diagnosis (adhesive capsulitis, tendonitis)
- linked to pathology
- by themselves seldom useful in guiding PT clinical decisions/txs
- provide little info on severity, irritability, nature, or stage of disease
impairment based diagnostic label
clinical subjective & objective findings
pt response to tx
independent examination findings drive tx selection; do what relieves symptoms of reduces impairments
-approach advocated by the Guide
*generated through a systematic process:
1: Generate hypotheses:
- history/intake: find subjective, functional asterisks
- systems review
- lab tests and imaging studies
2: eliminate and refine hypothesis
- physical exam/special tests: find objective asterisks
follow up visits
"how did you feel when you left last time?" "how did you feel the next day?" progress on subjective asterisks? "are you doing your HEP? Show me." Progress on objective asterisks
occasional formal re-eval:
progress on existing condition; revise goals?
new problems surfacing?
Red flag findings
1: do they belong here?? these findings require immediate medical attention
2: factors that require subjective questioning or are contraindications to selected manual therapy techniques
3: factors that require further physical testing and differentiation analysis
red flag category #1
*these findings require immediate medical attention
- pathological changes in bowel or bladder function
- symptoms not compatible with mechanical pain (symptoms don’t change w/ movement)
- blood in sputum
- numbness or parasthesia in perianal region
- progressive neurological deficits
- pulsatile abdominal masses
- neurological deficits not explained by momradiculopathy
- elevated sedimentation rate
red flag category #2
*factors that require subjective questioning or are contraindications to selected manual therapy techniques
- impairment precipitated by recent trauma
- writhing pain
- nonhealing sores or wounds
- fever
- clonus (upper motor damage)
- gait defects
- history of cancer
- long term steroid use
- hx of a disorder w/ predilection for infection or hemorrhage
- hx of metabolic bone disorder
- recent unexplained wt loss
- age>50
- litigation for the current complaint
- long term worker’s comp
- poor relationship w/ employment supervisor
clonus
ankle/upper
sign if problems in CNS
repeated beating of muscle contractions when put in a quick stretch
indicated upper motor damage
Red flag category #3
*factors that require further physical testing and differentiation analysis
- bilateral or unilateral radiculopathy or parathesia
- unexplained limb weakness
- abnormal reflexes
what is myelopathy?
spinal cord pathology
contraindication to orthopedic manual therapy
absolute vs. relative
different txs have different amounts of risk, so 1 list doesn’t cover all tis
lower risk -> higher risk
AROM-> PROM, AAROM, stretching, mobilization -> manipulation
absolute contraindications to active movement
- malignancy of the targeted region
- cauda equina lesions
- rheumatoid collagen necrosis
- red flags indicating neoplasm, fracture, or systemic disease
- signs of VBI
- unstable upper C-spine (except specific movements for stabilizing procedures)
VBI: vertebral basilar insufficiency
Drop attacks, sudden weakness, loss of consciousness Dysphagia= trouble swallowing Dysarthria= trouble speaking Dizziness Diplopia=double vision
Numbness on 1 side of face/body
Nystagmus= involuntary eye beating
Nausea
Headaches Hearing disturbances (ringing not loss)
Ataxic gait disturbances
Relative contraindications to active movement
- active, acute inflammatory conditions
- significant segmental stiffness
- systemic disease
- neurological deterioration
- irritable patient
- osteoporosis
- quickly worsening condition
- hamstring and upper limb active stretching on acute nerve root irritations
absolute contraindications to passive movement
**same as active movement!
- malignancy of the targeted region
- cauda equina lesions
- rheumatoid collagen necrosis
- red flags indicating neoplasm, fx, or systemic disease
- signs of VBI
- unstable upper C-spine
relative contraindications to passive movement
**same as active movement! PLUS*
- acute nerve root irritation (when S & O don’t add up; any pt condition (handled well) that is worsening; oral contraceptives (c-spine); long term oral corticosteroid use
- immediately post-pardum
- blood clotting disorder
- active, acute inflammatory conditions
- significant segmental stiffness
- systemic disease
- neurological deterioration
- irritable patient
- osteoporosis
- quickly worsening condition
- hamstring and upper limb active stretching on acute nerve root irritations
absolute contraindications to manipulation
**same as active & passive movement. PLUS*
- practitioner lack of ability
- spondylolithesis
- gross foraminal encrochment
- children/teens
- pregnancy
- fusions
- psychogenic disorders
- immediately post pardum
- malignancy of targeted region
- cauda equina lesions
- rheumatoid collagen necrosis
- red flags indicating neoplasm, fx, or systemic disease
- signs of VBI
- unstable C-spine
relative contraindications for manipulations
**same as passive movement
- active, acute inflammatory conditions
- significant segmental stiffness
- systemic disease
- neurological deterioration
- irritable patient
- osteoporosis
- quickly worsening condition
- hamstring & upper limb active stretching on acute nerve root irritations
- acute nerve root irritation
- immediately post pardum
- blood clotting disorder
