L2 Elements of Exam and Eval Flashcards
Primary reasoning errors during patient encounters
- failing to generate a key hypothesis
- retaining a hypothesis in the face of conflicting reasoning
Three necessary elements of reflection
- active engagement in intellectual processess
- exploration of problems or experiences
- subsequent changed perspective or new insights
Skills needed for reflection
self-awareness
description
critical analysis
synthesis
evaluation
Shared Decision Making
- results in improved outcomes compared to not implementing SDM
- considers patients’ individual circumstances, values, and preferences
Motivational interviewing and decision aids can help you
Total musculoskeletal assessment
patient history
observation
movement exam
palpation
joint play movements
reflexes, cutaneous distribution
special tests
diagnostic imaging
Observation
not palpation
starts the moment you come into visual contact with patient and continues during the session
Overt pain behaviors to observe
guarding
bracing
rubbing
grimacing
sighing
Structural deformity
present even at rest (fracture)
Functional deformity
result of a particular posture and disappears when posture is changed (scoliosis due to short leg)
Dynamic deformity
caused by muscle action
valgus moment at knee
Why should you be interested in detecting asymmetries of limbs/muscle/bones?
Can be a fracture, tumor, complete tear
Or can be normal asymmetry, sprain/strain, inflammation
Movement Exam
confirms or refutes the working diagnosis/hypothesis, which was formulated during the history and observation
Red Flags during examination
severe unremitting pain
severe spasm
psychological overlay
12 principles of exam (1-6)
- unless bilateral movement is required, the normal side is tested first
- the pt does active movements before examiner does passive movements
- any movements that are painful are done last
- if active ROM is not full, overpressure is applied only with extreme care to prevent the exacerbation of symptoms
- during active movements, if ROM is full, overpressure may be carefully applied to determine the end feel of the joint
- each active, passive, or resisted isometric movement may be repeated several times or sustained
12 principles of exam (7-12)
- resisted isometric movements are done with the joint in a neutral or resting position so that stress on the inert tissues is minimal
- for passive ROM or ligamentous tests, it is not only the degree of opening, but also the quality of the opening
- when examiner is testing ligaments, appropriate stress is applied and repeated
- myotomes, each contraction is held for a min of 5 seconds to see if weakness becomes evident
- examiner warns the patient that symptoms might be exacerbated
- examiner does not hesitate to refer out if needed
Exam of specific joints
- pompjrsd
- adjacent joints to clear
- looking for pt subjective and objective findings
- include scan of spine
- acute injury preclude complete exam
- exam is extensive enough to allow pattern to emerge
Spinal scanning
scanning is a quick check of the portion of the spine that relates to the limb in question
purpose is to rule out symptoms which may be referred from one part of the body to another
When to use the spinal scanning exam
- no history of trauma
- radicular signs
- trauma with radicular signs
- altered sensation in limb
- patient presents with abnormal patterns
- suspected psychogenic pain
Movement Exam
Goal is to differentiate between muscle, tendon, ligament, nerve, bone
Contractile tissue
effected by contraction or stretch.
Muscle or tendon
tested by AROM and resistance
Non-contractile tissue
effected by loading, compression/pinching
ligament, capsule, cartilage, blood vessels, bursae, skin
tested by PROM and special tests
Nervous Tissue
effected by stretching, compression, pinching
Bone Testing
bone is impacted by direct pressure, compressive load, torsion
Active motion looks at
available range, control, power, willingness to move
Observations to do during active movement
when and where S/S occurs
whether movement increases intensity
reaction of patient
amount of restriction
pattern of movement
quality of movement
willingness to move
Classic presentations/patters of contractile tissues
- no pain, movement is strong
- pain, and movement is relatively strong
- pain, and movement is weak
- no pain, movement is weak
no pain and movement is strong
normal, even if muscle hurts to the touch
Pain and movement is relatively strong
local lesion of muscle and/or tendon, 1 or 3nd degree strain
Pain and movement is weak
2nd degree or greater strain, and/or a significant lesion around joint like a fracture
no pain and movement is weak
severe 3rd degree strain/rupture, neurological involvement
Passive motion
used to find the anatomical barrier to further motion vs AROM which determines the physiological barrier to further motion
Examiner observations during passive movement
when and where symptoms begin
if intensity and quality increases with movement
pattern of limitation
end feel
ROM available
End-feel
barrier to further motion at the end of passive ROM
each joint has unique structure that will provide a stopping point to mobility
Abnormal end feel
early muscle spasm
late mucle spasm
spasticity
hard capsular
soft capsular
bone to bone
empty (bursitis)
springy block (meniscus)
Inert Tissue Presentations of Pain
- ROm is full and there is no pain
- Pain and limitation of movement in every direction
- Pain and limitation or excessive movement in some directions but not others
- limited movement that is pain free
ROM is full and there is no pain
no lesion in the direction of PROM
Pain and limitation of movement in every direction
entire joint is affected, indicating arthritis or capsulitis
Pain and limitation or excessive movement in some directions but not in others
ligament sprain or local capsular adhesion, non capsular pattern, internal derangement
Limited movement that is pain free
moderate OA, bone to bone
Capsular Patterns
pattern of limitation is the feature that indicates the presence of a capsular pattern in the joint
not well researched hence variations based on observations
Resisted Isometrics
for inert tissues
make sure to test in the position that is causing issues
Contractile tissue lesions
AROM and PROM are usually painful in the opposite direction
painful in opposite directions as they create opposing types of stress to the same tissue
Inert Tissue Lesions
AROM and PROM are usually painful in the same direction
pain occurs as the limitation of motion occurs
S/S of Upper motor lesions
spasticity
hypertonicity
hyperreflexia
positive pathological reflexes
absent or reduced superficial reflexes
extensor plantar response
S/S of Lower motor neuron lesions
flaccid paralysis
loss of reflexes
muscle wasting and atrophy
lost of synergistic action of muscles
fibrosis, contractures, adhesions
joint weakness, instability
decreased ROM and stiffness
growth affected
S/S of myopathy
difficulty lifting
difficulty walking
myotnia
cramps
pain
progressive weakness
Palpation
determine tissue at fault before using palpation
practice makes perfect
relax and support area
Assess during palpation
- tissue tension and tone
- tissue texture
- abnormalities
- tenderness
- temperature
- pulse, tremors
- pathological state of tissues
- dryness or excessive moisture
- sensation
edema that comes on soon after injury
blood
edema that comes on after 8 to 24 hours
synovial
edema that is boggy, spongy feeling
synovial
edema that is harder, tense feeling with warmth
blood
edema that is a leathery thickening
chronic
edema that is soft and fluctuating
acute
edema that is thick and slow-moving
pitting edema
Joint play movement
small ROM that can be obtained only passively by the examiner
accessory movement
required for nomal, pain free joint mobility
joints shoudl be tested in loose pack position
Facet loose pack
midway between flexion and extension
Hip loose pack
flexion, abduction, Er
GH loose pack
abduction, horizontal adduction
Knee loose pack
slight flexion
Close packed position
no accessory movement is posisble
Rules for joint play testing
pt should be relaxed and fully supported
one joint at a time
unaffected side first
movements aren’t forced and don’t cause discomfort
Reflex grading
0–absent
2–normla
4–hyperflexia
Sensory testing is used to
- determine extent of sensory loss, whether loss is caused by nerve root lesions, peripheral nerve lesions, compressive tunnel syndromes
- determine the degree of functional impairment
- determine nerve recovery after injury
Purposes of special tests
confirm tentative diagnosis
make a differential diagnosis
differentiate between structures
Caution w/special tests
osteoporosis, instability, severe pain, bone disease, apprehensions, major neuro
Clearing the CS
perform AROM
perform over pressure for lateral flexion, flexion, rotation, extension
If normal range of motion and overpressure is unremarkable
the clearance exam is negative
If reproduction of shoulder symptoms occurs
perform the CS scan exam
If a new pain/symptom is produced in CS or shoulder
perform the CS scan exam
CS Scan Exam
used to rule out referral of symptoms from CS to the shoulder
AROM
PROM
Over pressure
RROM
UE myotomes
Reflexes
Dermatomes
Compression and Distraction
Neurodynamics test
RROM for CS
Flexion
Extension
Lateral Flexion
Rotation
Myotomes for CS
Neck flexion (C1/2)
Lateral flexion (C3)
Shoulder elevation (C4)
Shoulder abduction (C5)
Elbow flexion (C6)
Wrist extension (C6)
Elbow extension (C7)
Wrist flexion (C7)
Thumb extension (C8)
Finger abduction (T1)
Cervical compression test
examiner exerts downward pressure on subjects head
Positive: increased pain or altered sensation indicates pressure on a nerve root
Spurlings Test
Patients neck is in slight extension, laterally flexed. Apply downward axial compression
Positive: pain radiates down the neck
High spin and snout
Cervical Distraction test
pull patients head at mastoid process
positive: patients symptoms are reduced with distraction
