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PHTY2220 > L3: Review of Interview and Physical Examination > Flashcards

L3: Review of Interview and Physical Examination Flashcards

1
Q

What are the 10 important pointers as a framework for the patient interview?

A
  1. Establish the reason the patient is consulting the physiotherapist
  2. History of presenting condition
  3. Area and nature of current symptoms
  4. Behaviour of symptoms
  5. Special questions
  6. Previous history
    • Includes treatment and investigations
    • Any implications for management
  7. Impact of condition: lifestyle and work
  8. Patients concerns about their condition – what they are hoping to find out about
  9. Existing knowledge/understanding
    • What their concerns and beliefs of the problem
  10. Expectations and goals
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2
Q

In the interview, when establishing the reason the patient is consulting you, give an effective example of what to say? What is not effective?

A

Can you start off by telling me a little about what brings you in today?

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3
Q

In the interview, when establishing the reason the patient is consulting you, why are these questions ineffective? Where is your pain? Can you tell me about your pain?

A

We cannot assume that the patient’s main concern is pain In many cases focusing only on the persons pain leads us away from a patient-centred focus and can inadvertently get them focusing only on the pain.

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4
Q

In the interview, when trying to obtain the patient’s history of presenting condition (acute/subacute pain), what is are 2 effective examples?

A

Can you tell me a bit about what has been going on? When did this start?

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5
Q

In the interview, when trying to obtain the patient’s history of presenting condition (persistant pain), what is are 4 effective examples?

A

Can you tell me about your experiences with your back? Can you tell me a little bit about the history of your back problems? Why do you think it hasn’t got better over this time? Why do you think it keeps getting aggravated?

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6
Q

In the interview, what is very important to ask when trying to obtain the patient’s history of presenting pain?

A

Ask about the progress of the condition since onset

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7
Q

What are the 4 main aims of the patient interview?

A
  1. Determined if symptoms are musculoskeletal
    • Rule out any red flags or possible diseases that could be masked as MSK
  2. Used and interpreted the information to construct working hypotheses of the nature of the patient’s complaint
    • To help guide physical examination, rule out other hypotheses
  3. Established what the patients goals, knowledge, concerns and expectations are
  4. Have information to guide an effective and safe physical examination to determine the nature of the physical problems
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8
Q

In the interview, when trying to obtain the patient’s area and nature of current symptoms, what are 6 characteristics of the body chart?

A
  1. Area of all symptoms (pain, paraesthesia, numbness), AND regions free of symptoms
  2. VAS
  3. Areas of greatest pain intensity (local areas, referred areas)
  4. Quality of pain (eg. Ache, sharp, shooting, lancinating, burning)
  5. Quality of other symptoms
  6. Relationships of areas/symptoms
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9
Q

What is very important in area and nature of current symptoms (body chart) that needs to be checked?

A

Neurological symptoms (very important to ask) - pins and needles, numbness, tingling (particularly in LL)

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10
Q

Quality of pain is not _________ but can help differentiate between _____ or ___ pain

A

diagnostic; nerve related (neurogenic); somatic

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11
Q

What are 7 words to describe the quality of nerve-related pain?

A
  1. intense
  2. radiating
  3. severe
  4. sharp
  5. darting
  6. lancinating
  7. well localized.
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12
Q

What are 4 words to describe the quality of somatic referred pain?

A
  1. deep
  2. achy
  3. diffuse
  4. poorly localized.
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13
Q

Somatic structures of the lumbar spine ___ (do/do not) refer pain consistently in a segmental pattern.

A

do not

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14
Q

Radicular pain (pain associated with a _______) from L5 and S1 consistently follows a ______ pattern into the lower extremity most of the time, especially if the pain extends past the ankle. It is difficult to distinguish between L5 and S1 radicular pain patterns above the ankle

A

nerve root; dermatomal

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15
Q

In the interview, what are 5 characteristics that need to be discussed in the “behaviour of symptoms” section?

A
  1. Aggravating, easing: relate to mechanical provocation, establish irritability and severity
  2. Getting an idea of which positions and/or movements reduce symptoms or improve ROM (directional preference to movement)
  3. Relationships between symptoms
  4. Effect of rest, local rest of part, resting positions
  5. Sleep patterns, 24 hour picture
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16
Q

The “behaviour of symptoms” section helps us establish that it is a_______ problem and response to mechanical factors such as posture or movement. Furthermore, inform management as indicates what helps or makes symptoms worse through determining the ________.

A

musculoskeletal; directional preference

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17
Q

What is directional preference?

A

a position or movement that needs to either be repeatedly loaded or the position sustained to improve one or more of the following:

  1. Range of movement
  2. Pain
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18
Q

Why is directional preference important?

A

During the interview through easing factors –> can help guide management

Can be helpful to give exercises towards the directional preference

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19
Q

What is centralisation?

A

When symptoms that are distal (eg. foot and calf) start to move more proximally when the patient does certain movements

  • Eg. pain in back and butt and leg when sitting for a long time –> get up out of chair –> pain moves from leg back to butt and back –> pain goes away
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20
Q

What are the 2 types of directional preference?

A
  1. Flexion
  2. Extension
    • Most common (going upright, standing, hands on hips and extending
    • Reduce or centralise pain
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21
Q

Advice and exercise towards the patients directional preference is useful for _____ especially in those with acute LBP in the short and medium term

A

treatment outcomes

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22
Q

In the interview, what are 8 characteristics that need to be discussed in the “special questions” section?

A
  1. Neurological symptoms
    • Pins and needles?
    • Tingling?
    • Numbness?
    • Loss of strength?
  2. Cauda Equina Symptoms
    • Any difficulty with going to the bathroom?
    • If so, do you have difficulty starting when you urinate?
    • Have you noticed any numbness or change in sensation in the area between your legs?
  3. THREADS
  4. General health?
  5. Any trauma?
  6. Weight Stable?
  7. Medications
  8. Investigations
    • e.g. X-rays, CT scans, MRIs etc. and other medical evaluations e.g. blood tests
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23
Q

What are 4 questions that need to be asked in the neurological symptoms bit in the “special questions” section?

A
  1. Pins and needles?
  2. Tingling?
  3. Numbness?
  4. Loss of strength?
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24
Q

What are 3 questions that need to be asked in the cauda equina symptoms bit in the “special questions” section?

A
  1. Any difficulty with going to the bathroom?
  2. If so, do you have difficulty starting when you urinate?
  3. Have you noticed any numbness or change in sensation in the area between your legs?
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25
Q

What is the cauda equina symptoms like?

A

Compromise of the lower part of spinal column (peripheral nerve) which can leave permanent symptoms

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26
Q

In the interview, what are 7 characteristics that need to be discussed in the “previous history” section?

A
  1. Relevant previous history to symptoms
  2. How often have symptoms occurred?
  3. How quickly did it recover?
  4. What treatment was received?
  5. Why has it happened again? (what does the patient understand)
  6. Have you had any investigations?
  7. Were you given an explanation of what happened or what is wrong?
    • what explanations the patient has been given may shape their beliefs
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27
Q

If a health professional has been seen previously, what can you say to your patient? Why is this relevant?

A

“Can you tell me what your doctor/physio..etc told you about what’s been going on with your back?”

What health professionals tell their patients about their back can really impacts their beliefs and can be a risk factor for persistent pain

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28
Q

In the interview, what are 7 characteristics that need to be discussed in the “previous history” section?

A
  1. Relevant previous history to symptoms
  2. How often have symptoms occurred?
  3. How quickly did it recover?
  4. What treatment was received?
  5. Why has it happened again?
    • what does the patient understand
  6. Have you had any investigations?
  7. Were you given an explanation of what happened or what is wrong?
    • what explanations the patient has been given may shape their beliefs
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29
Q

If the patient is off work, what are 3 possible things to ask?

A
  1. What are the plans for returning to work?
  2. Does your boss know about it?
  3. What is stopping you from working?
    • If its inability?
      • Would you be able to modify your work station?
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30
Q

Extended time off work is a major risk factor for ____ and _____.

A

persistent pain; disability It is important to stay at work if possible or returning to work as soon as possible

31
Q

What is a possible question that can be asked in the “patients concerns” section?

A

Do you have any particular concerns about your back/your problem that you are wanting to find out about today?

32
Q

What are 3 questions that they can be asked in regards to “what do they understand has happened?” Why is this section important?

A
  1. Have you been given an explanation as to what has happened with your back?
  2. What do you understand has happened (if acute) is happening (if persistent) with your back?
  3. Why do you think your back/your pain is not improving? (if persistent)
    • Incorrect beliefs can have detrimental effects
33
Q

What are 2 possible questions that can be asked in the “expectations and goals” section?

A
  1. What are you hoping to get out of Physiotherapy?
  2. Patient-specific functional scale for specific goals
34
Q

The “patients concern”, “what do they understand has happened?” and “expectations and goals” section directly informs what our _____ and ___ will be focused on

A

advice; education

35
Q

What are 9 things to ensure that after the interview, you have gained?

A
  1. Have a sound understanding about the patients symptoms, history and past history of their problem
  2. Can confidently rule in/out suspected red flags
  3. Can ensure the patient’s symptoms are musculoskeletal in nature
  4. Developed patient-centred goals
  5. Have an understanding about the patients perspective of their problem, concerns and expectations
  6. Have identified risk factors that the patient may have for developing or maintaining persistent pain
  7. Understand the impact of work and social factors on the patient
  8. Have gathered relevant outcome measures that you can use (VAS, PSFS, goals and standardised functional outcome measures)
  9. Have an idea of patients symptom severity and irritability to modify the physical assessment plan
36
Q

What are 7 aims of the physical examination?

A
  1. Safely determine that the patient has a musculoskeletal problem
  2. Identify patterns of movement (asymmetry, restricted movement, pain response, behavioural response)
  3. Further determine aggravating factors and directional preference (Extension or flexion)
  4. Obtain a regional or segmental location for the problem Particularly for acute and subacute
  5. Determine key contributing factors to the patients presentation including articular, muscle, neural, sensory systems or developed behaviours that are linked to patient’s problem
  6. Determine outcome measures that can be used to assess treatment effectiveness
  7. Continue to build rapport with the patient
37
Q

What are 2 risk factors for developing or maintaining persistent pain?

A

Risk factors can include:

  1. Unhelpful/maladaptive beliefs (from health professionals in the past)
  2. Troubles returning to activities they used to be able to do (eg. work, exercise, sport)
38
Q

Deviations may be _____variations (postural abnormality is not a cause of pain but may contribute)

A

normal

39
Q

What are 7 things that abnormalities (in postural variations) may reflect?

A
  1. Normal variations for individuals
  2. Structural changes
  3. Articular system impairments
  4. Muscle system impairments
  5. Neural system impairments
  6. Reaction to pain states
  7. Psychological factors
40
Q

____ (Large/minimal) relationship between low back pain and prolonged sitting at work

A

Minimal

41
Q

Standing without freedom to sit ____ (is/is not) associated with LBP

A

is

42
Q

No significant difference in _____, ______ or ______ between patients with severe back pain, moderate pain, or no pain

A

lumbar lordosis; pelvic tilt; leg length inequality

43
Q

No significant difference in the _______ of abdominal, hamstring, and iliopsoas muscles in 600 people with and without back pain

A

length

44
Q

Teenagers with postural asymmetry, excessive thoracic kyphosis and/or lumbar lordosis are _____ (more/no more) likely to develop back pain in adulthood than peers with “better” posture

A

no more

45
Q

Pregnant women with greater increases in low back curve during pregnancy were _____ (more/no more) likely to develop back pain

A

no more

46
Q

People with occupations involving frequent awkward postures _____ (do/do not) have higher levels of back pain

A

do not

47
Q

the link between pain and posture, showed no evidence between measurements of sagittal spinal alignment and ______.

A

pain

48
Q

Systematic review (failed to uncover high-quality studies to support causality between occupational sitting and_____.

A

LBP

49
Q

Another systematic review (2010) found six high-quality studies that showed no association between awkward postures and _____.

A

LBP

50
Q

The research indicates that if any correlation exists between posture and pain, it is _____.

A

weak

51
Q

What are 7 risk factors (not necessarily causes) in regards to postural factors linked to LBP?

A
  1. Working with the trunk in a bent and twisted position for more than two hours a day - stooped posture
  2. Not being able to change position regularly
  3. Greater than 4 hours in sitting positions with poor ergonomics (44% of computer users developed lower back pain) or driving for more than 4 hours a day
  4. Working for more than 75% of work time in front of a computer
  5. Working under pressure, to get tasks done at speed
  6. Having little influence on rest time
  7. Job stress and job dissatisfaction
52
Q

It is show that substantial occupational standing and the occurrence of _____symptoms The exact cut off point of what constitutes ‘excessive standing’ is however not known.

A

low-back

53
Q

Why does poor posture not necessarily “cause” pain?

A
  1. Tissues adapt to stress over time Posture = pain fails to consider that tissues have the capacity to adapt to stress. 2. Tissue damage or stress does not always = pain Even if poor postures could cause tissue damage, tissue damage does not equal pain. Studies consistently show that large percentages (e.g. 20 to >50%) of people with no low back pain have bulging discs and degeneration on MRI Pain is complex, and tissue damage is only one contributor to pain. 3. Different people are different Asymmetry and irregularity are the rule, not the exception. Different size and structure of individuals means “poor posture” for one person might be optimal for another. Comparing posture to an ideal model is inherently problematic.
54
Q

How does tissue adapt to stress over time and not cause pain?

A

Posture = pain fails to consider that tissues have the capacity to adapt to stress.

55
Q

How does tissue damage or stress not cause pain?

A

Even if poor postures could cause tissue damage, tissue damage does not equal pain.

Studies consistently show that large percentages (e.g. 20 to >50%) of people with no low back pain have bulging discs and degeneration on MRI Pain is complex, and tissue damage is only one contributor to pain.

56
Q

How does poor posture not cause pain with different people are different?”

A

Asymmetry and irregularity are the rule, not the exception.

Different size and structure of individuals means “poor posture” for one person might be optimal for another.

Comparing posture to an ideal model is inherently problematic.

57
Q

Posture is extremely ____ (variable/static). Why?

A

variable. Each time we stand we do it in a slightly different way

58
Q

Should we be concerned about posture in the LBP/pelvic pain population?

A

Many people need to sit or stand in the same basic posture for many hours at a stretch. If this is a contributing factor, making variations in posture and activity are likely a better strategy than maintaining one “perfect” posture.

59
Q

When should we assess posture (consider it), 4 features?

A
  1. Does the patient have a relationship between postures and their symptoms? Eg. if sitting is an aggravating factor- Posture might be related
  2. Do the history of symptoms relate to starting/resuming or changing postures? (new job, increased hours, new work tasks or requirements at home)
  3. Are high forces involved? Time AND Load. Posture may be more relevant in tasks that require excessive time and higher load.
  4. Is there variation in the posture? Is there breaks from the aggravating postures? How often? Does it relieve symptoms?
60
Q

What are 4 normal variables in standing posture?

A
  1. Flat back
  2. Sway back
  3. Military
  4. Kyphotic-lordotic
61
Q

What are 7 principles of postural assessment to observe?

A
  1. Pelvic alignment
  2. Real or apparent leg length difference
  3. Lateral curves - Scoliosis
  4. Sagittal curves - Lordosis, Kyphosis
  5. Leg posture, shoulder girdle and arm posture
  6. Look for – Hypertrophy or Wasting
  7. Observe for evidence of protection of joint and / or neural structures

Evaluate symptoms on correction

Evaluate ability to correct posture

Assess in all positions relevant to the patient’s complaint

62
Q

What are 3 possible findings in examination of lumbar flexion?

A
  1. Restriction in movement (physical or behavioural)
  2. Pain
  3. Abnormal movement pattern
63
Q

What is a restriction in movement (physical)

A

Structural changes in tissue ROM

64
Q

What is a restriction in movement (behavioural)?

A

○ The patient stops before they get pain as they feel the pain is going to come on Apprehension due to fear of pain

65
Q

What are 4 characteristics of restriction in movement (physical or behavioural)- possible findings in examination of lumbar flexion?

A
  1. Joint restriction
  2. Regional stiffness (muscle tightness)
  3. Neural tissue movement / extensibility and/or sensitivity
  4. Apprehension relating to fear of movement into range
66
Q

What are 3 characteristics of pain- possible findings in examination of lumbar flexion?

A
  1. Joint restriction
  2. Neural tissue movement / extensibility
  3. Central and/or peripheral sensitization
67
Q

What are 6 characteristics of abnormal movement pattern- possible findings in examination of lumbar flexion?

A
  1. Apprehension or avoidance of pain (behaviours)
  2. Segmental stiffness
  3. Regional stiffness (muscle tightness)
  4. Neural tissue movement / extensibility and/or sensitivity
  5. Muscle spasm
  6. Muscle weakness and inhibition
68
Q

What are the 3 effects of lumbar flexion?

A
  1. Increased intervertebral pressure
  2. Tensile loading in surrounding structures including ligaments, posterior muscles and Z joints
  3. Movement and loading of neural tissue
69
Q

What are the 3 effects of lumbar extension?

A
  1. Increased loading through posterior structures of lumbar spine
  2. Increased pressure on Z joints
  3. Reduced inter-foraminal space
  4. Increased laminal pressure
  5. Movement and loading of neural tissue
70
Q

What are the 3 effects of lumbar side flexion?

A
  1. Increased tensile load on contralateral lateral disc, ligaments and muscle groups
  2. Reduced ipsilateral inter-foraminal space on ipsilateral side
  3. Increased lamina pressure
71
Q

What are the 3 effects of lumbar rotation?

A
  1. Normal = 1-3° at each level.
  2. L5/S1 = up to 6°
  3. Increased lamina pressure
72
Q

L2–L3 and L3–L4 demonstrate a coupled ______ (contralateral/ipsilateral) bending towards the opposite direction of the axial rotation,

A

contralateral (contralateral side flexion)

73
Q

L4–L5 and L5–S1 demonstrate a coupled ______ (contralateral/ipsilateral) bending motion towards the same direction of the axial rotation.

A

ipsilateral

74
Q

Strong correlation between the primary ______ (side flexion) and the coupled bending was found at each vertebral level.

A

axial rotation

PHTY2220 (31 decks)

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