Lec 25 - Musculoskeletal scan Flashcards
what is a scan examination and when is it performed?
screening tool used on orthopaedic assessments after a subjective history is complete prior to the detailed assessment.
what is the principle of a scan examination?
Search for physical signs , positive and negative and their interpretation.
what are the 3 components/pillars of a scan?
- Selective tissue tension testing
- Contractile and inert structures
- Capsular patterns
when testing selective tissue tension, active movement gives us information about
the patient’s willingness to move, the range of movement possible, strength and end range/feel.
what do we often start with in a scan
an active movement selective tissue tension
when testing selective tissue tension, passive ROM gives us information about (3)
- the end feel and patterns in joint
restrictions (capsular pattern). - pain
- the inert tissues (joint capsule, ligament, bursa, fascia)
when testing selective tissue tension, resisted movements gives us information about
contractile elements, strength and pain produced.
what characterizes a resisted movement?
the patient contracts the muscle forcibly in mid-range against resistance (isometric contraction).
* Inert structures are relaxed.
what is what he calls the “golden test”
when you find an orthopedic test or movement that triggers their specific pain which you can come back to later in your session to see if what you’re doing is helping.
capsular pattern is
a limitation of range of motion in a fixed proportion (specific to each joint)
what disease gives the capsular pattern? what works well to treat it?
inflammatory arthritis or a disease/surgery that gives this type of restriction.
manual therapy and exercise that target the joint and capsule.
what are non-capsular patterns? and example
any other patterns not related to the capsule, examples Ligament sprain, tendon, internal derangement (disc, labrum), extraarticular limitation (bursitis, hematoma), bone (AVN, fracture, bone metastasis).
Mr. Jackson has pain with active shoulder flexion, no pain with passive shoulder flexion but pain with isometric shoulder flexion, what is the cause of his pain? inert or contractile tissues?
contractile tissues (it doesn’t hurt passively and related to active movement)
reasons why we do a scan examination (5)
- To ensure patient presentations are within the scope of physical therapy practice. (rule out red flags or referrals)
- The scan helps to streamline your detailed assessment. (find the joints that require your attention and rule out others)
- Briefly consider the presence of regional interdependence or victims and culprits within the quadrant. (pain at te elbow but shoulder if the problem)
- The scan alone can help identify common orthopedic lesions that present acute or sub-acute. (“flared-up”, patient can have multiple pathologies at once)
- To detect gross loss of function, ROM, strength, and movement control. (patient may not outline this is Subjective history)
T or F: 60-80% of the relevant information related to the diagnosis can be obtained from a detailed history.
true, history is the most powerful, versatile tool
what is some key information obtained from a patient history that can lead into your scan?
Main Problem
History of present illness
Medical treatment and medication
Location and quality of symptoms
Behavior of symptoms
General Health
Social history
Psychological History
sleep
what are some clinical red flags that may appear in subjective history?
- Fever
- Diaphoresis (unexplained perspiration)
- Sweats (can occur anytime night or day)
- Nausea, vomiting or diarrhea
- Pallor - pale
- Dizziness/syncope (fainting)
- Fatigue
- Weight loss
what are red flags and why is it important to determine them?
things that might be related to underlying pathologies and may be outside of the PT scope of practice.
name some examples of other flags
orange, yellow, blue and black
Clinical decision making involves two
modes of thinking, what are they?
- intuitive thinking: quick, usually effective, characterized by rules of thumb, clinical patterns and shortcuts. (EXPERIENCED CLINICIANS)
- Can lead to errors (cognitive bias).
- Good for when diagnosis is straight forward. - slower, analytical, and more resource intensive. (NEW GRADS)
- Good for when the patient’s presentation is unusual.
what is regional interdependence?
impairments in seemingly unrelated or remote anatomical regions can contribute to a patient’s primary concern. (biomechanics but could be influenced by neurophysiological mechanisms)
- can include multiple body systems
what are the 9 components of a scan?
- Observation
- Quick Screens
- Active movements & passive ROM
- Myotomes
- Deep Tendon Reflexes
- Sensation
- Neurodynamics
- Upper Motor Neuron Test
- Vascular scan
what are some quick screening tests?
- Quick gait assessment
- Walk on heels and toes
- Squat
- Twist
- One leg standing
- Hand behind back
- Hand behind head
what is a benefit of quick screening tools for the scan?
it looks at multiple systems/joints and coordinated movements
what are some different types of end feels and examples of where we might find them?
highlighted are physiologically normal
what is a myotome?
muscles that are supplied by a single segmental level (BUT most muscles are multi-segmentally innervated) -> motor neuron innervation
When trying to localize segment of lesion, the best option is to test the strength of:
specific key muscles which are most representative of a given segment.
how do you test a myotome? explain it.
a make test: isometric contraction held for 5 seconds.
- may do repitions if weakness suspected
- test one muscle per myotome
how can deep tendon reflex help us?
- Give some information to help localize lesion.
hypertonic reflexes suggests what neuron involment
UMN, inhibition is lost
what is the grading of deep tendon reflexed?
what is a dermatome?
the area of sensation mapped out by a single nerve root distribution
why do we use a wrap around technique when testing sensation?
Dermatomes overlap and are somewhat variable from person to person.
- If an area of hypoaesthesisa, hyperasthesia, dysaesthesia is found, farther testing needs to be completed in detail
dermatomes of the upper limb
dermatomes of the lower quadrant
what is a neurodynamic test
Test the ability of the nervous system and its supporting connective tissue to passively slide or glide in response to trunk or limb movement
what is dura pain?
Pain produced when dura is involved is multisegmental with no defined boundaries
* Pain tends to be “somatic”, like an ache
* Does not produce paresthesia
what kind of pain does problem with ventral root produce?
segmental pain, or radicular pain, which is pain felt along that nerve root’s dermatome
what kind of pain does problem with dorsal root produce?
segmental paresthesia or hypoaesthesias along that nerve root’s dermatome
(usually distal part)
what are examples of neurodynamic tests (5)
- Passive neck flexion (Upper Q)
- Upper limb neurodynamic tests (Upper Q)
- Slump test (Both)
- SLR (Lower Q)
- Prone knee bend (Lower Q)
examples of UMN testing
- babinski response (lower)
- hoffmans sign (upper)
things you look for in observation of upper quadrant scan
Head position, scar(s), muscle atrophy,
scapular position, deformities
what is overpressure
when a patient performs a movement and then clinician applies pressure at end range of movement.
myotomes of the upper extremity and their associated movements
what does the slump test test
- Tests extensibility of dura
what does a slump test look like?
- Patient seated at side of bed with feet unsupported and hands clasped behind
back. - ask patient to slump but down allow pelvis to rotate (slump at stomach)
- chin to chest and hold
- kick out foot and hold leg as close to straight as possible
when do you stop the slump test?
whenever stretch or pain is produced
what is an example of winding up the nervous system in the slump test
Maintain leg position but have patient
look up a little.
* Check if more knee extension is now
available (to onset of symptoms
what is a positive slump test?
produces their typical symptoms. therefore dura involved
describe passive neck flexion for both upper and lower cervical flexion
- Patient lies supine with no pillow
- arms and legs extended
- tuck chin
- Therapist gently maintains tuck and cradles the head around the occiput, then gently lifts head with patient relaxing (combined upper and lower flexion).
what does ULTT-A stand for?
upper limb tension test-A
describe the anatomical positioning of ULTT-A
Scapular elevation is prevented as the arm is sequentially brought into abduction, forearm supination, wrist and finger extension, shoulder external
rotation, and elbow extension.
describe the clinical prediction rule and why we use multiple tests during a scan?
getting a positive score on 4 neurodynamics test greatly increases the likelihood of proper prediction/diagnosis when compared to getting a positive score on 3 tests. Therefore, the more tests we do the more confident we can be in what is creating the symptoms.
what is the final item you want to do in an upper or lower body scan?
palpation
what are you testing for during palpation?
Check for pain provocation
Also check to see how willing the segment is to move
why types of things are you observing/looking for in a lower body scan?
- Postural Type
- Gross deformities
- Scoliosis
- Gait
what action can you perform to test different myotomes of the lower extremities?
what are 3 tests we can do in the lower quadrant to test neurodynamics?
- slump
- straight leg raises
- prone knee bend
What is the straight leg raise test
Nerve root tension test where patient lies supine (no pillow with both legs straight. Slow hip flexion with knee extension is performed to point of pain or tension in either posterior thigh, knee or calf extending to foot.
How many degrees of hip flexion is considered normal during straight leg raise test
70
T or F: Straight leg raise tests can be sensitized by adding additional movements like ankle dorsiflexion, eversion or hip abduction to wind up tissues
T
Describe the prone knee bend test
Patient lies prone and you slow, gentle passive knee flexion is performed while other hand monitors lumbar spine to see if their typical leg complaints show up
What is the prone knee bend test also called
Femoral nerve stretch
Where do you palpate lower back
Apply gentle pressure near lumber spine and level of pain
