Lecture 1: Introduction

Question 1

1. What is the sin of omission?

2. What is the sin of commission?

Answer 1

1. You delay their access to more appropriate care by your failure to diagnose
2. Make them worse or injure them

Question 2

What should an introduction, background and history give you?

Answer 2

Careful, succinate clinical examination, that leads to accurate diagnosis, selection of appropriate interventions and determination of prognosis = effective and efficient treatment

Question 3

A musculoskeletal assessments consists of what? There are 8 parts
slide 15

Answer 3

1. Patient history
2. observation
3. Examination of movement
4. Special tests- orthopaedic
5. Reflexes and cutaneous distribution
6. Joint play movements
7. Palpation
8. Diagnostic Imaging

Question 4

2. Tell me about the observation part?

starting slide 19-23

Answer 4

begins in the waiting room and patient doesn’t know your observing. Watch them get out of their, watch patient walk into the treatment room (leaning, fashion, pain accessories i.e. own chair, gait)
Here is a measure of how effective your treatment will be. You must build your bond with your patient through communication and gaining rap our.
-are there any physical defects or abnormalities related to the patients pain/ problem.
-you should look for:
-patients way of moving
-general posture
-psychological state
-willingness to cooperate
-any signs of illness behaviour- i.e. wearing braces, bring their own chair etc

1. Observe the posture- normal for this patient?
   Anteriorly: Nose, xiphoid and umbilicus should be straight line
   Posterior: mastoid process, shoulders, iliac crest and popliteal creases should all be level bilaterally
   Laterally: Tip of the ear, tip of the acromion, the high point of the iliac crest and lateral malleolus (anterior aspect) should be in a straight line.
2. Is there any obvious deformity?
   Structural deformity= present at rest e.g. torticollis (abnormal, asymmetrical head or neck position, which may be due to a variety of causes), fractures, scoliosis, kyphosis
   Functional deformity= result of assumed posture and disappear when the posture is changed.
   Functional curves may be positional. For example, if a person stands asymmetrically, with one knee bent, and the pelvis tilted downward, a curve will be present, but this will go away as soon as the knee is straightened and the pelvis is held parallel to the floor. Structural curves are those that have stiffness within them, such that they do not go away with changes of position. These therefore have much more significance than functional curves.

Dynamic deformity= caused by muscle action a d are present when muscles contract or move joints e.g. hiking of the shoulder for an injured joint capsule.

3. Is there symmetry?
   - very few people are perfectly symmetrical
   - deviations should be noted as they maybe contributing to problems e.g. lower shoulder
   - bone contours and soft tissue contours should be checked for asymmetry e.g. muscle wasting.
4. Colour and texture of the skin:
   - skin markings- melanomas
   - bruising
   - skin disorders can lead to arthritis e.g. psoriasis
   - perioheral skin lesions can present with skin problems
5. Are there any scars?
   - old or new, shows surgery and injuries
6. Are there any abnormal sounds when the joint moves? Crepitus and snapping? ( popping and cracking sounds in joints.)
7. Are there any signs of inflammation?
   - redness, heat, swelling, pain
8. Patient reactions:
   - is the patient apprehensive, restless or perhaps depressed (withdrawn, partners made them come)
   - is patient willing to move
   - is their pattern of movement normal?

Question 5

3. Examination of movement.
   what do you have to do first in this section?
   Why do you do this?
   Have to be aware of what?
   In what order does the sequence take place and what do you do in each section?

Answer 5

1. First you must gain informed consent.
   - the exam is used to confirm or refute the suspected diagnosis
   - if patients in pain be mindful of this.
   - good side should be assessed first
   - Active > passive then resisted isometric contractions.
   - Any painful movements should be performed last
   - If AROM is full application of over pressure can be use to assess joint end feel
   - resisted movements are done with joint in neutral position (stress only contractile tissue)
   - must warn patient it may exacerbate their symptoms
2. Active ROM- examiner should note:
   -which movement causes pain or any other symptoms
   -Where in the movement the pain or symptoms occur
   -amount and quality of pain that results (type of pain)
   -The rhythm of movement
   -Any limitation, unusual or tick movements
   May be abnormal due to:
   -pain
   -weakness, paralysis, spasm

3. Passive ROM
Differences in AROM and PROM may be due to:
-muscle contraction 
-spasm 
-muscle deficiency
-neurological deficit 
-contractures 
-pain 
Hypermobile joints more likely:
-ligament sprains, joint effusion, chronic pain, recurring injury, paratenonitis from instability, early osteoarthritis. 
more susceptible to:
-Muscle strains, pinched nerve syndromes, paratenonitis from overstress

4. Resisted isometrics movements: start from resting, neutral position. Does contraction cause pain? If so where and the pains intensity and quality
   -Strength of the contraction, and type of contraction which causes pain
   Grading 1-5 (5 normal)

Question 6

4. Special Diagnostic Tests consist of:

Used to?

Answer 6

-orthopaedic tests/ neurological tests
-lab tests
Used to:
-confirm a tentative diagnosis
-make a differential diagnosis
-differentiate between structures
-understand unusual signs
-unravel difficult signs and symptoms

Diagnostic tests should never be done in isolation e.g. lasletts criteria

Joint play:
Asses while joints in resting position, unaffected side tested first
Grading:
1- Patient complains of pain
2- Patient complains of pain and winces
3- patient winces and withdraws the joint
4- Patient will not allow palpation of the joint

Deep tendon reflexes (0-4) 2 is normal