Musculoskeletal Flashcards
What are the Goals of the MS Assessment?
- Exclude serious pathology
- Consider pain mechanisms (nociceptive, neurogenic, central sensitization)
- Determine influence of contextual factors and other co-morbidities
- Understand how other psychosocial factors are influencing the condition (emotions, beliefs, etc.)
- Identify the nature of the symptoms (joint specific, soft tissues, motor, etc.)
- ID appropriate **course of treatment **
Clinical Guidelines
- Follow a framework
- Have 4 Components
What are the 4 Components of Clincial Practice Guidelines?
Component 1: Medical Screen
Component 2: Differentiation of body functioning, acitvity, and participation restrictions associated with health conditions - “Pattern recognition”
Component 3: Assessment of severity, irritability, stage and stability of condition
Component 4: Match intervention strategies based on findings
Component 1: Medical Screening
- PMH
- Subjective and Objective information
- Ransford Pain Diagram/ Visual Analog Pain Scale
- Psychological Risk Factors (Tampa Sclae of Kinesiophobia, Pain Catastrophizing Scale)
- Functional Outcome Measures (Ex: Shoulder Pain and Disability index)
Component 2: Differentiation fo Subjective and Examination Findings
ID Source of Pain
Differentiation of Patient Subgroups!
Pattern recongition
Standardized Examination
Patient Centered Examination
Functional Asteriks/Comparable Sign
ID Source of Pain
Nociceptive Pain (more “acute”)
Proportionate pain
Aggravatign and alleviating factors
Intermittemnt sharp or dull ache
No dysesthesia, burning or shooting
May be reffered pain (Joints, muscles, heart)
Peripheral Neurogenic (radiating pain)
Pain in dermatomal or cutaneous distribution
ULTT (Upper or Lower Tension Test) and sensitivity to nerve palpation
Hx of nerve injury
Central Sensitization
Disporpotionate pain
Disporotionate aggravating and alleviating factors (or unable to ID them)
DIFFUSE non-anatomic tenderness. Lower threshold to produce pain
Psychosocial issues – pain affected by mood, emotions, beliefs
Differentiation of Patient Subgroups
- Cognition and Personal Beliefs
- Mobility/Flexibility
- Motor Function
Cognition and Personal Beliefs
Patient understanding of their condition
Fear avoidance beliefs/kinesiophobia
Mobility/flexibility
Joint Mobility (arthritis, impingement)
Soft Tissue mobility/flexibility/tone
Neurodynamic mobility
Motor Function
Motor control/coordination (Moving normal)
Muscle Strength (force)
Muscle endurance (maintain force over time)
Patient Centered – Identify an Asterik Signs
During exam, ID an asterik sign yo continually assess to determine effectiveness of intervention and refine your clinical reasoning of what is best for patient
Common are:
Specific motions, findings or functions which provoke symptoms
Qualitative and Qualitiative changes within or between session changes
Component 2: 2 Parts of the Examination
- Standardized Exam : Done on EVERYONE
- Differing Elements: Done to differentiate impairments to mobility
Standardized Exam - Musculoskeletal
Patient Interveiw
Systems Review/Screening (as needed); Integument, Neuro, CV
Structural inspection-position (Posture/gait)
Motion Assessment
Functional assessment
AROM
PROM
PROM w/overpressure
Differentiating elements - tests
Joint palpation and mobility/accessory motion
Muscle palpation and muscle length/flexibility
Neurodynamic Mobility
Motor Assessment
-Acitvation/coordination
-Strength (MMT)
-Endurance
Special Tests
1a. Patient Interview
Chloride PA
Contextual Factors
1b. Systems Review
MD referral vs patient self refferal
PMH
Surgery or no surgery
Type of meds
Subjective interview
1c. Structural Inspection – Assessing Posture and Gait
What is ideal posture?
-No ideal posture!
-Don’t teach posture can cause fear!
**Asymmetries from side to side or from what you expect
-Structural vs functional deformities
–Structure: Cannot change. Related to bone/muscle
–Functional: Can change! Body has adapted to symptoms such as pain. **
-Overall shape or area
-Deformities, swelling, atrophy
Gait (Covered later)
Posture and Alignment: Priority or Pointless?
Priority
Initial evaluation of every new patient
Is posture relevant?
Guide you assessment/treatment
Limiting Factor: STATIC ASSESSMENT; Cannot make assessment on function
1d. Assessing Joint Movements
4 Parts:
-Functional Movemnt
-AROM
-PROM
-Overpressure at end ROM
Search for Quanitity, Quality, Symptom reproduction
Functional Movement
Global assessment
Functional motions to replicate symptoms
Put on a coat
AROM
Assess contractile (muscle) actively
Assess noncontractile (bone, cartilage, tendon) tissues actively and passively
Reveals quantity and quality
PROM
a. Stress contractile structures passively by stretching them
b. Stress non-contractile tissue passively
c. Assess what occurs at end range (“end feel”, pain,etc)
d. Assess Muscle tone
Voluntary: muscle guarding (can modify it)
Involuntary: tonal abnormalities
Hypertonia – UMN
Hypotonia – LMN
Flaccidity – Both
Rigidity – UMN
Feeling of limb chnages with change in tone
Apply Overpressure at end range of motion assess “End-Feels” - 5 Types
Muscular (Elastic)
Capsular
Ligamentous
Bony
Soft Tissue Approximation
Muscular (Elastic)
Elastic feel, slow resistance, creep at the end
Ex: Hamstring
Capsular
Sudden end with firm arrest
Less creep
Ex: ER of shoulder at 90 degrees, knee extension
Ligamentous
Sudden end with firm arrest
No creep
Ex: Varus and Valgus
Bony
Hard, rigid, sudden stop
Ex: Elbow extension
Soft Tissue Approximation
Soft and Spongy
Ex: Biceps Flex
What are “Abnormal” End Feels?
Spasm/guarding/empty
Springy
Bony
Capsular
Loose (unstable)
Boggy
Spasm/guarding/”empty”
Patient prevents the PT to get to end range
Muscle guarding
Associated with pain an/or fear
Springy
Rebound effect
Cartilaginous block in joint due to intraarticular derangement
Ex: Hip – labral tears, Knee – Meniscus
Bony
In a joint not expected – OR
Occurs sooner than expected
Ex: OA
Capsular
In a joint not expected – OR
Occurs sooner than expected
Ex: Hip Capsular
Loose (unstable)
Hypermobile joint or unstable joint
Boggy
Prescence of joint effusion
Ex: Infection/Abscess in joint
Ex: “Capsular Pattern” to PROM Limitation
- Each joint has a characteristic pattern of loss of motion if capsule is tight/restricted
- Will observe limited motion with capsular end feel during multiple motions
- Ex: Shoulder. Loss of ER, Abduction and IR
- Ex: Hip. Loss of Flexion, ER, and IR
2a. JOINT Palpation and Joint Accessory Movements
2 Parts:
A. Palpate joint and joint structures (when able to)
B. Assess joint “accessory motion” (aka: joint mobility or joint play)
In Search of:
* Reproduction of pain with palpation
* Abnormal findings with palpation
* Limitations of accessory joint motion
* Bilateral comparison
Accessory Movements “joint mobility”
- AKA: Joint mobility, Joint play, Arthrokinematic movements
- Assessing the movement of the joint that the patient does not have control of
- Normal joint mobility is necessary for full motion and function of the joint
- Replicates the arthrokinematics the joint undergoes to achieve full active movement
- “Roll”, “glide”, “rotation” of the joint
- Limitations often related to capsule/ligament tightness
Classification of Joint Movement
Normal
Hypomobility: Pathological
Hypermobility (Laxity): Somes pathological (Nonpathological)
Instability: Pathological
Other:
* More laxity inferiorly
* Takes lots of experience to determine “normal”
* Can help with capsular restrictions with joint mobility: improves mobility and flexibility of joint capsule
Joint Mobility Assessment
- Due to limited mobility, difficult to assess
- Where the pain is felt indicates patients irritability
- If patient is more irritable, pain will be seen earlier in the ROM
- Hypomoblity seen in capsular tightness
Assessing Congenital Hypermobility
- (aka: Benign Hypermobility Joint Syndrome)
- Hyperextension of fingers parallel to the forearm (2)
- Place thumb on ipsilateral forearm (2)
- Hyperextension of elbows and knees over 10° (4)
- Lumbar flexion – able to touch palms to the ground (1)
- **May be acquired joint laxity. **
- More points, more likely to have general hypermobility
- 4+ is considered hypermobility
- Ex: Someone with this condition is more likely to dislocate shoulder
Muscle Palpation and Muscle Length/Flexibility/Tone
2 Parts:
A. Muscle palpation to assess for pain/tenderness/ tone
B. Muscle length/flexibility testing
In search of:
* Reproduction of pain/symptoms with palpation
* Abnormal findings with palpation(increase tone)
* Limitations of muscle length/flexibility
* Bilateral comparison
Which muscles are more susceptible to irritability Grouping of muscles?: Postural (tonic) vs. Phasic muscles
Postural (tonic)!
Postural Muscles
- “Facilitated muscles” (Increased neural input and increased neural tone; tend to be more tight/limited)
- Tend to be biarticular
- Increased tendency to tighten/high tone compared to phasic muscles
- Lower irritability threshold (“Biased recruitment” AND more tender to palpation)
- Commonly symptomatic (pain with palpation and limited flexibility)
Biased Recruitment
Doesn’t take as much to cause contraction
Phasic Muscles
- “Inhibited muscles”
- Tend to be uniarticular
- Antagonistic to postural
- Tend to have more limited motor control or force production deficits (get weak as a result of pain, immobility or disuse)
Lower Cross Syndrome is also called…
Lumbo-pelvic complex
Upper Cross Syndrome is also called…
Cervico-thoracic-scapular complex
Lumbo-Pelvic Complex - Postural Muscles
- Erector spinae
- Latissimus dorsi
- Quadratus lumborum
- Iliopsoas & rectus femoris
- TFL
- Hip Adductors
- Piriformis
- Hamstring
- Gastroc & soleus
Lumbo-pelvic complex - Phasic Muscles
- Gluteus maximus
- Biceps femoris
- Transversus abdominus
- Internal oblique
- Multifidus
- Pelvic floor muscles
Cervico-thoracic-scapular complex - postual muscles
- Upper trapezius
- Levator scapulae
- Suboccipitals
- SCM
- Scalenes
- Latissimus dorsi
- Pec major / minor
Cervico-Thoracic-Scapular Complex - Phasic Muscles
Deep neck flexors
Serratus anterior
Rhomboids
Mid and lower trapezius
Shoulder external rotators
Why are muscles palpated?
- Tone: as in increased tone side to side as a result of muscle guarding or increased pain
- Pain Pressure Threshold (tenderness): How much force does it take to elicit pain. Ex: Put a pressure gauge on someone somewhere
- Every muscle has a specific referral pattern. When you press and refers it is known as a “trigger point” (Latent trigger point “pain but no refer”)
–People who are more sensitive are more likely to have referral pain
– Chronic muscle irritability is more likely to refer to begin to refer symptoms
Assessing Muscle Length/Flexiblity
2 Methods:
- Active Assessment
- Passive Assessment
- MUST BE AWARE OF MM INFLUENCE ON JOINTS THEY CROSS
Altered Muscle Tone/Flexibility Theories (2)
- Prolonged or habitual positioning can lead to muscle shortening or lengthening (DISPROVEN)
OR
- Pain and/or guarding can lead to increased tone in mm - Abnormal muscle tone/length may lead to:
– Diminished joint active and passive ROM
– Abnormal or inefficient movement patterns
– Compensatory motions
– Pain: sensitivity to pressure
Neurdodynamic Mobility
- Perform when pain is of neurogenic origin
- Assess the irritability of peripheral nerves to increase in tension
- “Limb Tension Tests”
– Upper Limb Tension Tests (3 primary nerves of UE)
– Lower limb Tension Tests: SLUMP Tests of LE (Sciatic Nerve of LE)
Joint/Muscle/Nerve Mobility Assessment:
- Where the pain is felt, indicates patient irritability
- Pain before you feel resistance is a highly sensitive injury
MS Assessment Sequence
Lack of AROM -> Normal PROM is likely a muscle coordination issue; strength deficits
We need to match appropriate treatment to appropriate impairment
Altered cognition/beliefs - Pattern Recognition Example
- Interview: patient states uncertainty and fear
- AROM and PROM may be limited due to fear of movement
- Overpressure: not allowed
- Palpation: Tenderness and tone with apprehension
Joint mobility deficity - Pattern Recognition Example
- Feels tight in joint
- AROM AND PROM: Limited with BOTH
- Overpressure: capsular end feel
- Joint mobility assessment: deficits in mobility
- Palpation: Tenderness of joint structures
Soft Tissue Tone - Pattern Recognition Example
- Feel a stretch with motion
- AROM may be limited
- PROM limited if muscle stretched
- Overpressure: muscular (elastic) end feel
- Flexibility tests: deficits noted
- Palpation: Tenderness of muscle structures
What are the 4 factors that affect motor function?
- Pain
- Injury to nerve tissue
- Injury to joint
- Length Tension Relationship of Muscle
Pain
Pain inhibition
Apprehension/Fear
Cortical mapping changes
Injury to nerve tissues
PERIPHERAL NERVOUS CONDITIONS
Nerve root = Myotomal weakness
Peripheral nerve = weakness of all muscles innervated by the nerve
CENTRAL NERVOUS SYSTEM CONDITIONS (Stroke/TBI/SCI)
Injury to Joint
Several studies have correlated joint injury to weakness of muscles that cross joint AND joints proximally and distally
Length Tension Relationship of Muscle
Depending on position of the joint, a muscle may either be strong or weak according to its length.
Note: Optimal force is between extremes. This is why we do MMT at midlength. It is the safest for joint and can produce more force here.
Motor function Testings - 3 Parts
- Muscle Coordination/Activation/Balance
- Strength
- Endurance
Muscle Coordination/Activation/Balance
- Patient awareness of how to activate/contract mm on command without compensation
- Coordinate movement patterns: dissociate movements (Move femur seperate from hip)
- Commonly need to perform with PHASIC muscle due to pain
- Pain inhibits phasic muscle activation
- Assess ability of patient to activate muscle on command WITHOUT COMPENSATION OF TONIC MUSCLES
Strength Assessment
Isometric testing: MANUAL MUSCLE TESTING
Manual or standardized resistance through ROM
Isotonic testing with use of machines (Manual resistance: One repetition vs. multiple repetitions)
Test strength using a constant external resistance: May use 1-RM or repetition max of a specific weight
Advantages and Disadvantages of MMT
Advantages
cheap
done in variety of positions
Quick
Easy
Disadvantages
muscle length held constant
strength at only one point of the range
unreliable
inconsistent how people do it
Endurance Testing
Assess ability of muscle to maintain contraction at a statice resistance against external force for a period of time.
Ex: Side Plank
What do we assess in component 3?
Assess Symptom severity, irritability, nature, stage, stability : SINSS
Severity
- Intensity of symptom (0-10, How does the symptom affect life/ADL)
Mild Severity
Verbal, facial or body language indicate minimal pain
No limitation of ADL’s
Recreation is minimally affected or not limited
Sleep is OK
“mild, dull, ache, annoying, tight, stiff”
Pain 0-3/10
Moderate Severity
Verbal, facial or body language indicate pain and/or guarding
Modified ADL’s
Doing 40-80% recreational activity
“Throb, hot, burning, deep ache”
Meds needed
4-7/10
Severe Severity
Verbal, facial or body language indicate severe pain
Some ADL’s avoided or severely limited
Recreation/work abandoned
Sx’s force pt to stop activity
Deep, boring, lancinating, shooting, stabbing
8-9/10
Irritability
- “Ability to aggravate and ease symptoms (sx’s)”
- High, Moderate, Low
- Based on 3 variables
– Amount needed to cause/provoke the sx
– Severity of sx provoked
– Activity and time to ease sx
Why test for irritability?
Guides vigor of intervention
Non-irritable
Sx’s ease quickly
Symptoms provoked with OVERPRESSURE during ROM assessment
Moderatley Irritable
- 1:1 ratio of symptom ease : time to provoke
- Symptoms provoked at end range during ROM assessment
- Do not provide overpressure
Severly irritable
- Sx’s quickly provoked and are severe and take long time to ease
- Symptoms provoked prior to end range during ROM assessment
Tissue Irritability =
Treatment Vigor
What limits the VIGOR of treatment?
Moving to a limit of Pain- Stopping at the limit where pain commences - Severe /irritable patients
Moving to the limit of Motion- Moving to end-range and appreciating end-feels - Less severe /irritable patients
Nature of Symptoms and Pain
Hypothesis of structure involved and/or classification of pathology. “Pattern recognition” (Cognition, joint mobility, etc.)
Hypothesis of primary pain component
Ex:
- Cognition/personal beliefs affecting function
- Joint vs. muscle vs. nerve mobility affecting function Neurogenic vs. muscular
- Motor function affecting function
Stage
- Acute: 0-10 days (usually more nociceptive pain)
- Subacute: 1 week to 6 weeks
- Chronic: Beyond 6 weeks (pain becomes more central sensitization)
- Acute on chronic: Chronic symptoms with acute exacerbation
- Assists in determining prognosis
- Assists with intervention
The sooner we see patients the better the prognosis
Stability
- Symptom progression over time
- Stable: Worse/better/same
- Worse: symptoms becoming more frequent or more intense or covering a larger area
- Better: Less frequent, less intense, smaller area
-
Same: has been fairly stable over a period of several weeks/months
-OR- - Unstable: difficult to determine a pattern
- Assists with clinical reasoning with treatment
What is component 4?
Intervention based on findings
Intervention strategies based on findings
Match up appropriate intervention with appropriate impairment
- Examples
* Cognition – Patient education
* Joint mobility issue – Specific joint mobilization techniques
* Flexibility issue – soft tissue mobilization and stretching
* Motor issue – enhance muscle coordination/strength/ endurance through exercise
* THEN: ASSESS HOW THE PATIENT RESPONDS TO THE TREATMENT. ASTERISK SIGN
