Principles in the PT Management of pts inconvenienced by musculoskeletal pathology Flashcards
steps of PT care
Exam, evaluation, diagnosis, prognosis, intervention, outcomes
Review of Systems (ROS)
historically collecting data from pt about different systems of body
systems review
tests and measures (objective measurements)
principles
a fundamental guiding sense of the requirements and obligations of right conduct
management
to take charge, control or care of
patient
individuals who are recipients of PT management who have a disease, disorder, condition, impairment, functional limitation and/or disability
what does it take to become a successful PT
- cognitive realm
- affective realm
- psychomotor realm
what is a history and why is it useful?
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systemic gathering of data
-related to why PT services are requested
Use data to form initial hypothesis of diagnosis and etiology
Obtaining the history
- chart or medical record review
- typically obtained during your interview, but may be augumented by questionnaires or other sources
what do we get from the history
- demographic profile
- social/family/history
- occupational employment
- living working, playing environment
- current and past general health history
- current and past functional status
- prior medical alternative, or other interventions
- current condition
- current complaints
- patient expectations/goals
Patient-Therapist History Interview
- first impressions
- LISTEN TO THE PATIENT
- Appropriate for age, gender, culture, etc
- taken in an orderly or systematic sequence
- may result in arriving at a PT diagnosis
- focus the pt on relevant information
- attempt to start the interview “open ended” and progress to “close ended”
- AVOID LEADING THE PATIENT
- -when did this episode begin
- -does this reproduce your symptoms?
P-T history interview: open ended approahc
- guides but not restricts discussion
- patient is allowed to express what they feel is important
- often enhances rapport building
P-T history interview: closed ended interview
- direct question approach
- list of predetermined questions
- answers are assumed to fall into predetermined categories
- be cautious not to “lead” the patient
the Patient history interview sequence
- age, gender, referral source, Dx, hand dominance
- occupation (employment and recreation)
- -requirements, elections or aspirations
- -environment (home environment as well)
- -status
- why has the pt come for help? (overview of present condition, chief complaint)
- onset of condition (traumatic/insidious)
- previous related injuries or episodes
Pt history interview: symptoms
- quality
- anatomical location
- constant/intermittent
- pattern
- provocative or associated activities
functional status
- past and present
- parameters
symptom quality
- mechanical c/o (locking, stiffness/tightness, clicking/popping/snapping/grinding=degenerative instability, giving way/buckling/slipping out=instability)
- –something in joint if locking, sitff/tight could be bone on bone
- color and/or temperature changes (infection, inflammation, lack of color, ecchymosis)
- numbness, parathesias, dysathesias
- weakness
- spasm
- pain
numbness
nothing felt at all
parathesias
loss, tingling, half of body (one arm vs the other)
dysathesias
altered sensations
pain quality
see note chart
anatomical location of symptoms
- localized pain
- de-localized pain
- -referred vs radicular
referred pain
- within a sclerotome
- emanates from deep somatic tissue, confusion of brain
radicular pain
- dermatome/myotome
- nerve root
- spreads down one arm
patient history interview: other risk factors and co-morbitities
- lifestyle (smoking, alcohol, drugs, nutrition, actvity level, social history)
- family history
- any similar symptoms
patient history interview: residual patient thoughts
- other important/significant thoughts or concerns regarding:
- -symptoms
- -contextual relevance of condition
- -goals, needs or desires
- -expectations of PT intervention
- patient opinions as to what the problem is
systems review
- brief screening procedure
- provides information about the bodily systems involved in the pts current condition or health
- helps identify possible health problems that require consult or referral to other health care professionals
- results may effect further examination and intervention procedures
how does history affect the systems review
-determines the necessity and extent of the review
systems to be screened objectively
- cardiovascular/pulmonary
- integumentary
- neuromuscular
- musculoskeletal
- communication ability
Screen exam
- upper/lower quarter screen
- musculoskeletal subset of the system review that emphasizes joints of the body to help determine where the pathology is located
- -r/o referral of symptoms from other issues
5 reasons to perform a screen
- no history of trauma (insidious)
- suspect referred/radicular symptoms
- doubt about locatoin of pathologies exists
- altered sensation
- unusual pattern or collection of symptoms
tests and measures
- conducted after history and systems review
- range from brief to lengthy
- generate data most often regarding impairments and functional limitations
- order should be prioritized
- ask yourself: “should this be compared bilaterally?”
- –answer=ALWAYS
- start uninvolved/less involved-baseline
prioritize tests and measures: considerations
- safety
- comfort
- goals
- social needs
- cognition
- physiological needs
- psychological needs
- functional needs
- financial needs
- vocational needs
- medical treatment priority
PT musculoskeletal tests and measures
- ROM
- Muscle Performance
- Joint Integrity and Mobility
- Posture, body mechanics and motor function
- gait, locomotion and balance
- pain
- sensory integrity
- reflex integrity
- athropometric characteristics
- special tests
- assistive and adaptive device
ROM exam should include
- quantity of AROM and PROM
- Quality
- smoothness, movement pattern - Symptom provocation
- does this reproduce your symtoms
documentation of ROM
- type of motion assessed
- quantity of AROM and PROM
- quality
AROM: quantity and quality
- if limited/abnormal, ask yourself why?
1. Active muscle dysfunction? - problem w/muscle “organic weakness”
- reflex inhibition due to pain or effusion
- tissue reactivity: inflammation, abnormal motor recruitment (guarding or splinting w/antagonists and subsititutions with synergists)
2. passive motion restriction? - blocking ability to go forward, tightness
3. joint stability? - will present w/limited AROM b/c uncomfortable
PROM: quantity and quality
- if PROM is limited, ask why?
- ROM limited b/c instability w/opposing group
1. passive insufficiency? - looking at muscles that cross two joints
2. intrarticular obstruction - loose body
- ROM may change each time
- vs acl tear with limitation at same spot each time
3. muscle guarding or splinting? - apprehension
- pain from tissue reactivity
- biomechanical load intolerance
resisted isometric testing: 4 exam responses
- strong and painless
- strong and painful
- weak and painless
- weak and painful
different end feels
- hard end feel-bone on bone
- soft end feel-soft tissue approximation
- firm end feel-shoulder flexion, springy rebound
- empty end feel- complaint of pain that prevents full endfeel
ROM: pain provocation: compression load
compression load intolerance->Reactivity
- articular cartilage subchondral bone
- periosteum
- bursa/fat pad
- tendon and/or tendon sheath
- meniscus or articular disk
- neural tissue
ROM: pain provocation: tensile load
- capsule
- ligament
- tendon or muscle
- neural tissue
AROM and PROM findings
- if AROm is full and pain free you may often choose not to perform PROM
- if AROM
Specific tests and measures: muscle performance
s
strength
10 rep max, % of 10 rep max
power
1 rep max
endurance
longevity, duration
contraction types
concentric
eccentric
isometric
muscle performance examination: resisted isometric tests
- myotomal, break patient
- cyriax classifications
- force to pain onset-dynanometer, objective measure
MPE: strength/endurance tests
- MMT
- isotonic x RM testing
- isokinetic testing
- functional task testing
How should the presence of pain during resistive testing guide our use of strength testing in the patient population
dont use strength testing if pain during brake testing
resisted isometric testing (break)
testing abilities of contractile unit -innervation (myotome/peripheral nerve) -muscle -myotendinous junction -tendon -tendoperiosteal junction examining gross strength in a static position possible reactivity (pain production)
examiner observations during resisted isometric movement
- whether the contraction causes pain and, if it does, the pains intensity and quality
- strength of contaction
- type of contraction causing problem
resisted isometric testing: procedure
- test position is neutral and mid range joint position
- joint should be kept still
- instruct the patient to hold the test position while resisting the examiner’s break or make force
- PT gradually increases force until a maximal muscle contraciton is achieved or patient cannot resist the force
- hold 3-5 seconds at peak force
cyriax’s isometric testing results
Grade 0: strong and painless
Grade 1: strong and painful: minor muscle/tendon involvement
Grade 2: weak and painful: more severe muscle/tendon lesion
Grade 3: weak and painless: complete muscle or tendon rupture or neurological problem. organic weakness
isometric force to pain onset testing
- test position is a neutral joint position
- joint kept still
- instruct the pt to hold the test position while resisting the break force
- PT gradually increase force until onset of pain
- -handheld dynamometer
- -weights
- -time
- record force measure bilaterally
proceed to MMT
- once resisted isometric break testing has confirmed weakness within a nerve root, MMT should be performed to isolate specific muscles innervated by that root
- important tool for determining the muscular cause of movement dysfunction
joint integrity and mobility testing
- examination of accessory motions
- -component motion and joint play
- testing performed by the PT
- normally
component motion
motion that accompanies active motion, but not under voluntary control (upward rotation of the scapula with clavicular rotation
joint play
motion that occurs between the joint surfaces (arthrokinematics-roll, slide distraction, compression)
loose pack postion
loosest postion for joint where you can get the most ROM
mennels rules for joint play testing
- pt should be relaxed and fully supported
- examiner should be relaxed and should use firm but comfortable grasp
- one joint should be examined at a time
- the movement should be examined one a time
- unaffected side should be tested first
- one articular surface is stabilized while the other surface is moved
- movements must be normal and not forced
- movements should not cause undue discomfort
posture, palpation, body mechanics and motor function
begin palpation procedure with a visual examination -skin and subcutaneous tissue in the affected area -note any: areas of localized edema or effusion ecchymosis or hematoma -abrasions or lacerations -discoloration of skin and nail beds -calluses, blisters, scars -atrophy or hypertrophy -alterations in contour
palpate to examine
- tissue temp
- -increase temp: increase inflammation decrease sympathetic activity
- -decrease: decrease vascularity, increase sympathetic activity
- moisture and texture
- -moist and smooth (inc. symp)
- -scaly and dry (dec. symp)
- -skin mobility via rolling: adhesions?
- tenderness (inflammation, trigger sites, leave to end of exam if known
- sensation
- muscle status
- -increased/decreased tone
- -trigger sites
- -continuity or defects
- swelling
- -edema: pitting or non-pitting
- -effusion
- pulse
- bony alignment and relationships
- mechanical signs
- bilateral comparison
palpation procedure
- inform pt as to what is coming
- have target and purpose in mind
- confidently proceed
- use no more pressure than necessary
- start superficial then progress to deep
- may choose to use the back of the hand to detect temp
- tips of the fingers most sensitive and discriminating
palpable tenderness grading
grade 1: pt complains of pain
grade 2: pt complains of pain and winces
grade 3: pt winces and withdraws the joint
grade 4: pt will not allow palpation of the joint
sensory integrity testing
- assessment of deep and superficial sensations
- proprioception
- kinesthesia
- touch sensitivity: peripheral sensory
- touch discrimination
- bilateral comparison
proprioception
static joint position sense
kinesthesia
dynamic, passive awareness of movement
touch sensitivity: peripheral sensory
light brush or wisp of cotton
- temp
- pressure
touch discrimination
-2 point and sharp/dull
reflex integrity
- used to determine excitability of the nervous system and the integrity of the neuromuscular system
- developmental reflexes (pediatrics)
- pathological reflexes-not normally present (babinski, clonus, etc)
- muscle stretch reflexes/deep tendon reflexes
deep stretch reflexes (MSR)/Deep tendon reflexes (DTR)
- pt and muscle must be relaxed
- tendon placed on slight stretch
- elicit: strike tendon with reflex hammer
- repeat 5-6 times to note fading response-bilateral comparison
- hyporeflexia: lower motor neuron
- hyperreflexia: upper motor neuron
- if needed, jendrassik maneuver to enhance DTR
- -UE: adduct LE together
- -LE: clench UE together
anthropometric characteristics
- describes human body characteristics including atrophy and edema
- measures:
- -height (ruler)
- -weight (scales)
- -body fat (caliper, electrical impedance)
- -girth: flexible ruler, volumetric technique
- bilateral comparison or normative comparison
mesomorphic
athletic build
endomorphic
round/curvy frame
ectomorphic
very skinny, low body fat
special tests
- regional tests designed to confirm whether or not a specific condition is present
- often many available per condition
- often provacative
- special tests are used in conjuction with other examination data to formulate a diagnosis
- not the be all end all of pt
- test validity is often questionable
- -skill of examiner
- -presence of multiple conditions
special test uses
- to confirm a tentative diagnosis
- to make a differential diagnosis
- to differentiate between structures
- to understand unusual signs
- to unravel difficult signs and symptoms
