Principles of MSK Examination and Evaluation: Test 1 Flashcards
1
Q
what are the 2 models of disablement
A
traditional biomedical model for pain = doesn’t consider other complaints/sources
international classification of functioning, disability, and health = includes pain/function but also diseases/impairments; measures level of disability
2
Q
key components of history (x7)
A
symptoms and behavior
onset/prior injury
symptom impact/function
imagining/diagnostic tests
pt perspective/goals
past med history/medications
RED Flags
3
Q
what falls into the “symptoms and behavior” of a patient history
A
location
duration
changes
irritability
type (i.e. sharp, numb, deep ache, etc)
4
Q
why isn’t all tissue in a stage of healing
A
can have pain and inflammation with symptoms but no healing is taking place
5
Q
describe the use of imagining in creating a dx
A
high sensitivity low specificity
really good at ruling things out, not so good at telling what specifically IS wrong
6
Q
what is the difference between a rigid and flexible body type
A
rigid = flatter spine with tight hips and genu and calcaneal varus; more propulsive
flexible = excessive spinal curve with hyper mobile hips and genu/calcaneal valgus; more absorbing
7
Q
what are some examples of normal dominance asymmetries
A
ipsilateral shoulder depression
ipsilateral thoracolumbar SB an dRT
more hyperextended knee
flatter foot
8
Q
difference between signs and symptoms
A
symptoms = subjective; reported by patient
sign = objective; measured by clinician
9
Q
purpose of a scan (x5)
A
further assess for Red flags
assess neurological status
determine if symptoms are referred or radicular
assess severity of condition
identify need for more in depth biomechanics exam
10
Q
what are AROM tests for (x5)
A
test willingness to move
ROM
integrity of contractile tissues
pattern of restriction
symptom reproduction
11
Q
what does PROM test
A
integrity of inert and contractile tissues, ROM, and sensitivity
12
Q
what do resisted tests test
A
integrity of contractile tissue (strength and sensitivity)
13
Q
what do dural tests do
A
test dural mobility
14
Q
what do neurological tests tell you
A
nerve conduction
15
Q
what do dermatome scans test
A
afferent sensation
16
Q
what do myotomes test
A
efferent (strength and flexibility)
17
Q
how do you start a scan WITHOUT a recent trauma
A
start with respective spinal scan and work out
especially if history of spinal P!
18
Q
how do you start a scan WITH a recent trauma
A
start with involved areas and then assess adjacent regions
19
Q
aberrant motion in ROM testing indicates what
A
joint hyper mobility/instability
20
Q
sharp curve for fulcrums in ROM testing indicate what
A
joint hypomobility
21
Q
what are essential ADLs
A
walking, reaching, squatting, bending, turning, etc
22
Q
improved function/pain with AROM indicates (x3)
A
inhibited muscle, regional interdependence, or disc injury
23
Q
worse pain or function with AROM indicates what
A
acute injury/irritation
24
Q
what is a red flag in regards to AROM
A
unwillingness to move/splinting
25
if during ROM testing pain occurs in the direction of the same AROM and PROM then what is indicated
a non-contractile tissue (i.e. cartilage, capsule, ligament, etc)
26
if during ROM testing PROM is restricted similarly to AROM in the same direction want is indicated
joint hypomobility or protective guarding is indicated
27
if during ROM testing PROM is significantly greater than AROM in the same direction then what is indicated
joint hyper mobility/instability
28
if both WB and NWB motions are limited, what is the likely cause and general Rx
cause = fused, fixated, or hypo mobile joint
Rx = improve joint mobility
29
if WB motion is limited but NWB motion is WNL, what is the likely cause/Rx
cause = joint hyper mobility/instability with impaired neuromuscular control
Rx = improve neuromuscular control
30
what is a capsular pattern of restriction
based on PROM
firm end feels; characteristic loss of motion
typically due to arthritis or prolonged disuse
31
what is non-capsular pattern of restriction
any pattern not in a capsular pattern
variety of reasons
32
what is indicated with there is a consistent block with combined motion
blocked no matter the path = hypo mobility
follow up with accessory motion test
33
what is indicated if there is an inconsistent block with combined motions test
hyper mobility/instability
follow up with stability tests
34
what is indicated with there is limited motion in opposing spinal quadrants during a combined motion test (i.e. L SB/RT into fox and R SB/RT into ext)
indicates fibrotic joint (scar tissue)
follow up with accessory motions
35
proper position for resists testing
slightly back off from P! that occurred with ROM
primarily test midrange with break test and "don't let me move you"
36
what is resisted testing
NOT manual muscle testing/grading
apply gentle pressure to distal segment of joint
hold at least 3 sec to assess neuromuscular adaptation capacity and NOT max strength
37
strong and painful result of resisted test indicates what
mild injury (i.e. grade I strain)
only painful in lengthened range
38
weak and painful response to resisted testing indicates what
acute (mod to severe injury)
i.e. grade II/III strain or fracture
39
what does a weak and painless response to resisted testing indicate
neurological damage or chronic contractile rupture (i.e. tendon tear that has healed but not reattached properly)
40
what is indicated if the same pain occurs in one direction of AROM and/or resisted testing and the opposite direction of PROM
contractile tissue indicated
41
what is indicated with resisted testing go there are symptoms upon release
possible non contractile tissue as glide is released when muscle is relaxed
i.e. when you make the muscle contract it stabilizes the joint, but when you let off of that resistance the instability/symptoms return
42
what is indicated with there are multiple planes of weakness at one joint during resistance testing
possible acute/severe injury
i.e. fracture
43
what is indicated during resistance testing if there are multiple joints of weakness
indicates possible CNS issue
i.e. all UE joints are weak
44
what is indicated with weakness throughout a range and not just midrange during resisted testing
possible pathology is indicated
45
with repeated resisted testing, what does improved function/pain indicate
inhibited muscle and/or regional interdependence
poor muscle recruitment, but signal to recruit more as reps go on
46
with repeated resistance testing what does decreased force indicate
possible N palsy
fatiguing weakness
47
with repeated resistance testing what does consistent weak force indicate
deconditioned/torn muscle is indicated
something in contractile property isn't changing; no capacity to recruit more muscle fibers
48
with repeated resistance testing what does worse pain/function indicate
acute condition
aggravating with more reps
49
when do you not perform a stress test
if known damage, deformity, or fusion is present
50
what are the steps of performing a stress test and the possible indications
start with rapid/shallow force
pain indicates acute condition (doesn't take much to aggravate)
if no pain then apply a slower, larger, and deep force; hold for 10 sec
if only 10 sec hold causes pain a persistent condition is indicated (i.e. joint hyper mobility/instability)
51
what are some signs that further indicate hypermobility/instability with a stress test
** stress via compression/distraction not same as PROM end feel** (stressing joint structures)
late, empty, and/or soft end feels
click, clunk, and/or spasm (muscle guarding)
52
if there is increased pain with distraction this indicates what
capsule, ligament, or annulus involved
53
if there is decreased pain with distraction then what is indicated
indicates joint surface tissue(s)
i.e. cartilage, nucleus pulposus, bone, or spinal N involved
54
if compression decreases pain what tissues are indicated
capsule, ligament, or annulus involved
55
if increased pain occurs with compression what tissues are involved
joint surface tissue(s)
i.e. cartilage, nucleus pulposus, bone, or spinal N involved
56
what is indicated if both compression and distraction produce pain
acute condition
57
what is a dermatome
area of skin sensation supplied by a single segmental spinal nerve
considerable overlap
typically creates paresthias
58
what is cutaneous nerve distribution
area of skin supplied by peripeheral N
more distinct boundary
typically creates numbness
59
what should you do if during sensory testing both light and sharp touch are within normal limits in the presence of paresthesias
use pinwheel to check for hyperpesthesias due to nociplastic P! (increased sensitization of the brain)
60
if sensation of light or sharp touch is diminished in sensory testing what is the next step
repeat for incrimination of other spinal nerve or cutaneous nerve pattern
61
what should you test for if light/fine touch sensation is lost and you are concerned about an UMN injury
check vibration, 2 pt discrimination, and proprioception
62
what should you test for if there is loss of sharp touch and you are concerned about an UMN injury
check temperature and crude touch for possible spinothalmic tract issues
63
what are the levels of results for sensory testing neurological tests
0 = absent
1 = diminished
2 = WNL
3 = hyperesthesia
64
what are the levels of results for the DTR or myopic reflex
0 = absent
1+ = hyporeflexive; LMN condition
2+ = WNL
3+= hyperrefelxive - large arch but normal dampening; UMN condition or nociplastic pain
4+ = clonus; > 3 beats; UMN condition
65
release of primitive reflex indicates what
UMN impairment
66
what are myotomes
key muscle or group of muscles innervated by a single spinal nerve
67
what is tension restriction in a dural mobility test
inelasticity
pain increases from both ends of nerve being "pulled"
68
inelasticity or inflammation of a nerve may lead to what
reproduction of achy or sharp symptoms or paresthias
69
how would you describe the muscle tone of a patient with a LMN injury
decreased or flacid
70
how would you describe the muscle tone of a patient with a UMN injury
increased/spastic velocity
dependent to resistance; co contractions
synkinesis: UE flexion causes LE flexion
71
bowel/bladder of patient with UMN injury
spastic/retentive
72
bowel/bladder of patient with LMN injury
incontinence/leakage
73
describe the dermatome/paresthesias of a patient with LMN injury
often a single segment diminished
rarely multisegmental
74
describe the dermatome/paresthias of a patient with a UMN injury
multi segment diminished with face, extremities, and or trunk
including vibration, temp, and proprioception
75
describe the deep tendon reflexes of patients with UMN vs LMN injuries
LMN = hypoactive
UMN = hyperactive
76
describe the myotomes of patients with LMN vs UMN injuries
LMN = often single segmental fatiguing weakness; rarely multi
UMN = multi segmental weakness/incoordination/paralysis of face, extremities, or trunk
77
what signs might be present with an UMN injury but not a LMN injury
pathological reflexes (i.e. clonus or babinski)
mentation changes
78
describe the superficial reflex in UMN patients vs LMN patients
LMN = not present
UMN = hypoactive
79
purposes of a biomechanics exam x3
confirm/reject findings
assess for more details in indicated areas
continue to assess for red flags
80
what types of tests may be included in a biomechanical exam x6
additional functional testing (as needed)
quantity limited ROM
accessory motion
special tests
MMT and muscle activation after fully assessing joint integrity
palpation
81
describe the additional functional testing that might take place during a biomechanical exam
functional movement screen - general application
higher level includes jumping/hopping, agility, and running analysis
82
how would you quantify limited ROM in a BM exam
with a goniometer
83
when do you perform an accessory motion test
if limited ROM and/or consistent block is present during combined motions
84
how would you go about an accessory motion test
asess in neutral or open packed = easier feel (but could also access towards block)
compare both sides/adjacent joints in same position
85
describe the ease/predictability of doing an accessory motion test
easier to pick up hypo mobility than hyper
intra-examiner (within) reliability is much greater than inter-examiner (between) reliability
86
what is PPM
passive physiological mobility
assess glides with extremity osteokinematics
87
what is PAM
passive accessory mobility
assessing glides without osteokinematics
more commonly performed in extremities
88
what is PPIVM
passive physiologic intervertebral mobility
assessing glides with spinal osteokinematic
more commonly performed in spine
89
what is PPAIVM
passive physiologic accessory intervertebral mobility
assesses glides without osteokinematics (spine)
90
what is indicated with accessory motion and ROM is limited
restriction is articular or related to a joint restriction (i.e. capsular shortening or joint restriction)
91
what is indicated if accessory motion is WNL but ROM is limited
restriction is extraarticular (i.e. muscle shortening, guarding, or joint hyper mobility/instability)
92
what does accessory motion abnormality indicate
indicates improper axis of joint motion and subsequent excessive stress on adjacent tissue
93
describe what a normal axis of motion should be like
should never be on the articular surface of a joint
should always be changing due to gliding/rolling
94
describe special tests/why we use them
typically more precise than stress tests
may help identify more specific tissues, their integrity, and assess progress
not as "special" as they are thought to be; don't always get a result/indication
95
how do you choose a special test
based on usefulness per research and working dx
composite/cluster testing is more accurate than isolated testing
96
what is a provocative test
type of special tests
identify tissues indicated by the reproduction of symptoms during the test
97
describe stability tests
assess integrity of non-contractile tissue for 3 things
1- provocation
2-late/empty/soft end feels (i.e. grade I, II, or III strain)
3- segmental play- assessing for excessive linear shearing of vertebra
also perform if excessive ROM and/or inconsistent block noted with combined motion
no immediate symptoms = then hold for 10 sec like with stress tests
98
if pain or laxity occurs with stability tests what is the next step
retest with m.activation, closed packed position, corrected posture, or external support
if symptoms and/or laxity improves than a confirmation of joint hyper mobility and a better prognosis
99
what is a muscle length tests
passive flexibility of muscles
100
what are anthropometric tests
body dimensions with tape measurer
101
describe the usefulness of special tests
sensitivity or SNOUT = so good at finding positives that when you get a negative test you can rule that tissue out (good at avoiding false negatives
specificity or SPIN = so good at finding negatives that when the test is positive you can rule the tissue/condition out (good at avoiding false positives)
~ 90% is acceptable level for sensitivity and specificity
102
describe the likelihood ratio of special tests
combines sensitivity and specificity
OPTIMAL diagnosis statistic
not affected by condition prevalence
103
what is a positive likelihood ratio
likelihood of a positive test when the patient has the condition
the higher the better
large likelihood shift > 10
moderate likelihood shift 5-10
104
what is a negative likelihood test
likelihood of a negative test when the patient does not have the condition; the lower the better
large likelihood shift < 0.1
moderate likelihood shift 0.1-0.2
105
what is QUADAS score
quality assessment of diagnostic accuracy studies
examines the quality of research
greater than or equal to 10/14 = higher quality studies
106
what is a MMT
manual muscle testing
attempting specific muscle testing and grading (0-5)
typically performed in mid range with break test and "don't let me move you"command
lengthened - passively insufficient position is used to locate milder/grade I strains
107
when would you test strength in a fully lengthened, mid range, and fully shortened positions respectively
lengthened = tightens inert components and tests for muscle tears
mid = muscle in strongest position/tests overall power
shortened = weakest position; used to detect palsies, especially if coupled with eccentric contraction
108
describe the hold/force for MMT
hold at least 3 sec to better assess neuromuscular adaptation capacity and not maximal strength
force should be smooth, exponential increase to a linear force
109
why is MMT not very reliable or valid
it's subjective with all 4/5 and 5/5 scoring
tends to overestimate strength
especially unreliable with inexperienced users or in the presence of pain or other ligamentous tests
cannot be used to predict function
110
what is MMT not good at
finding smaller deficits
111
symptoms upon release of MMT indicate what
possible articular issue as glide is released when muscle relaxes
112
multiple planes of weakness at one joint indicates what with MMT
possible acute and/or significant injury
113
multiple planes of weakness with MMT indicate what
possible CNS issue
114
weakness throughout a range with MMT indicates what
possible pathology
115
if there is a weak or painful response to MMT how many times should you repeat testing
at least 3
116
with repeated MMT what does improved pain/function indicate
inhibited muscle and/or regional independence
117
if there is decreased force with repeated MMT what does that indicate
N. Palsy
118
if there is consistent weak force with repeated MMT what does that indicate
reconditioned/ torn muscle
119
worse pain/function with repeated MMT indicates what
acute injury/irritation
120
what are you assessing and how would you assess muscle activation and endurance
often assessing stabilizing, postural and local mm
utilize palpation/observation as able
endurance holds should be solid for 20s
compare bilaterally as a reference
121
what can you assess with palpation in a BM exam
temp - warm = acuity, cold = poor circulation
turgor and possible pain - with skin rolling indicates dehydration or nociplastic pain
swelling - watery indicates acuity and thickness/pitting indicates chronicity
122
what does a scratch test look for
significant reddening indicating acuity
123
hypertonicity of a muscle indicates
inhibited mm that are overworked/protecting
palpation is not reliable on the spine
124
how would you rate circulation with pulses during palpation exam
0=absent
1+=diminished
2+=WNL
3+=bounding
125
what does tenderness to palpation indicate (TPP)
localizing involved tissue or deformity like a fracture or tear
126
describe TTP grades 0-iV
0 = none
1=mild; TTP without grimace/flinching
2=moderate; TTP with grimace/flinching
3=severe; TTP to palpation with withdrawal (jump sign)
4=hypersensitive; withdraws sign to non-noxious stimuli
