The examination: subjective, physical and clinical reasoning Flashcards by Julia Armenti

What are the 5 main aims of the subjective examination?

collect and interpret info about problems from pt’s perspective
develop therapeutic alliance
understand pt’s beliefs, understandings, goals, preferences, insights
identify any flags
provide a basis and direction to p/e

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What are red flags an indication of?

recent major trauma, severe pain with minor trauma, pain worse at night, pain that doesn’t improve with physio, history of cancer, IV drug use, immune suppression, neuro S+S, bowel or bladder disturbances

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What are constitutional symptoms?

loss of appetite, unexplained WL, fever, chills, night sweats, fatigue, general malaise –> systemic illness

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What are the 4 types of yellow flags?

Cognitive, affective, unhelpful/maladaptive behaviours, social

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Why are yellow flags important to address?

influences behaviour
influences compliance
acts as a barrier to recovery
transition from acute to chronic
strong predictor of outcome

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Yellow flag: cognitive

thoughts and beliefs -ve/unhelpful atitudes and beliefs, inappropriate expectations, poor self-efficacy, low expectations of recovery

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Yellow flag: affective

emotional: depression, anxiety, fear, stress, worry

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Yellow flag: unhelpful/maladaptive behaviour

slow rigid movements, inappropriate protection, inconsistent movement behaviours linked to attention, passive coping strategies, feat avoidance, withdrawal from interactions

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What are blue flags?

employee and workplace factors that are barriers to recovery

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What are black flags?

compensation and system factors

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Yellow flag: social

low SES, low education, poor health literacy, poor family support

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Examples of lifestyle factors

poor sleep - increased pain sensitivity
smoking - poor healing
chronic stress
sedentary lifestyle
adipose tissue

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Examples of whole person considerations

poor self reported general health
widespread pain
diabetes
genetics

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What is symptom severity?

how firm therapist needs to be to reproduce symptoms

-high SS = pain at rest, 7/10 pain, significant referred pain, sleep disruption

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What is disorder irritability?

how easily (or not) the symptoms get worse, symptom severity when exacerbated, how quickly symptoms ease back to baseline level

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What are the key components which point towards non-mechanical pain?

constant/widespread pain
stimulus-response decoupled
disproportionate pain in response to mechanical stimulus
inconsistent/unpredictable

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What is the difference between a risk-screening tool and an outcome measure?

risk screening tool: identifies pts at risk of a poor outcome
outcome measure: used to evaluate change from one point to another

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Why is it important to gain social history early?

To determine the effect of the pt’s problem on their function

What should be included in the body diagram?

area of symptoms (in pt’s words), areas of parathesia, constancy of pain, nature of symptoms, 24h behaviour, depth, severity, relationship

What is the significance of superficial vs deep pain?

Superficial: from localised tissue, precise location of perceived pain
Deep: referred or from deep structures, may have vague boundaries

What is the significance of night pain?

spontaneously waking up/moving in bed causes pain = mechanical
preventing sleep = acute inflammation

What is the significance of morning pain + lengthy stiffness?

inflammatory condition/state

What is the significance of pain that increases through the day?

related to sustained or repeated loading

What are asterisk signs?

signs that can be compared/reassessed between treatment sessions

What are the key aims of the p/e?

- confirm source of symptoms and nature of pathology - confirm/negate mechanical nature of injury - identify impairments and correlate with symptoms - establish involvement of neuro - exclude red flags

What are the general components of the p/e?

Observation --> functional testing --> screening tests (AROM, PROM, passive over-pressure) --> combined movements --> passive accessory movements --> resisted isometric muscle tests --> manual muscle testing --> muscle length test --> motor control examination

When would you test PROM?

when AROM is impaired

What is the purpose of passive over-pressure?

- pick up subtle ROM losses - get joint EF - gain comparable signs

What are three normal end feels?

soft (soft tissue), form (capsular), hard (bony)

What are three pathological end feels?

different on each side, springy, empty

What are passive accessory movements?

normal subtle passive movements that occur between joints

What is the purpse of resisted isometric muscle tests?

determines whether or not contractile muscle tissue is a source of symptoms

What position should the joint be in when assessing resisted isometric muscle tests?

loose packed/mid position to minimize joint compressive forces

What is the difference between open and closed packed positions?

Open packed: position with the least amount of joint congruency, capsule and ligaments are lax, joint play is maximised Close packed: position with the most amount of joint congruency, capsule and ligaments are tight, accessory motion is minimised

What is the definition of a diagnosis?

a patho-anatomical source of symptoms and underlying pathology

What is the difference between a specific and non-specific diagnosis?

specific: specific patho-anatomical S+S, underlying pathology and MOI established non-specific: patho-anatomical S+S not established with certainty

What are the classifications>

Acute, sub-acute, chronic/persistant

Acute classification

- response to trauma/noxious events - traumatic onset - inflammatory response - non traumatic onset - tissue sensititsation - adaptive responses to facilitate natural recovery and prevent further damage - Mx: pain control, prevent further damage, explanation, reassurance, active Mx

Sub-acute classification

- traumatic - normal expected healing - non-traumatic - symptoms subside as part of disorder's natural history - adaptive responses gradually extinguished - Mx: gradual restoration of function, address impairments, pain control

Chronic/persistent classification

- symptoms extend beyond expected period of healing - pain behaviours become mal-adaptive - Mx: ensure no red flags are missed, identify and address symptoms contributing to chronic symptoms

What are the two classifications of peripheral MSK pain disorders?

- movement impairment disorders: articular hypomobility, tight/hypertonic contractile tissue - motor control impairment (muscle imabalance

Signs of articular hypomobility

- pain/stiffness at EROM - decreased AROM and PROM - RI muscle tests pain free - firmer end feel earlier in range - decreased PAM - secondary impingements in muscle length, strength, endurance

Signs of tightness/hypertonic contractile tissue

- AROM and PROM decrease in direction that lengthens tissue - firm end feel - pain on palpation - normal PAM - pain free resisted iso - pain/pull at end of ROM

Signs of motor control impairments (muscle imbalance)

- pain provoked by movement - may be associated with joint laxity/instability - normal ROM - normal/increased PAM