Week 1 Flashcards
What can we do as a physio?
PEMAT
Physical devices
EPA
Manual therapy
Advice and education
Therapeutic exercise
aims of patient interview
- To establish rapport with the client, including cultural safety.
- To begin the process of identification of a musculoskeletal disorder as opposed to other causes (red flags)
- To determine any precautions &/or contraindications to assessment or treatment
- To determine any relevant psycho-social factors for the patient (yellow flags)
- Determine and document a clear and accurate representation of the client’s consultation today
- to create goals
types of yarning
social yarn
managemrnt yarn
diagnostic yarn
patient interview - main problem
- Establish why the client has come to see you or why they have been referred
○ “What brings you here today?” (90 second rule)
red and yellow flags
Red flag:
○ Symptoms, signs and patterns suggestive of serious pathology
Yellow flag
○ Psychological and social predictors of chronicity
patient interview - body chart
- Indicate area of body involved (and possible structures)
- Clear other areas using a tick
aggravating factors
- “What aggravates the pain?”
- “Is there an activity or movement that brings on the pain or makes it worse?”
- “How long can you do the activity before pain starts or increases?”
- “Does the pain stop or can you continue?”
- “How long before the pain eases?”
Example record: Aggr. Going up 12 stairs, Pk immed (5/10), stops immediately after
AM-PM (day) - patient interview
- “Does the pain change during the day?”
- “Is the pain worse on waking or does it worsen during the day?”
Irritability - patient interview
- Severity (VAS)
- Duration to onset
- Duration to ease
- Consider type of activity that aggravates e.g. pain immed with waling vs pain immed with running
- Classify as mild, moderate or severe
Current history (CHx) - patient interview
- “When did the pain/sympton start?”
- Duration of symptoms may indicate stage of pathology e.g.
acute or chronic/overuse injury, stage of healing
Mechanism of injury (MOI) - “How did the injury happen?”
Predisposing factors - Ask patient if they have changed any factors recently
Progress - “Is the pain better, worse or unchanged?”
This information can help you decide if the condition
Treatment to date - “Have you had any treatment?” “Was the treatment effective?”
- Duration of symptoms may indicate stage of pathology e.g.
Previous history (PHx)
- “Is this the first episode/time you’ve had this injury/symptom?”
- “When was the first time?”
- “Is it occurring more frequently and/or more severely?”
- “Have you recovered completely after each episode?”
Medical and social history - patient interview
Explain to the patient why you need to know this
- Determine contraindications and precautions to Rx and examination
- Diagnosis
Observation (Obs)
- Starts from as soon as they/you enter room, or even prior
- Observe total body posture
- Gross changes in skin, muscle contours, body alignment
observations at the local area
- Then in detail at local area
○ Deformity
○ Swelling
○ Skin colour
○ Muscle wasting
○ Muscle spasm
○ Muscle imbalance
○ Traumatic or surgical scars
Active movements (AROM) purpose
To find movement impairments with signs (pain, resistance, spasm, etc) that are comparable with the patient’s symptoms & disability (“their pain”).
Passive movements (PROM) purpose
To differentiate between contractile and non-contractile sources of symptoms
- E.g. joint versus muscle/tendon
- Q: the movement is painful when performed actively, but not when performed passively - interpretation?
Passive Physiological movement (PPM)
Movements that a person can carry out actively
e.g. ankle dorsiflexion
Passive Accessory movement (PAM)
Movements that a person cannot perform independently but are
necessary for joint movement
- Roll, spin, slide/glide
- Distraction, compression
e.g. anteroposterior glide of talus during ankle dorsiflexion
Quantitative tests
Strength testing
- Manual muscle test (through range)
- Handheld dynamometry
Isotonic/Isokinetic testing
Qualitative tests
- Functional muscle testing
- Resisted isometric contractions
Recruitment /activation patterns
- Resisted isometric contractions
Resisted/Static Manual Muscle Testing (MMT)
- Assess whether muscle/tendon is a source of pain
- Provides a quick screen of general strength
- Standardised test procedure
- Note if there is pain and where (“what are you feeling and where are you feeling it”, “is that YOUR PAIN that you came to me about”?)
Recruitment/activation pattern
- Hip extension should be initiated by gluteus maximus, then hamstrings (hamstrings often dominant in hip / lower limb dysfunction)
- Knee extension should recruit VL & VMO simultaneously (often VMO delay in dysfunction of the knee)
Adjacent joints or regions
- May refer pain/symptoms to the area of primary problem
- May have altered function that is a predisposing factor to presenting problem (e.g. ↓ calf strength = ↑ risk Achilles Tendinopathy
Special orthopaedic tests
- Depends on the area examined and its unique anatomy and function
○ Ligament stress tests (e.g. valgus stress test for MCL)
○ Dynamic instability tests (e.g hop)
○ Meniscal (e.g. McMurrays)
Neurological assessment
- Neurological examination
○ Tests nerve conduction and function- Neurodynamic tests
- Tests sensitivity to movement
- Neurodynamic tests
observation and initial palpation - knee and patella
Position of the limb - evidence of deformity such as genu varus or valgus
Swelling – size of effusion, location, intra vs extra capsular
* Bruising
* Scars
- Position of patella in the transverse plane – centrally, medially or laterally positioned.
* Squinting of patellae
* Patella height (patella alta or baja)
* Fat pad hypertrophy at base of patella
* Quadriceps (VL vs VM), VMO bulk
q-angle
- normal is approx 17 degrees in females and 14 degrees in males
General - observation and palpation
- Symmetry of weight bearing / ability to weight bear.
- Lower limb positioning e.g. if OA hip may stand with hip in ER and slight flexion.
- Swelling, bruising, scars
- Leg length
Feet - observation and palpation
- Observe resting fore, mid and rear foot positions.
- Hallux valgus or bunions
- Abducted or adducted relative to midline and rest of leg.
- First toe – hallux valgus (adducted first toe) deformity.
- Location of calluses
- Often useful to look at wear patterns on shoes for insidious onset problems.
Mid foot - observation and palpation
- Malleolar height (R vs L)
- Medial longitudinal arch – intact, high (pes cavus), flattened (pes planus)
Ankle - observation and palpation
- Swelling in lower leg or ankle – joint versus soft tissue
- Location of bruising if present
Femur and Tibia - observation and palpation
- Tibial inclination, any impression of tibial IR or ER
- Lower tibial varus or valgus
- Tibial torsion
- Femoral torsion
- Muscle bulk (esp. calf)
pelvis - observation and palpation
- Iliac crest heights R vs L
- Symmetry of height of ASIS
spine and trunk - observation and palpation
- Symmetry of shoulders
- Abdominal tone (lower abdominal wall, external oblique, rectus abdominis)
Standard Procedure for all Functional Movements
- informed consent
- test unaffected side
- before movement ask about symptoms
instruct the patient - perform moveemnt
- record
Examples of functional movements/tasks for the lower limb:
- Walking: assess gait speed (1.2m/s for community ambulation, Langlois et al, 1997; normative values dependent on age and gender, Bohannon & Andrews, 2011)
- 10MWT
- TUG
- Walking on toes and heels, medial and lateral foot borders
- Heel raise (bilateral +/- unilateral)
- Standing on one leg (+/- higher level proprioceptive challenges)
- Single Leg Squat
- Standing hip flexion
- Squat
o 1⁄4 Squat, 1⁄2 Squat etc. - Steps/stairs
- Sit to stand.
- Sitting – cross legs, figure 4
- Jumping (Landing Error Scoring System)
- Hopping
- Jog or running
- Foot loading (from non-weight bearing to weight bearing)
- Picking something up off the floor, putting on a sock (lumbar/pelvis/hip)
- Activities described by the patient in patient interview.
- Dorsiflexion in WB/Lunge Test (Knee-to-wall test)
DF in WB/Lunge Test/Knee to Wall Test
- Patient standing with foot perpendicular to wall with middle of calcaneus & 2nd toe on a line perpendicular to wall.
- Lunge forward with knee until anterior knee just touches wall with the heel and foot in remaining in position above.
- Ensure heel does not lift.
- Use tape measure to record
- 10cm is normal
Assessment of active and passive physiological movement and clearning tests - hip
hip joint quadrant or F/Add test
Assessment of active and passive physiological movement and clearning tests - knee
- Flexion (allowing hip flexion), with abduction/adduction
- extension, with abduction/adduction
