MSK ~ Overview Musculoskeletal Exam
When are special tests most accurate?
- Immediately after an injury (Ligamentous or instability examinations) - Under anesthesia (cortical inhibition, less reflexive or muscular guarding) - In chronic conditions may be other factors that devalue tissue specific tests.
Test and Measures-a systematic approach/funnel approach
-Broad to specific -Palpate throughout exam •Observation •Posture (Head to thoracolumbar) •Edema •AROM/PROM/PROM w overpressure •Muscle performance/MMT •Flexibility •Joint Mobility •(not so) Special Testing •Functional Activity
During resisted isometrics, you find the ms/movement is weak and painless. How would you interpret this finding?
-Complete rupture of muscle tendon unit -Neurologic cause - either peripheral or nerve root origin
How do you document ROM?
-Documented as a "RANGE" with a start and end value -end feel assessment
What do you need to know to fully describe the pt's pain?
-Intensity (Pain scales) -Duration -Frequency -Location -Type (descriptors) -Associated with? (specificity → activity, time of day, OR I eat a meal and 3 hours later my shoulder blade hurts)
What to look for with concordant sign?
-Looking for test, measures, function that reproduces the pain. -Those symptomatic tests, measures, or functions become our assessment/re-assess variable
What do you need to know about the Hx of Present Illness/Chief Complaint (CC)?
-Mechanism of Injury/Reason for PT -SINSS -Traumatic Vs. Non-traumatic/ Insidious
What should you try to find out in the pt hx and subjective info?
-Medical/Other Mngmt -PMH/PSH -Medications
During resisted isometrics, you find the ms/movement is strong and painful. How would you interpret this finding?
-Minor lesion in muscle tendon unit -No neurologic pathology
What is contractile tissue testing?
-Muscles, their tendons, & insertions -When assessing contractile tissue, check pain & strength.
What is systemic pain?
-Pain in a full system (e.g., gastrointestinal, integumentary, rheumatological) -Red and yellow flags -May use Review of Systems to identify
During resisted isometrics, you find the ms/movement is weak and painful. How would you interpret this finding?
-Partial rupture of muscle tendon unit -Pain inhibition -Concurrent neurologic pathology
During resisted isometrics, you find the ms/movement is strong and painless. How would you interpret this finding?
-R/o muscle - tendon unit -No pathology
•The Guide to Physical Therapy states, "The tests and measures performed as part of an initial examination should be only those that are necessary to (1) ________ and (2) _______."
1. confirm or reject a hypothesis about the factors that contribute to making the individual's current level of function less than optimal 2. support the physical therapist's clinical judgments [assessment/hypothesis] about the diagnosis, prognosis, and plan of care
If you feel that a pt has a red flag, how many more questions should you ask to confirm?
3-4 more questions
How long to hold an MMT?
5 seconds
What is your first objective at the initiation of patient care?
Are you the appropriate provider for the patient? → Should you refer, co-manage, consult, retain/treat
What does observation include?
Assessing movement/dynamic postures, transfer, coordination, etc. from moment you see patient
What are you assessing with muscle length?
Assessment of structures (usually contractile) that can impair/impede ROM
When does assessment start with patient?
Assessment starts when visually observing the patient
Pain & Tolerance for function: Level 6
Constant dull ache at rest that does not disturb sleep
Pain & Tolerance for function: Level 7
Dull aching pain that disturbs sleep
T/F: Special tests work great used alone.
False
T/F: Psychosocial factors won't limit force production/effort in certain people.
False; they may
During resisted isometrics, you find all movements hurt. How would you interpret this finding?
Hysteria (Medically incongruent pain)
Why is initial communication beneficial?
Initial communication adds more information (more assessment/synthesis of information)
Order of the PT exam for looking/viewing, palpating, and listening.
Listen, Look, Palpate
If AROM is limited during UQS, what should be done next?
PROM
If AROM is full during UQS, what should be done next?
PROM w/ overpressure
Describe nature of sx's.
Pain Type: nociceptive, neurogenic, viscerogenic, central sensitization Pain complaints: sharp, aching, deep, burning Affective: Red/Yellow Flags Age, Personality, Cultural Factors
Pain & Tolerance for function: Level 1
Pain after specific activity
Pain & Tolerance for function: Level 2
Pain at the start of activity, resolving with warm up
Pain & Tolerance for function: Level 4
Pain during & after activity, which does affect performance
Pain & Tolerance for function: Level 3
Pain during & after activity, which does not affect performance
What is MSK pain?
Pain from specific musculoskeletal structure (e.g., bone, nerve, muscle)
Pain & Tolerance for function: Level 5
Pain with activities of daily living (ADL)
What does SINSS stand for?
Severity Irritability Nature Stage Stability
Describe a useful exercise for synthesizing information to determine postural deviations.
Start listing out postural impairments per upper quarter segments and associating impairments that would cause said postural deviation: Ie: Elevated shoulder....impairments: ↑ tone of UT, GHJ OA, RC impairment
Concordant Sign(s) / Asterisk
The concordant sign defined as the [provocative] pain or [provocative] symptom that is familiar to the patient, i.e. usually the symptom for which the patient is seeking physical therapy. Anything I can do to make the pain better or cause it
T/F: Grip strength may be useful for overall F production of the UE.
True
T/F: Special tests, if negative, they do not necessarily rule out the problem (low sensitivity).
True
T/F: Special tests, if positive, they are strongly suggestive of a particular problem (high specificity).
True
Examples of visceral pain.
Vascular: migraine, dissecting aneurysms, ischemia Other: pancreatitis, cardiac ischemia, peritoneal inflammation
In pt centered care what should be considered?
What does the patient value? •Communication -Verbal -Non-Verbal •What do you need to consider to include the patient in the process -PCM 2
What are Mennell's Rules for Joint Play?
a. Patient should be relaxed and supported b. Examiner should be relaxed and should use a firm, but comfortable grasp c. One joint/movement should be examined at a time d. The unaffected side should be tested first e. One articular surface is stabilized while the other surface is moved f. Movement should be normal and not forced g. Movements should not cause undue discomfort
What is guarding?
abnormally stiff, interrupted or rigid movement while moving the joint or body from one position to another
rule in vs out slide
all normal findings
What is rubbing?
any contact between hand and injured area (touching, rubbing, holding painful area)
In the systems review, what should you consider for neuromuscular fx?
balance, gait, coordination, transfers
What is the systems review?
brief or limited examination of: (1) the anatomical and physiological status of the cardiovascular/pulmonary, integumentary, musculoskeletal, and neuromuscular systems (2) the communication ability, affect, cognition, language, and learning style of the individual. -The physical therapist especially notes how each of these last 5 components affects the ability to initiate, sustain, and modify purposeful movement for performance of an action, task, or activity that is pertinent to function.
In the systems review, what should you consider for communication/cognition?
comprehension, concisely explain, oriented, etc
What does PROM > AROM potentially mean?
contractile element weak, neurologic, psychosocial factors
Jendrassik maneuver
cross legs and pull or grasp hands and pull
Examples of PNS disorders.
diabetic neuropathy, postherapeutic neuralgia, trigeminal neuralgia
Severe enough proximal insult leads to distal ______ due to the gravity.
edema/swelling
Why may repeated contractions could be useful when assessing ms performance?
fatigable
High level/chronic stage of rehab may require muscle performance testing in ________.
functional positions (overhead athlete, grip strength)
What are the 5 overt pain behaviors?
guarding, bracing, rubbing, grimacing, sighing
What range are resisted isometrics performed?
midrange → not optimal ms length
If AROM is FULL and overpressure is applied at end of AROM and there is no pain then ________.
no further ROM assessment in this plane of motion (b/c it is normal)
What does AROM = PROM potentially mean?
obstruction to normal motion of joint, entrapment of structures (labrum, meniscus) *inert
What is sighing?
obvious exaggerated exhalation of air usually accompanied by the shoulders first rising and then falling; patients may expand their cheeks first
What is grimacing?
obvious facial expression of pain that may include furrowed brow, narrowed eyes, tightened lips, corners of mouth pulled back and clenched teeth
Passive InterVebratal Motion (PIVM) vs. Passive Accessory InterVertebral Motion (PAIVM)
passive flexion, extension, SB, Rot and can be done in s/l, prone, sitting vs. PA glide, unilateral PA glide, Sideglide, etc
Examples of CNS disordes.
post stroke pain, spinal cord injury, MS
What should the morning after therapy feel like in respect to pain?
same level of pain or less as prior day before therapy
Why do we start with non painful muscles/plane of motion?
so patient understands expectations
What is bracing?
stationary position in which a fully extended limb supports and maintains an abnormal distribution of weight
Is the concordant sign subjective or objective?
subjective but can use objective of functional → related to physical impairment or limitation in activity or participation
When to use special tests?
use when ruling in/out hypothesis or specific structure/pathology, since most tests are poor at this *clusters of tests are better
Two types of nociceptive pain.
visceral and somatic
What would inert structure finding look like?
•+ Reproduction of sx (usually pain maybe crepitus) with AROM & PROM •May be position dependent, duration of position, or abnormal feeling in a specific point in the joint motion •No pain with RI •Palpation of ligaments, bursas, tendon sheaths, and joint line •Joint/Articular Cartilage, Jt Capsule, Bursa, Ligaments, Fascia, Dura Mater & Dural Sheaths of Nerves
Findings from screening exam that would indicate peripheral joint pattern (Intraarticular: Bone, cartilage, bursa, ligament, tendon, labrum):
•AROM - Limitations in motion 2° pain •PROM - May or may not see limitations 2° pain opposite vs. same direction findings •RI - Strong/Weak and Painful/Painless dependent upon length of time involved → should be strong/painless? •Myotome: Intact •Dermatome: Intact •Reflex: 2+ (Normal)
Findings from screening exam that would indicate nerve root pattern:
•AROM - Limitations in motion, if ms weakness present •PROM - No limitations/No pain •RI - Weakness present •Multiple muscles affected 2° many N. Roots/ms •Myotome: Weakness (asymmetry) specific to N. Root •Dermatome: Deficit specific to N. Root •Reflex: D in Reflex, if specific to N. Root •Visible atrophy possible in multiple muscles (ie: C7= tricep and thenar eminence)
Findings from screening exam that would indicate peripheral nerve pattern:
•AROM: Limitations in motion if ms weakness present •PROM: No limitations or pain •RI: Weakness present (no pain) •Myotome: Weakness (asymmetry) specific to P. Nerve •Dermatome: Deficit specific to P. Root •Reflex: D in Reflex (depends on peripheral N affected) •especially seen with muscle weakness •Muscle atrophy visible in only muscles innervated by peripheral nerve (Axillary N =Deltoid and Teres Minor)
What are the stages of healing and their time frames?
•Acute 7-10 days •Subacute 10 days - 6 weeks •Chronic- >6 weeks (some say >12weeks) •Acute on chronic - chronic tissue reinjured •Subacute on chronic
During pt hx, what specific pattern of sx do you need to know when deciding severity and irritability? (4)
•Aggravating /Relieving postures or activities •Changes in sx presentation - initially, present, course of day, Night Pain •Pain Descriptors -Generic e.g. Pain - VAS, McGill Pain Questionnaire -Region Specific e.g. SPADI •Identification/Recognition of Yellow or Red Flag items -Yellow - Need for a more extensive examination -Red - Need for Referral
Diagnosis: Movement Coordination Symptoms
•Altered Motor Control •Muscular Imbalance •Impaired Sensation/ Proprioception
During UQS, describe how is resisted isometrics are performed.
•Assess contractile aspect of Cervical Spine and Upper Extremity musculature Performed with Cervical Spine and UE jts in Neutral
What is the review of systems?
•Assessing other bodily systems as contributor to symptom or condition •Asking questions related to other bodily systems and/or ruling in/out RED FLAGS Ie: Someone has gluten intolerance. PT discusses if they had work up for Crohn's Disease/IBS b/c polyarthorpathy of the spine relationship
Diagnosis: Movement Coordination Objective Findings
•Biomechanical Movement Pattern disorders •Pain at end range/ specific Movements •Decreased Power •Decreased Endurance
During UQS, describe how is PROM is performed.
•Cervical & entire Upper Extremity •Performed in Sitting •Assess end feel (sequence to pain) - determine acuity
What should POC include?
•Communication/Coordination/Documentation •Client Education •Client Preference •Interventions •Timeframe of Healing
What 5 factors do you need to consider during UQS?
•Consider joints above and below (Regional Interdependence) •C/o of radicular (numbness/tingling or pain) or referred pain patterns (ie: supraspinatus refers to the lateral elbow) the neck should be screened •If there is noted weakness that is not local to the site of injury the upper quarter screen needs to be further examined •If there are complaints of neck pain •Neuropathic pain requires screening (carpal tunnel vs C7 radiculopathy)
How can systemic pain be identified?
•Deep, aching throb •Reduced by pressure •Constant waves of pain & spasm •Not affected by movement/little to no mechanical provocation •Associated with jaundice, skin rash, fatigue, weight loss, low- grade fever, weakness, signs of infection, multi-joint arthralgia and/or bilateral involvement of multiple joints •Progressive symptoms or non responsive to various treatments
What are you analyzing and documenting with joint play assessment?
•Document hypo, hyper, or normal •Consider End Feel Assessment •Assess peripheral joints compared to unaffected side •Assess PAIN RESPONSE to joint motion assessment (concordant sign!)
What is included in Medical/Other Mngmt?
•Dx Imaging •Lab Work •Aggravating/alleviating factors
How do we measure UE edema?
•Fig 8 @ wrist •Hand/wrist volumetry •Circumferential at elbow or humerus
Diagnosis: Pain (shouldn't be only classification) Objective Findings
•Guarded Motion •Cogwheeling in MMT •Hyperalgesia •Allodynia •Yellow Flags
Diagnosis: Pain (shouldn't be only classification) Symptoms
•Guarded Posture •Overt Pain Behaviors
When do we need to document integumentary? (observation wise)
•If there was insult to the skin (trauma, burn, surgery, etc) •If the integumentary system is impaired (Diabetic neuropathy, chronic edema/trophic changes). Really then this is considered Systems Review as it is not the principle reason they are seeing you but a very relevant consideration •When we have provided a treatment that has affected the skin (thermo, electro, or mechanical [cupping or sustained inhibition])
What should pt goals include?
•Impairment level •Activity levelàtreatment should be relative to client goals (not yours) •Participation levelàyou may need to lower your expectations •Should consider •Prioritizing •Relationship between Impairments & Function (Activity/Participation)
Describe stability.
•Improving •Worsening •Not Changing •Variable
Diagnosis: Hypermobility/Instability Objective Findings
•Increased Accessory Motion in Joints •Increased PROM •ORIF/ Casting
What do PT's look for concerning irritability?
•Intensity of activity required to provoke symptoms? •How long do symptoms last? •How quickly do symptoms abate? -low stimuli, high response -easy to produce and stay for awhile
What are the components of the Upper Quarter Screen?
•Joint ROM screen (including above and below): AROM→ PROM → PROM w/ overpressure •Myotomal and dermatomal assessment •Reflexes (LMN and UMN)
Diagnosis: Pain (shouldn't be only classification) Interventions
•Joint/ Nerve Mobilization •Electrical Stimulations •Cognitive/Behavioral Therapy •Medication Usage Education
What are the 4 categories of msk diagnosis PT's perform?
•Medically Based •Impairment Based •Movement Based •Biopsychosocial
Diagnosis: Movement Coordination Interventions
•Motor Control Retraining •Gait Retraining •Transfer Training. •Balance Training •Functional Retraining
Diagnosis: Hypermobility/Instability Interventions
•Motor Control Retraining •Joint Protection Techniques •Bracing (Orthoesis) •Neuromuscular re-education
What would contractile structure finding look like?
•Muscle, Tendon, Tenoperiosteal Junction, Musculotendinious Junction •Cluster of Findings: •+ Reproduction of sx with AROM & RI •No Pain with PROM (may see pain with stretch in opposite direction of muscle action) •RI: Per Slide # 28 •Palpation: Tender to touch
Diagnosis: Force Production Deficit Interventions
•NMES Electrical Stimulation •AAROM-AROM-RROM Progression •Strengthening •Centralization Mobilizations. •Nerve Mobilization/ Techniques
What do PT's look for concerning severity?
•NPRS, Visual Analog Scale, Functional Limitation •Does high severity correlate w/ ↓ function? •If high function and self reported high severity (8/10 pain)?
What types of end feels would you feel with a jt?
•Normal - Firm •Abnormal - Muscle Guarding, Empty, Springy, Soft, Hard
Types of end feels:
•Normal - Firm, Soft, Hard •Abnormal - guarding, springy, boggy, empty
What is nocicpetive pain?
•Pain from stimulation of pain receptors or nerve endings •Tissue specific (tendon tear, muscle tear) inflamed stomach or intestine (gastroenteritis), headache due to vascular spasm
Diagnosis: Mobility Classification Interventions
•Passive ROM •Muscle/ Capsular Stretching Techniques •Soft Tissue Mobilization •Heat/Ultrasound
What is included in PMH/PSH?
•Past medical hx is part of your ROS •May need to dive deeper into these pt. responses for red/yellow flags •Family Hx - may lend evidence to systemic, genetic, auto-immune conditions •Social Habits, e.g. smoking, ETOH, nutrition, stressors, coping mechanisms etc all can play part in both tissue healing and pain levels (SIns)
6 elements of pt examination:
•Patient Hx •Review of Systems •Systems Review •Tests/Measures •Clinical Impression/Judgment •Plan of Care
To perform muscle length test effectively and correctly you must comprehend the following: (5)
•Proximal and distal muscle attachment •Muscle action •One joint/two joint muscles/multi-joint muscles •Active insufficiency •Passive insufficiency
Diagnosis: Hypermobility/Instability Symptoms
•Recurrent subluxation/ dislocation •Ligamentous/ Osseous Surgical Procedures- Acute
Diagnosis: Force Production Deficit Objective Findings
•Reduced Active ROM > Passive Motion •Decreased Endurance •Decreased Power •Radicular/ Nerve Signs (weakness,sensory) •Soft Tissue Changes/ Atrophy
Diagnosis: Mobility Classification Objective Findings
•Reduced Active and PROM approx. equal •Reduced Accessory Mobility •Soft Tissue Impairment •Muscle Length Impairment
Diagnosis: Mobility Classification Symptoms
•Reduced Movement •Increased Pain with Movement •Acuity
Diagnosis: Force Production Deficit Symptoms
•Reduced Movement Actively •Increased Pain with Movement •Radicular/referred Pain •Pain to Palpation Specific Area •Swelling
What should prognosis include?
•Rehab Potential •+/- Factors
What is neuropathic pain?
•Related to injury of the nervous system •Central- (MS, SCI, Stroke) •Peripheral (disc herniation, Diabetic neuropathy, carpal tunnel)
How can msk pain be identified?
•Sharp, superficial not always •(OR) •Associated with movement •Aggravated by mechanical stress •Associated with trauma or overuse
What do PT's look for concerning nature?
•Specific Dx and associated impairments so... LBP w radiating pain and or impaired gait and altered balance due to hip pain
What do PT's look for concerning stage?
•Temporal (acute, subacute, chronic) •Consider acute on chronic so "I had mild knee pain for years and then just twisted it the other day."
How do you assess posture?
•Three Planes of Observation: -Standing -Sitting