chapter 7 KNES a
activity-specific functional testing
*before permitting an individual to return to sport and physical activity after an injury*, the individual's condition must be fully evaluated so risk of reinjury is minimal; _______________ involve the performance of active movements typical of the movements executed by the individual during sport or activity participation; these movements should assess strength, agility, flexibility, joint stability, endurance, coordination, balance, and activity-specific skill performance; for example, in a lower leg injury, testing should begin by assessing walking, jogging, and then running forward and backward; if these skills are performed pain-free and without a limp, the individual might then be asked to run in a figure eight or zigzag pattern; each test must be performed pain-free and without a limp 93
characteristics of the symptoms
-Location, onset, severity, frequency, duration, limitations caused by the pain -Questions -Pain •Somatic •Deep •Diffuse or nagging; with possible stabbing pain; longer lasting •Injury to bone, internal joint structures, or muscles •Superficial •Sharp, prickly; brief duration •Injury to skin •Visceral •Deep, nagging, and pressing; often accompanied by nausea and vomiting •Injury to internal organ •Referred pain slide 7
key components of the injury evaluation process
HISTORY of the current condition, visually OBSERVING or inspecting the area for noticeable abnormalities, physically PALPATING the region for abnormalities, and completing FUNCTIONAL, STRESS, or SPECIAL TESTS 89
passive range of motion (PROM)
SLIDE •The injured body part is moved through ROM with no assistance from the injured individual. •Distinguishes injury to contractile tissues from noncontractile or inert tissues •End of the range, gentle overpressure to determine end feel •Differences in ROM between AROM and PROM •Accessory movements Loose packed position Close packed position slide 15
active range of motion (AROM)
SLIDE -Objectively measure using goniometer -*Objective measure of AROM and PROM -May compare to normal ROM slide 17* -Age and gender may influence ROM -________________ •Joint motion performed voluntarily by the individual through muscular contraction •Perform before PROM •Indicates willingness and ability to move body part •Determines possible damage to contractile tissue;measures muscle strength and movement coordination •Measurement of all motions, except rotation, starts with the body in anatomic position slide 14
neurologic testing
SLIDE INFO •Neurological testing -Nerve root •Somatic •Visceral -CNS: assess using dermatomes, myotomes, and reflexes •Dermatome: area of skin supplied by a single nerve root •Assess sensation •Abnormal: hypoesthesia, hyperesthesia, paresthesia •The cutaneous sensation patterns of the spinal nerve dermatomes differ from the patterns innervated by the peripheral nerves. slide 20-21
referred pain
______________ *is a type of visceral pain* that travels along the same nerve pathways as somatic pain; it is perceived by the brain as somatic in origin; in other words, the injury is in one region but the brain considers it in another; for example, _______________ occurs when an individual has a heart attack and feels pain in the chest, left arm, and sometimes the neck 90
special tests
______________ have been developed for specific body parts or areas as a means for detecting injury or related pathology; in general, ______________ occur across planes and are not graded; for example, Speed's test is used as a technique for assessing pathology related to biceptal tendonitis; Thompson's test is used to assess potential rupture of the Achilles tendon 92 SLIDE INFO -Specific body parts -Detect injury or pathology -NOT GRADED slide 19
deep somatic pain
______________ is described as diffuse or nagging, as if intense pressure is being exerted on the structures, and may be complicated by stabbing pain; _________________ is longer lasting and usually indicates significant tissue damage to bone, internal joint structures, or muscles 90
functional tests resistance testing
_______________ manual muscle testing (MMT) or resisted range of motion (RROM) can assess muscle strength and detect injury to the nervous system; __________________ is performed by applying an overload pressure in a stationary or static position, sometimes referred to as a break test, or throughout the full ROM; muscle weakness and pain indicates a muscular strain; muscle weakness in the absence of pain may indicate nerve damage 92 SLIDE INFO •Can assess muscle strength and detect injury to the nervous system •Break test or entire ROM •MMT will isolate one single muscle slide 16
observation
_________________ and inspection begins the objective education in an injury assessment; it is initiated the moment the injured person is seen and continues throughout the assessment; the initial ______________ focuses on the individual's state of consciousness and body language, which may indicate pain, disability, fracture, dislocation, or other conditions; valuable information is also obtained by noting the individual's general posture, willingness or ability to move, ease in motion, and general overall attitude 91
superficial somatic pain
_________________ results from injury to the epidermis or dermis, and is usually a sharp, prickly type of pain that tends to be brief 90
somatic pain
_________________: arises from the skin, ligaments, muscles, bones, and joints, and is the *most common type of pain* encountered in musculoskeletal injuries; it is classified into *two major types: deep and superficial* 90
peripheral nerves
__________________ are assessed using manual muscle testing and noting cutaneous sensory changes in peripheral nerve patterns SLIDE INFO -Manual muscle testing -Cutaneous sensation testing -Special compression tests slide 25
red flags indicating serious emergency and emergency medical plan should be initiated
__________________ include: airway obstruction respiratory failure severe shock severe chest or abdominal pains excessive bleeding suspected spinal injury head injury with loss of consciousness severe heat illness fractures involving several ribs, the femur, or pelvis 94
palpation
__________________ involves the healthcare provider physically touching and feeling the body of the injured individual; ___________________ begins with gentle, circular pressure followed by gradual, deeper pressure; it is initiated on structures away from the injury site and progresses toward the injured area; _______________ the most painful area avoid any carryover of pain into noninjured areas 91 SLIDE INFO PRIOR TO CONTACT, PERMISSION MUST BE GRANTED TO TOUCH THE PATIENT bilateral palpation -Temperature -Swelling -Point tenderness -Crepitus -Deformity -Muscle spasm -Cutaneous sensation -Pulse •*Gentle, circular pressure, followed by gradual, deeper pressure* •Begin away from injured site and move toward injury
visceral pain
__________________ results from disease or injury to an organ in the thoracic or abdominal cavity, such as compression, tension, or distention of the viscera; similar to deep somatic pain, it is perceived as deeply located, nagging,, and pressing, and it is often accompanied by nausea and vomiting 90
diffuse pain
___________________ around the entire joint may indicate inflammation of the joint capsule or injury to several structures 90
functional tests
____________________ identify the patient's ability to move a body par through the range of motion (ROM) actively, passively, and against resistance; active range of motion (AROM) is motion performed voluntarily by the individual through muscular contraction; unless contraindicated, *AROM is performed before passive range of motion (PROM)*; AROM indicates the individual's willingness and ability to move the injured body part; active movement determines possible damage to contractile tissue (i.e. muscle, muscle-tendon junction, tendon, and tendon-periosteal union), and measures muscle strength and movement coordination; the individual's willingness to perform a movement, the fluidity of the movement, and the extent of the movement (joint ROM) is assessed; limitation in motion may result from pain, swelling, muscle spasm, muscle tightness, joint contractures, nerve damage, or mechanical blocks, such as a loose body; if the individual has pain or other symptoms with movement, it can be difficult to determine if the joint, muscle, or both are injured 92
palpation
____________________ of anatomical structures can detect eight physical findings, namely temperature, swelling, point tenderness, crepitus, deformity, muscle spasm, cutaneous sensation, and pulse
palpation
____________________ of anatomical structures can detect eight physical findings, namely temperature, swelling, point tenderness, crepitus, deformity, muscle spasm, cutaneous sensation, and pulse; each of these findings provides information that helps to determine the nature and severity of the injury; for example, skin temperature can be noted when the fingers first touch the skin; increased temperature at the injury site could indicate inflammation or infection, whereas decreased temperature could indicate a reduction in circulation; in a similar manner, feeling an area with the fingers can determine the presence of localized or diffuse swelling as well as general or precise point tenderness; localized swelling and precise point tenderness could be indicative of a fracture 91
symptom
a ________________ is information provided by the injured individual regarding their perception of the problem; examples of these SUBJECTIVE feelings include blurred vision, ringing in the ears, fatigue, dizziness, nausea, headache, pain, weakness, and the inability to move a body part 89
first respondent
a coach, physical educator, or fitness specialist is often the _____________________ in an injury situation, and as such, must be able to perform an injury assessment; the assessment is necessary to determine the appropriate management of the condition; the coach must be prepared to respond to a range of injuries, from a seemingly minor orthopedic condition to a potentially life-threatening emergency; in completing an assessment, the coach must ensure that their actions are consistent with their standard of care 89
sign
a diagnostic _________________ is an OBJECTIVE, measurable physical finding regarding an individual's condition; a __________________ is what the evaluator hears, feels, sees, or smells when assessing the patient 89
neurologic testing
a segmental nerve is the portion of a nerve that originates in the spinal cord and is referred to as a nerve root; most nerve roots share two components: (1) a somatic portion which innervates a series of skeletal muscles and provides sensory input from the skin, fascia, muscles, and joints and (2) a visceral component, which is part of the autonomic nervous system; the autonomic nervous system supplies the blood vessels, dura mater, periosteum, ligaments, and intervertebral discs among many other structures 92
subjective information
although information provided by the individual is ________________, examiners attempt to gather and record information as quantitatively as possible; this is accomplished by using numbers to establish the intensity of the described symptoms; for example, the individual can rate the severity of pain using a scale from 1 to 10; the patient can also be asked to quantify the length of time the pain lasts; in using such measures, the progress of the injury can be determined; if the individual reports that pain begins immediately after activity and lasts for 3 to 4 hours, a baseline of information has been established; as the individual undergoes treatment for the injury, a comparison with baseline information can determine if the condition is getting better, worse, or remained the same 90
history
although the intent of taking a ________________ is to narrow the possibilities of conditions causing the injury, the ________________ is to be taken with an open mind; if too few factors are considered, premature conclusions may be reached, resulting in failure to adequately address the nature and severity of injury; it is essential to document in writing the information obtained during the _________________ 90
HOPS (history, observation, palpation, special testing)
an injury assessment should follow a consistent, sequential order to ensure that as much information as possible is obtained; such an assessment can be completed by the coach adapting an assessment format known as __________________; the __________________ format uses both subjective information (i.e. history of the injury) and objective information *(i.e. observation and inspection, palpation, and special testing)* to recognize and identify problems contributing to the condition; this format is easy to use and follows a basic consistent format 89
injury evaluation process
as part of the ___________________, healthcare professionals (e.g. physicians; emergency medical technicians; athletic trainers) use standard clinical practices to make decisions relative to the nature and severity of an injury or illness; the ___________________ typically includes *several key components*, namely taking a HISTORY of the current condition, visually OBSERVING or inspecting the area for noticeable abnormalities, physically PALPATING the region for abnormalities, and completing FUNCTIONAL, STRESS, or SPECIAL TESTS 89
primary survey
assessment of acute on-site injuries, regardless of their perceived severity, should always include a ________________; the purpose of the ______________ is to identify and initiate management of any life-threatening conditions; the ________________ determines the level of responsiveness and ASSESSES AIRWAY, BREATHING, and CIRCULATION (ABCs); the _________________ begins as the coach approaches the individual by observing their body language (E.g. movement; absence of movement) and observing any talking (e.g. absence of any talking or sounds; screams or statements attributed to pain); level of responsiveness is sometimes referred to as the shake and shout action; if the individual is not responsive when the coach arrives, the coach should try to arouse the individual by gently shaking or pinching without moving the head or neck and by shouting 93
central nervous system
dermatomes, myotomes, and reflexes are used to assess the integrity of the ____________________; SLIDE INFO -Reflexes •DTRs (deep tendon reflexes) Abnormal: diminished, exaggerated or distorted, absent •Superficial reflexes •Pathological slide 24
stress tests
each body segment has a series of tests to assess joint function and integrity of joint structures, primarily noncontractile tissues (e.g. ligaments, intra-articular structures, and joint capsules); some tests occur in a single plane and are graded according to severity; specifically, sprains of liagemtous tissue are generally rated on a three- degree scale after a specific stress is applied to a ligament to test its LAXITY; LAXITY describes the amount of give within a joint's supportive tissue; INSTABILITY is a joint's inability to function under the stresses encountered during functional activities 92 •Stress tests -Assess joint function and integrity of joint structures -Laxity versus instability -Test at proper angle SLIDE 18
history
identifying the ___________________ of the injury can be the most important step in injury assessment; a complete _______________ includes information of the primary complaint; cause or mechanism of injury; characteristics of symptoms; and related medical ______________________ that may have a bearing on the specific condition; this information can provide potential reasons for the symptoms and identify injured structures prior to initiating the physical examination 89
radiating pain
if _________________ into other areas of the limb or body, it may be traveling up or down the length of a nerve or it could be indicative of an internal injury (e.g. heart attack, ruptured spleen) 91
primary survey
if at any time during the _______________ assessment, conditions exist that are an immediate threat to life or red flags are noted, the assessment process should be terminated and the emergency medical plan activated; if more that one individual is injured, triage must be performed; triage is the rapid assessment of all injured individuals followed by return to the most seriously injured 94
localized pain
if pain is ________________, is suggests limited bony or soft tissue structures may be involved 90
assessment of unconscious individual
if the individual appears to be unconscious do the following: do not move the individual if there is any possibility of a spinal injury! call their name loudly and gently touch the arm if this does not elicit a response, pinch the soft tissue in the armpit and note any withdrawal from the painful stimuli if there is no response, immediately initiate the primary survey if the individual is not breathing and there is no pulse, activate the emergency plan, including summoning of emergency medical services (EMS), and initiate cardiopulmonary resuscitation (CPR) if the individual is breathing and has a pulse, activate the emergency plan, including summoning of EMS and monitoring the condition of the individual through continued assessment of their vital signs 93
functional tests
if the individual is unable to perform active movements at the injured joint due to pain or spasm, passive movement can be performed; in passive movement, the injured limb or body joint is moved through the ROM with no assistance from the injured individual; PROM distinguishes injury to contractile tissues from noncontractile or inert tissues (i.e., bone, ligament, bursa, joint capsule, fascia, dura mater, and nerve roots); if no pain is present during passive motion but is present during active motion, injury to contractile tissue is involved; if noncontractile tissue is injured, passive movement is painful and limitation of movement may be present 92
observation
in acute injury, the localized injury site is inspected or ____________ for any deformity, swelling, or discoloration (e.g. redness, pallor, bruising, or ecchymosis); more detailed observation as deemed appropriate given to the potential injury includes a visual analysis of symmetry, general motor function, posture, and gait to ascertain information that could aid in identifying the structures involved and the seriousness of the condition; the injured area should be compared to the opposite side if possible; a bilateral comparison helps to establish normal conditions for the individual 91 SLIDE INFO -Assess state of consciousness and body language that may indicate pain, disability, or other conditions -Note posture, willingness/ability to move, overall attitude -Symmetry and appearance •Congenital and functional problems •Gait -Motor function •Assess general motor function •Rule out injury to other joints
primary complaint
in assessing the ________________ and characteristics of the symptoms of an acute injury, it is also important to determine if the individual experienced other unusual sensations at the time of injury; *responses to the questions did you hear anything? and did you feel anything?* can provide valuable input regarding the type of injury and the structures involved; for example, the unusual sound of hearing a *pop is characteristic of a rupture to a ligament or tendon*, while report of a *snapping or cracking sound may suggest a fracture*; an unusual feeling can be presented in various ways; for example, having sustained a tear to the anterior cruciate ligament, an individual may report a feeling of the knee giving way or following a rupture of the Achilles tendon, an individual may report a feeling of being shot or kicked in the lower leg 51
related medical history
in many scenarios involving acute conditions, obtaining information regarding other problems or conditions that may affect the current condition is also advantageous; for example, awareness of a previous history of exercise-induced bronchospasm or determining no previous history of EIB may offer insight into the individual's response to the condition and, ultimately, influence the ongoing assessment and immediate management; while knowledge of a history of ankle sprains may not change the continued assessment of the injury or its immediate management, *it may offer explanation relative to the individual's ability to provide efficient and insightful responses to questions* 91
acute injury
in the case of an _________________, questions used to obtain information about pain could include *where is the pain, is there one spot in particular that is painful? is the pain limited to an area or does it radiate into the extremities? how bad is the pain on a scale from 1 to 10? and how would you describe the pain (e.g. dull, sharp, aching)?* 90
acute injury
obtaining information about signs and symptoms can determine if the individual has an ___________________ resulting from a specific event leading to sudden onset of symptoms or a *CHRONIC INJURY* characterized by a slow, insidious onset of symptoms that culminates in a painful inflammatory condition 89
testing
once fractures and or dislocations have been ruled out, soft tissue structures, such as muscles, ligaments, the joint capsules, and bursae, are assessed using a variety of ____________; _____________ *includes functional tests (i.e. active, passive, and resisted range of motion), stress tests, special tests, neurologic testing, and sport or activity- specific functional testing* 91
coach
the _________________ should be prepared to assess a range of acute conditions as the first respondent; *it is not within the duty of care of a _____________- to assess and manage post-acute, chronic, or stress-related injuries*; rather, it is the responsibility of the _____________ to refer those injuries to healthcare professionals 93
primary complaint
the __________________ focuses on the injured individual's perception of the current injury; as such, the individual is asked questions that permit responses that describe the current nature, location, and onset of the condition; *the questions posed are simple and open-ended, such as "what is the problem?" and "what hurts?"* while listening to the response to questions, additional information about the condition can be obtained by noting the words and gestures used to describe the condition as they may provide clues to the quality and intensity of the symptoms 90
mechanism of injury
the ______________________ is the physical cause or circumstance under which the injury occurred; for example, a mechanism could be a hit in the head by a thrown ball that results in an acceleration force involving the brain; another possible _________________ could be tension that results form stress placed on the lateral ankle due to landing on another person's foot when attempting to rebound a basketball shot; an understanding of the ______________ aids in identifying possible injured structures and, subsequently, guides the ongoing assessments and directs the objective component of the evaluation; in the case of an acute injury, *questions used to determine the ___________________ include what happened, what were you doing, and are you able to demonstrate how the injury happened* 90 -Attempt to visualize injury to identify possible injured structures slide 6
primary survey
the arousal actions will determine whether the person is alert, restless, lethargic, or nonresponsive; assessment of the ABCs involves: A- airway: the first step in the process is to assess and ensure an open airway; the assessment involves for any abnormal sounds or noises as well as the total absence of any sounds (i.e. complete silence); maintaining an open airway is typically accomplished by placing the individual's head in a position of hyperextension by tilting the head to the chin; this technique should only be performed if a neck fracture has been ruled out; if a neck injury is suspected, a modified jaw thrust can be used to establish an open airway B- breathing: breathing is assessed by using the look, listen, and feel technique; the examiner looks at the chest to determine any movement, while listening for any sounds and feeling for any air coming from the nose/and or mouth c- circulation: assessment of circulation involves determining the presence of a pulse; the carotid and radial pulses are typically used 94
neurologic testing
the main component of a segmental nerve is tested using a myotome, a group of muscles "MOTOR FUNCTION" primarily innervated by a single nerve root; the sensory component is tested using a dermatome, an area of the skin supplied by a single nerve root; an injury to a segmental nerve root often affects more than one peripheral area and does not demonstrate the same motor loss or sensory deficit as an injury to a single peripheral nerve; dermatomes, myotomes, and reflexes are used to assess the integrity of the central nervous system; peripheral nerves are assessed using manual muscle testing and noting cutaneous sensory changes in peripheral nerve patterns _________________ *is only necessary in orthopedic injuries when an individual complains of numbness, tingling, or a burning sensation, or suffers from unexplained muscular weakness* 92 SLIDE -Myotome—group of muscles primarily innervated by a single nerve root •Assess muscle contraction (hold at least 5 seconds) •Abnormal: paresis, paralysis
characteristics of the symptoms
the primary complaint is explored in detail to discover the evolution of _______________, including the location, onset, severity, frequency, duration, and limitations caused by the pain or disability; the individual's pain perception can indicate which structures may be injured; there are two categories of pain: somatic and visceral 90
signs and symptoms
when evaluating any injury or condition, diagnostic __________________ are obtained and interpreted to determine the type and extent of injury 89
coach
when faced with assessing an on-site injury, the __________ must remain calm at all times; it is also important that the injured individual remains calm; the individual is less likely to remain calm and cooperative, if the __________ is panicked and disorganized 93
on-site evaluation
while the background of the COACH does not permit evaluation at the level of care of a healthcare professional, the COACH should still be prepared to perform an ________________- of acute injuries sufficient to determine the nature and severity of the condition and, subsequently, the immediate management of the condition 89
HOPS (history, observation, palpation, special testing)
while the medical background of a coach limits their ability to accurately and definitively assess a condition, adapting the ___________ method provides a means by which the coach can follow an established step-by-step plan of action; by following a deliberate and planned approach to assessment, the coach is more likely to be more effective and efficient; lack of organization can readily transfer to confusion and loss of valuable time 93
history
•Can be most important step in assessment •Involves not only asking questions but also establishing a professional and comfortable atmosphere •Information provided is subjective but should be gathered and recorded as quantitatively as possible. •Document history in writing •Includes -Primary complaint -Mechanism of injury -Characteristics of symptoms -Disability resulting from the injury -Related medical history Documentation •Required to maintain accurate records •Health Insurance Portability and Accountability Act (HIPAA) •Purpose -Enhance communication -Facilitate continuity of care -Provide evidence of services for billing and legal protection slide 32
history
•Disability resulting from injury -Determine limitations because of pain, weakness, or disability -Questions (include ADLs) •Related medical history -Information regarding other problems/conditions potentially affecting this injury *-Use of preseason physical exam* slide 9
evaluation process (HOPS/ SOAP)
•Establish a reference point by assessing the opposite, noninjured body part Methods -HOPS •Subjective—history •Objective—observation, palpation, special tests -SOAP •Subjective and objective—same as HOPS •Additional—assessment and planning •Assessment -Suspected site of injury, involved structures, and severity of injury -Establish long- and short-term goals •Plan -Therapeutic modalities and exercises, educational consultations, and functional activities -Action plan for achieving goals slide 3-4