Health Assessment Quiz

Review Lecture - October 28, 2024

• The lecture was given by Dr. Marissa Lee, DC, HBSc, MSc
• The contact email for the presenter is [email protected]
• The date of the lecture is October 28, 2024
• The location of the lecture is Canadian Memorial Chiropractic College (CMCC)

Written Exam

• Each written exam is worth 35%
• The first exam is scheduled for January 17, 2025
• The second exam is scheduled for May 12, 2025

Lecture Hours 1-6 History Taking

• Key components of a patient history include well patient history, report writing, pain-based history and pain perception, and pain questionnaires.

Quote

• "Listen to your patient. He is telling you the diagnosis." - Sir William Osler, co-founder of Johns Hopkins School of Medicine

Guided Questioning

• Move from open-ended questions to focused questions
• Use questions that elicit a graded response
• Ask a series of questions, one at a time
• Offer multiple answer choices
• Clarify the patient's meaning
• Use encouraging phrases (continuers)
• Use echoing

Components of a Health History

• Identifying patient data (source, reliability)
• Chief complaint(s)
• Present illness
• Past history
• Family history
• Personal and social history
• Review of systems

Systems Review

• General
• Skin
• Head, Eyes, Ears, Nose, Throat
• Neck
• Breasts
• Respiratory
• Cardiovascular
• Gastrointestinal
• Peripheral vascular
• Urinary
• Genital
• Musculoskeletal
• Psychiatric
• Neurologic
• Hematologic
• Endocrine

Motivational Interviewing

• This is a guiding interviewing style that helps patients understand their need for change.
• Ask open-ended questions (ASK)
• Listen to understand the patient (LISTEN)
• Provide information, and ask for implications (INFORM)

Motivational Interviewing - Do's and Don'ts

• Do engage with the patient as an equal partner
• Do be patient
• Don't give unsolicited advice
• Refrain from instructing, directing, or warning

Clinic Records

• Follow your regulatory college's standards (Nov 12, 2014.qxd (cco.on.ca))
• Justify your diagnosis and plan of management
• Protects you from malpractice claims
• For patient care and continuity

The Clinical Record

• Must include date, patient's name and identifiers, practitioner's name, clinic name, and address

SOAP Format

• The SOAP format (Subjective, Objective, Assessment, Plan) is common for progress notes.
  • S = subjective
  • O = objective
  • A = Assessment
  • P = Plan

Pain

• An unpleasant sensory and emotional experience associated with actual or potential tissue damage
• Subjective, thus difficult to measure
• A vital protective sensory phenomenon
• Not always tied to a stimulus
• Perceived intensity and severity of tissue damage are not always correlated

TABLE 1.2 Differentiation of Systemic and Musculoskeletal Pain

• Systemic pain characteristics: disrupts sleep, throbbing, reduces with pressure, and constant/wave-like during spasms. It isn't often worsened by mechanical stress.
• Musculoskeletal pain characteristics: typically lessens at night, sharp/superficial, often decreases with cessation of activity, usually continuous or intermittent, often aggravated by mechanical stress.

TABLE 1.3 Pain Descriptions and Related Structures

• Lists different pain types and their associated structures (e.g., cramping/dull/aching = muscle, sharp/shooting = nerve root)

Pain Terminology

• Allodynia: Pain due to a stimulus that does not normally provoke pain
• Dysesthesia: Unpleasant abnormal sensation, spontaneous or evoked
• Hyperalgesia: Increased pain from a stimulus that normally provokes pain
• Neuropathic pain: Pain caused by a lesion or disease of somatosensory system
• Phantom pain: Perception related to a limb/organ not physically present

Pain Terminology (Continued)

• Nociceptive pain: Pain from actual or threatened damage to non-neural tissue
• Sensitization: Increased responsiveness of nociceptive neurons to normal input
• Paresthesia: Burning or prickling sensation
• Hyperesthesia: Excessive/increased physical sensitivity
• Hypoesthesia: Diminished/decreased physical sensitivity
• Anesthesia: Insensitivity to pain

Referred Pain vs. Radicular Pain

• Referred pain: Segmental nociceptive pain perceived away from the original injury site
• Radicular pain: Neuropathic pain caused by compression/inflammation of spinal nerve roots/dorsal root ganglion

Pain Modulation

• The process by which the body alters a pain signal as it is transmitted along the pain pathway

Pain Modulators (Endogenous)

• Bind to opioid receptors and modulate pain signals; Enkephalins, Endorphins, Dynorphins
• Neurotransmitters; Serotonin, Norepinephrine

Pain Modulators (Drugs)

• Analgesics: Acetaminophen (Tylenol), NSAIDs (Ibuprofen, Naproxen, Acetylsalicylic Acid), Opioids (Morphine, Fentanyl, OxyContin, Vicodin)
• Anesthetics

Pain Modulators (Cannabinoids)

• Delta-9-tetrahydrocannabinol (THC)
• Cannabidiol (CBD)
• Reduce inflammatory and neuropathic pain

Pain-Based History - Goals

• Gather information related to the patient's current illness
• Understand how the illness affects their lives
• Formulate a list of potential diagnoses
• Guide the physical examination
• Formulate a management/treatment plan

Symptom Attributes (OLD CARTS)

• Onset: When did the pain start?
• Location: Where is the pain located?
• Duration: How long has the pain lasted?
• Character: Describe the pain (sharp, dull, burning)
• Aggravating/Alleviating Factors: What makes the pain worse/better?
• Radiation: Does the pain spread?
• Timing: When does the pain occur (e.g., morning, evening)?
• Severity: Rate the pain on a scale of 0-10

Severity

• Pain scale: 0-10, with 0 being no pain and 10 being the worst pain imaginable.

Explore the Patient's Perspective (Disease vs. Illness)

• Feelings, Ideas, Function, Expectations

Patient's Perspective (ICE)

• Gathering info for a patient-centered approach
• Reason for the patient's encounter
• Clue to correct diagnosis
• Aids in shared decision-making
• Aids in patient compliance

Patient Questionnaires

• Purpose: baseline status, aid in diagnosis, monitor pain over time to gauge recovery

Types of Patient Questionnaires

• Oswestry Disability Index (ODI)
• Neck Disability Index (NDI)
• Symptom Diagram
• Visual Analog Scale (VAS)
• Lower Extremity Functional Scale (LEFS)
• Quick DASH
• McGill Pain Questionnaire (MPQ)
• Roland Morris Disability Questionnaire (RMDQ)
• Tampa Scale of Kinesiophobia (TSK)
• Rivermead Post-Concussion Symptoms Questionnaire (RPQ)

Scoring the ODI

• Summed score/total possible score x 100
• Probe patient if a question isn't answered; reduce denominator by 5 if not applicable
• Use the highest scored statement if multiple statements apply

Interpreting the ODI

• 0%-20%: Minimal disability
• 21%-40%: Moderate disability
• 41%-60%: Severe disability
• 61%-80%: Crippled
• 81%-100%: Bed-bound or exaggerating symptoms

NDI Scoring

• Summed score/total possible score
• May or may not convert to %
• Probe patient if a question isn't answered; reduce denominator by 5 if not applicable
• Score is not valid unless at least 8 of 10 sections are answered

NDI Interpretation

• 0-4: No disability
• 5-14: Mild disability
• 15-24: Moderate disability
• 25-34: Severe disability

• 35: Complete disability

VAS Examples

• Visual Analog Scale (VAS) for pain rating from 0-10
• Verbal scale correlation with visual scale:
  • 1-3: Mild pain, minimal impact on ADLs
  • 4-6: Moderate pain, moderate impact on ADLs
  • 7-10: Severe pain, major impact on ADLs

Summary

• Shows which questionnaire is associated with the body part
• Indicates the high score means for each questionnaire

Lecture Hours 7-8 Vital Signs

• This section covers the aspects of taking vital signs

Vital Signs

• Temperature
• Respiratory rate
• Heart rate
• Blood pressure

Methods of Taking Temperature

• Oral
• Axillary
• Rectal
• Tympanic
• Temporal artery

Temperature

• Body core temperature: 37°C
• Pyrexia (Fever): Elevated body temperature
• Hyperpyrexia: Elevated above 41.1°C
• Hypothermia: Abnormally low temperature below 35°C rectally

Respiratory Rate

• Rate (breaths/minute)
• Rhythm (consistency)
• Depth (shallow/deep)
• Effort of breathing
• Normal range: 12-20 breaths/minute

Terms used to describe breathing

• Tachypnea: Rapid, shallow breathing
• Hyperpnea: Rapid, deep breathing
• Bradypnea: Slow breathing

Heart Rate

• Use radial pulse, index and middle fingers
• Count rate for 30 seconds and multiply by 2
• Normal range: 60-100 beats per minute
• If irregular rhythm, further examination is needed.
• Auscultate at the cardiac apex

Terms used to describe heart rate

• Tachycardia: Rapid heart rate
• Bradycardia: Slow heart rate

Blood Pressure

• Procedure: Estimate systolic pressure first, palpate radial artery and rapidly inflate, read pressure and add 30 mmHg, deflate promptly and wait 15-30 seconds

Blood Pressure - Purpose of Estimate

• Prevents discomfort from unnecessarily high cuff pressures
• Avoids occasional error caused by an auscultatory gap, which is a silent interval between systolic and diastolic pressures

Ankle Systolic Blood Pressure

• Locate posterior tibial artery
• Apply cuff 2-3cm above artery
• Ensure center of bladder is above artery
• Inflate 30mmHg above previously taken arm SBP
• Deflate at 2-3 mmHg per second
• Read manometer after first audible sound
• Calculate ABI (Ankle Brachial Index)

ABI Measurement

• 1.3: Abnormal arterial calcification/incompressible vessels

• 1.0-1.29: Normal value
• 0.90-0.99: Borderline PAD
• 0.60-0.89: Mild PAD
• 0.40-0.59: Moderate PAD
• <0.39: Severe PAD, rest pain, and focal tissue necrosis

Body Mass Index (BMI)

• Use height and weight to calculate BMI
• BMI incorporates estimated but more accurate body fat measurements than weight alone

Lecture Hours 9-20 Low back and Pelvis

• Standard low back exam
• Mechanical low back pain (MLBP)
• Differential diagnoses for MLBP
• Red and yellow flags
• Disability determination

Observation: Gait

• Normal gait
• Tandem gait
• Walking on heels
• Walking on toes

Observation: Markings

• Café-au-lait spots
• Tuft of hair

Neurological Exam: Reflexes

• Deep tendon reflexes (DTRs)
• 2 primary DTR: patellar (L3-4), Achilles (S1-2)
• DTR tests integrity of associated nerve root

DTR Response and Grading

• Patellar: knee extension
• Achilles: ankle plantar flexion
• Jendrassik maneuver: used to enhance difficult-to-elicit reflexes
• Grading scale: 0-Absent (areflexia), 1-Diminished (hyporeflexia), 2-Average (normal), 3-Exaggerated (brisk), 4-Clonus, very brisk (hyperreflexia)

Pathological Reflex: Babinski Reflex

• Use reflex hammer to stroke lateral sole of foot medially across ball
• Normal: plantar flexion (foot pointing downwards)
• Positive: big toe extends and fans out; abnormal; possible upper motor neuron lesion

Neurological Exam: Myotome Testing

• Testing muscle power for neurological weakness
• Myotome locations for lumbar and sacral spines

TABLE 9.14 Myotomes of the Lower Limb

• Table listing nerve roots and their associated muscle and testing actions

Myotome Testing-Interpretation

• Table categorizing grades of muscle strength with corresponding values and movement grades

Neurological Exam: Sensory Testing

• Dermatomes: areas of skin innervated by a single spinal nerve root

Light Touch

• Lightly touch skin with cotton wisp, filament, or fingertip
• Compare sensation in different areas
• Anesthesia, hypesthesia, hyperesthesia

Pain

• Use suitable tool to test pain sensation (e.g., broken tongue blade)
• Ask patient if sharp or dull
• Analgesia, hypalgesia, hyperalgesia

Special Tests for Lumbar Radiculopathy

• Straight leg raise (SLR)
• Well leg raise test
• Bragard's test
• Bowstring test
• Modified SLR
• Slump test
• Valsalva

Well Leg Raise Test

Bragard's Test

Bowstring Test

Modified SLR

Slump Test

Valsalva

Kemp's Test

Observation: Step Deformity

• Spondylolisthesis
• Spondylosis
• Spondylolysis

A Note about Fractures

• Spinous percussion: using a reflex hammer or manual percussion to gently percuss the spinous process
• Positive finding: significant pain due to vibration
• Fracture suspected with positive finding

Special Tests for Spondylolisthesis and Hypermobility

• Spinal "Instability" Cluster
• Apprehension Sign
• Instability Catch Sign
• Painful Catch Sign
• Prone Instability Test

Lumbar Hypermobility

• Hypermobility is not synonymous with instability
• Lumbar hypermobility is not technically instability
• Instability typically requires surgical stabilization due to risk of neurological or vascular compromise

Functional Stability

• Joint centration is essential for optimum spine movement
• Requires muscle strength and dynamic coordination

Spinal Stabilizers (Anteriorly)

• Core musculature
• Transverse Abdominus
• Obliques

Spinal Stabilizers (Posteriorly)

• Erectors Spinae, Iliocostalis, Longissimus, Spinalis
• Multifidus

These stabilizers generate intra-abdominal pressure aiding in spinal stability

Other Tests

• Active SLR: raise leg to assess for hypermobility, also assess speed, tremor, trunk rotation and verbal/nonverbal responses
• Bridging Maneuvers: assess patient's ability to hold a prone or supine bridge

Non-specific Low Back Pain/ Mechanical Low Back Pain

• Terminology used in evidence-based medicine (used when pathoanatomical cause of LBP cannot be determined)
  • Examples: lumbar facet joint syndrome, lumbar sprain/strain, sacroiliac joint (SIJ) syndrome, thoracolumbar syndrome

Non-Specific Low Back Pain (Continued)

• Refers to back pain originating from the spine, intervertebral discs, or surrounding soft tissues
• Non mechanical lBP is caused by factors like Cauda equina syndrome, facture, infection or malignancy

More Specific Diagnoses

• Lumbar facet joint syndrome
• Lumbar sprain/strain
• Sacroiliac Joint (SIJ) syndrome
• Thoracolumbar syndrome

Lumbar Facet Joint Syndrome (Clinical Prediction Rule)

• Localized unilateral back pain
• Pain aggravated/reproduced by pressure on facet joint or TVP
• No nerve root symptoms; pain does not extend beyond the knee
• Eased by flexion
• Reduced movement on painful side; unilateral muscle spasm over facet joint; pain on extension and extension with lateral flexion/rotation to the same side.

Laslett et al.'s Clinical Prediction Rule (Sacroiliac Joint)

• These are sacroiliac joint (SIJ) provocation tests: Compression, Distraction, Sacral Thrust, Thigh Thrust, Gaenslen's Test, Pain on palpation medial to PSIS.
• If 2 of the first 4 tests or ≥3 of the 6 tests are positive → sacroiliac joint pathology

Flamingo Test

Pubic Symphysis

Leg Length Test

FABER/Patrick's Test

Trendelenburg Sign

Trendelenburg Gait

• Observe patient walking away from you
• Pelvis drops on unaffected side; trunk shifts to affected side.
• Indicates L5 nerve root paresis or glute medius weakness

Skin Rolling Test for TL Syndrome

• Assess the skin roll of thoraco-lumbar fascia for possible TL/Maigne Syndrome

Lumbar Spinal Stenosis

• Stenosis: narrowing
• Lumbar spinal stenosis (LSS): narrowing of the spinal canal
• Results in pressure on the spinal cord and nerves

Neurogenic Claudication

• Most common symptom of LSS: painful cramping/weakness in the legs
• Differentiate from vascular claudication

Vascular Claudication

• Calf muscle pain on exertion, relieved by rest.
• Associated with peripheral arterial disease (PAD)

Peripheral Arterial Disease (PAD)

• Narrowed arteries = reduced blood flow to legs/arms
• May have mild/no symptoms
• Pain ends with rest

PAD Risk Factors

• Smoking
• Diabetes
• Family history of PAD, heart disease, or stroke
• High blood pressure
• High cholesterol
• Age >65 or >50 if other risk factors present
• Obesity

Differentiating Neurogenic & Vascular Claudication

• Table comparing various findings and symptoms/characteristics for neurogenic vs. vascular claudication

Physical Exam for LSS

• Observation: Check ROM, tandem gait
• Neurological Exam: Nerve tension test
• Maintain Active Extension
• Functional Tests

ROM

• Pain with lumbar extension
• Relief with lumbar flexion

Tandem Gait

Romberg Test

Sustained Active Extension

Sphinx Test

Functional Tests

• Squat
• Stand/hop on one leg

Non-Operative Management

Comprehensive Boot Camp

Myofascial Pain Syndrome

Myofascial Pain Syndrome (MPS)

• Acute or chronic musculoskeletal condition characterized by sensory, motor and autonomic findings; associated with trigger points
• Symptoms include muscle/fascia pain at rest.
• Trigger points are localized, taught regions of muscle and fascia.
• Fascia is thin layer of connective tissue covering/supporting organs, vessels, bones and muscles.

Active Trigger Points

• Spontaneous pain
• Tenderness in taut band
• Familiar pain (twitch response when stimulated manually)
• Referred pain

Latent Trigger Points

• Focus of hyperirritability
• Local twitch response
• Tenderness
• Refered pain
• No pain unless compressed; can become active trigger points

Special Tests for DGS Summarized

• Hibb's Test
• SLR with internal/external rotation
• FAIR
• Pace Sign
• Seated Piriformis Test

Quadratus Lumborum Syndrome

Ober's Test

Iliopsoas Syndrome

Ely's Test

Thomas Test

Coccydynia

Internal Coccyx Mobilization/SMT

Waddell Signs

• 8 Clinical physical signs
• History of use
• Detect psychogenic manifestations of LBP
• Not used to detect credibility of patient complaint
• Not used to detect malingering
• Not used to detect non-organic causes of LBP

Waddell Signs (continued)

• Superficial tenderness
• Non-anatomical tenderness
• Axial loading
• Acetabular rotation
• Distracted SLR discrepancy
• Regional sensory disturbance
• Regional weakness
• Overreaction

Low back physical exam- AS tests

• Occiput-wall distance
• Chest expansion
• Modified Schober's

Non-Musculoskeletal Differential Diagnoses for Low Back Pain

Red Flags

• Indicators of potential serious physical pathology
• Contraindication to manual therapy

Examples of Red Flags

• Previous history of cancer
• Intravenous drug use/urinary infection
• Long-term corticosteroid use
• Age <40, chronic morning stiffness lasting >30-60 minutes
• Numbness in groin

Yellow Flags - Psychosocial Risk Factors

• There are 4 yellow flags that indicate a delayed recovery:

1. Belief that back pain is harmful and severely disabling,
2. Fear avoidance behavior,
3. Depressed or low mood or social withdrawal,
4. Expectations that passive treatment will help recover.

Good Luck on your Mod 2 Exams!

• Health history
• Questionnaires
• Vitals
• Low back exam
• Differential diagnoses
• Dr. Rocco Guerriero takes over lecturing in Mod 2
• Dr. Lee resumes lectures in Mod 3