Assessment And Clinimetrics_ Topic 1-9 (1).pdf

UNIT 1: JOINT MOBILITY ASSESSMENT AROM (Active Range of Movement) Provides information about articular surfaces (bones, cartilages, ligaments) + F (muscles, nerves, tendons) + Coordination (Cerebellum, Motivation, Kinesophobia) Doesn’t discriminate between contractile/ not contractile components. If...

UNIT 1: JOINT MOBILITY ASSESSMENT AROM (Active Range of Movement) Provides information about articular surfaces (bones, cartilages, ligaments) + F (muscles, nerves, tendons) + Coordination (Cerebellum, Motivation, Kinesophobia) Doesn’t discriminate between contractile/ not contractile components. If pain appears during the motion: Contraction, Stretching ( muscles and ligaments) and Pinching (Meniscus, capsule and nerves , intervertebral disks) Main physiological movements Combined physiological movements Movement quality —> visual inspection PROM (Passive Range of Movement) Slightly greater than the AROM Information about Art. Surfaces No relying upon force or coordination If pain appears: -at the beginning of—> related to non contractile structure. -at the end of —> related to both contractile & non contractile structure ROM influencing factors Widely recognised (EB). Others -Age. -Position -Gender. -Experience -BMI. -Day time -Physical activity habits -Warm up -Professional occupation -Leisure activities Gender Women (increased ROM due to increased connective tissue laxity) Age Children under 2yr have a higher ROM than adults. Gender doesn’t influence it Adults, varies according to the joint, also affected by associated pathologies such as Sclerosis. BMI Muscle hyper trophy and increased fatty tissue Physical condition Warm up routine Measuring Devices Tracing paper (e.g contours of fingers and feet) Measuring tape (e.g measuring lung capacity around chest) Goniometer Electronic goniometer Movement analysis systems Rulers Goniometry Measurement of a corporal segment related to other through particular joint, by the use of graded devices. The examiner MUST know: -Subject position -Required stabilisation -Physiological final sensation (passive ROM assessment) Procedure -Bony prominences location -Appropriate alignment/posture stabilisation -Device proper alignment * -Segment displacement and end stop -Device interpretation -Right data registration Before measuring… -Visual inspection of the movement look at quality of movement and how movement is performed. -Establish a logical sequence -Keep the required materials within reach -Clear up the instructions for the patient (Active ROM) Types -Static For measuring positions, deformities, stationary angles. -Dynamic For measuring movements (passive and active) Inclinometer - Gravity dependent - Comprising: angle conveyor, pendulum needle (frontal + sagittal planes), magnetic Compass (horizontal plane) -Placed upon the distal segment. -Not recommended for: Small joints Deformities Swollen areas Precautions to take using a compass: ASK FOR PACEMAKER Electronic Goniometer Used in research Appropriate for dynamic measurements Accurate calibrations and subject positioning required. Comprising: Potentiometer, fixed arm and mobile arm. Goniometer Alignement Arms placement Bony references must be PRECISELY LOCATED -Proximal / Fixed arm —> Parallel to longitudinal axis of the proximal segment. -Distal / Mobile arm —> Parallel to longitudinal axis of the distal segment Fulcrum Placement On the movement axis of the assessed joint Since it will vary during motion … MAKE SURE THE ARMS ARE PROPERLY ALIGNED AT ALL TIMES. Keep in mind … 1st —> Visual Estimation —> increases accuracy Goniometer should NOT accompany ROM Bilateral measurement. Results Recording X/ 0/ Y Sytem X: Flexion, Abduction, External Rotation, Supination 0: Neutral position (reference) Y: Extension, Adduction, Internal Rotation, Pronation. -Effective angle: Possible range of motion (angle) in each measurement. # -Functional angle: Minimum range of motion (angle) required for joint functioning. Other measurement device Measuring Tape and Ruler -Measures distances and perimeters -Requires bony or cutaneous references at all times -Assess indirect mobility of the spine. Contours outlining -For measuring small joints TOPIC 2: MUSCULAR ASSESSMENT Muscular assessment Part of the physical assessment. Provides information that cannot be obtained from other assessment methods. Useful in … -Differential diagnosis -Prognosis -Neuromuscular and musculoskeletal processes. Muscular Concepts Primary muscle Main responsible for a specific movement. I.e.Agonist All muscles are primary muscles they just switch between agonist and synergist. Accessory muscle * Complement the agonist i.e. Synergist No muscle is exclusively synergist Stabilizer muscle ( Are short muscles and mono articular) Fix the assessed segment while the agonist is being tested. Hold the segment while others are in charge of movement. Stabilizers and pain work hand in hand. # Neutraliser muscle Override secondary agonists functions. -Act simultaneously with agonists -Avoid unwanted movements (synergic antagonists of the primary muscle) Method Visual inspection Atrophy/Hypertrophy Contours Motion Palpation Tone Pain/ Soreness Passive tests Tension/ Shortening Painful stretching * Resisted movements tests 1. Isometric manual testing Normal —> Energic + Painless isometric contraction Slight - Moderate MT(myotendinous injury)—> Weak (force and trembling)+ Painful isometric contraction Neurological impairment —> Weak + Painless isometric contraction 2. Isotonic manual testing Determine the maximum weight that can be lifted —> 1 rep max Requires: warming up by getting started with low weight, Position, Technique, Correct breathing (Apnea meaning no respiration). Disadvantages: speed uncontrolled and synergists take part as well. Muscle Manual testing Main procedure in Physiotherapy assessment. Proposed by Wilhelmine Wright during the Poliomyelitis epidemics Patient influences the muscular testing Real muscle strength may VARY according to… -Yearning to maximize the performance Vs Pretend greater impairment than real … -Discomfort/Pain threshold (competitive Vs wimpy) -Comprhension skills (Autism, Children, Alzheimer’s, Cognitive issues) -Motor + Proprioceptive skills (Sensory) -Lack of interest -Depression -Cultural, Social and gender habits Examiner influences the muscular testing as well… Real muscle strength may VARY according to… Q * -Knowledge + Technical skills —> ACCURACY + RELIABILITY Anatomic features: Muscle location, Fibers direction, Muscle function Palpation skills: -Identify muscle shape and volume + tone -Detect muscle contraction Notice: Muscle fatigue —> Influencing the result Joint laxity(looseness) and/ or deformity Muscle innervation DON’T touch or hold the muscle belly during test performance. -Unless while assessing pain, hypersensitivity and tone. An expert clinician never ignores patient’s comments, and knows how to interpret the terms employed. Preparing muscular testing… -Painfree + comfort position -Quiet atmosphere -Temperature —> decreased temperature means increased tone maintained -Firm support -Minimum friction (Isotonic contraction) -Appropriate height/approach -Avoid excessive postural changes “Healthy muscle” Resistance: * -Next to the distal attachment of the tested muscle -Varies at the end of AROM -Bi/ Poliarticular muscles —> half AROM amplitude. -Smooth + Progressive + Regular —> max intensity tolerated -Aligned to traction force of the tested muscle Hands- Body placement of PT Muscle Manual Testing Grades According to … -Objective factors: Patient’s ability to: -Complete the whole ROM. -Move the segment against gravity -Subjective factors: Examiners impression about: -Resistance required before getting started in testing -Max resistance the patient will tolerate Break test (Isometric) -At the end of ROM or Appropriate movement amplitude —> Resistance -Command: “Hold without letting me break that position” Make test (Isotonic —> Concentric (muscle shortening), Eccentric (muscle lengthening)) -Manual progressively increased resistance Vs the movement tested. -Command: “Hold as I’m pushing down” Exam Question !!!!! whole ROM E * full ROM ROM incomplete absence of muscle activity Validity and Reliability Both are satisfactory for clinical use. Concerning research… -Difficulties in assessing grade 4 (G) -Questionable under 3 (F) Dinamometry Dinamometer -Measures static F+R -Target muscles: Tensors Spine erectors Lower limb Muscle functional Testing I/t and A/t curves Physiological/ Physiopathological muscle behaviour +innervation Electrical muscle stimulation (EMS) Electric shock on the muscle Charts I/t ( Intensity/ time) Curve (Rectangular pulse) —> For muscular fibres A/t (Accomodation/ time) (triangular pulse) —> For nerves Healthy Injured Tensomyography Detects and analyses superficial single muscle properties. Diagnosis Continuous monitoring of the fiber condition and progression. Current —> Induced contraction —> Displacement/ Time Curve. Electromyography - Where you put surface electrodes on the muscles you want to check to see the electrical activity. Assessment of the muscle eletrical activity Electromyograph Surface we can used is Electromyography / Intramuscular EMG used by a medical doctor Isokinetic Dynamometry - Assesses muscle dynamic force in a specific ROM and at constant o speed. Advantages: -Charts: Force - ROM -Associate the obtained values Applications: -Quantify the F produced -Reestablish F after muscular injury -Training - Isokinetic foundations 1st Variable R according to speed —> Settles according to fatigue, pain and length - variations. 2nd Preset speed —> 500 degrees/second maximum -Slow (60degrees/s) -Intermediate (90-120 degrees/ s) -High (300 degrees/s) 3rd Allow both concentric and eccentric exercising 4th Very important! Position Supports setting Execution speed ROM Commands (motivation) + Stimuli —> maximum force Resting periods between contractions 5th Comparative assessments Treatment effectiveness (PRE_POST) —> Progression Compared to healthy/less affected side TOPIC 3: CLINICAL INTERVIEW Communication process between the health professional and patient Chance to get to know the patient. Clinical Interview, Physical examination (DATA OBTAINING) Powerful tool —> brings an accurate diagnosis in 75% of cases. Professional communication skills are related to: -Patient satisfaction -Treatment compliance -Perception of professional competence -Perception of the own health status Patient trust is gained within the first minutes of a PT consultation PT- Patient Relationship Peculiarities - Proximity with the patient: Emotional and Physical - Type of therapy - Dealing with pain, disabilities - Frequence of Treatment -Time of consultation Types of clinical Interview According to the structure: Free/ Non-formal: Psychology and psychiatry Directed/ Structured: Research, school, office. Semi-Directed/ Semi-structured According to the orientation: Patient Oriented Activates patient’s own resources (exercises, change of habits) Work with patient’s ideas, expectations, and emotions as part of the health problem. PT Oriented Centered on the PT (paternalistic approach) Problem solver Key aspects oriented to the patient: Connection Empathizing (express emotional solidarity) Educating (evaluate the understanding and allow asking) Expectations (explore and take into account beliefs and opinions of the patient + demonstrate you have understood them) Enrolling (patient involvement = assume responsibilities) Influencing Factors Context Professional image: Physical appearance Basic hygiene Body language Aware of non-verbal signs Orientation, body position Gestures Genuine behaviour OUR POSITION AS RELAXED AS POSSIBLE AND OPEN, AND NEUTRAL AT THE SAME TIME. Physical space Avoid barriers Patient - PT distance Listening Ability to listen vs hear, and to look vs see. Speed slow and clear Open and short questions —> less limits, more genuine allows MORE info. Closed questions —> when i need specific info SEMISTRUCTURED INTERVIEW A. Exploratory Phase 1. Greeting Welcome Warm Formalisms 2. Define reasons of consultation Complaints of … Open questions (beware of influencing responses) On time questions 3. Get info on the nature of the problem and beliefs and expectations Spontaneous comments/ reactions Feelings (FEARS!) 4. Include family, social and job data Important in some complex situations. Narrative supporting techniques LOW REACTIVITY = Less interruptions FUNCTIONAL SILENCE = Emotional reaction catalyst FACILITATION, verbal & non-verbal = Mediate and focus EMPATHY (unbiased) PARAPHRASING (repeat using different words) DO NOT ABUSE ! CONFRONTATION Work Handling Skills Parallelisms i.e: “Do you associate your change of job with the onsite of your symptoms ?” Brevity Spontaneous information Key words (in and out of context) Common mistakes Impersonal greeting Not clarifying the reason of consultation Focus the interview on secondary complaints Bias the questions Lack of control of the interview A. RESOLUTION PHASE 1. Informative Stage Announce information: -Inform of the health problem -Propose a treatment plan State the problem(s) identified: -Use easy examples -Check for understanding -Two-way communication Common mistakes Use of voice Too many technical terms One-way conversation Interrupting the patient Not check for understanding Negotiation stage Negotiation skills: -Topics for discussion -Exchange of views, brainstorming -Final agreements 2. Dialogue stage -Outline the problems -Accept or make suggestions 3. Agreement stage Make a deal: compromises and/ or responsibilities of PATIENT AND PT= Double deal Wait: take the time needed to see how it evolves. Refer Broken record: situations that need limits, or assure information, avoid damage. Negotiation Goals Recognise the patient’s right to participate Develop an evolutive answer Develop negotiations skills Respect the patient’s final decisions Closure of the interview General summary, verification “Safety net” Warning of possible unfavourable developments Report of the most probable diagnosis = Control the situation Final clarifications: When to come back. TOPIC 4: CLINICAL RECORDS AND REPORTS IN PHYSIOTHERAPY Medical records A chronological written account of a patient’s examination and treatment that includes the patient’s medical history and complaints. Physical therapy records management Keeping Storage Retrieval Disposal Patient rights: legal protection Legally the right to health protection is regulated. Principles of dignity and individual freedom. -Guarantee confidentiality -Avoid discrimination Each country develops laws and rules to protect these rights and obligations. Clinical records in PT Necessary to keep a clinical record for: clinical purpose, scientific research or legal purpose. Important for: PT assistance and legal point of view. Purposes of clinical records To provide an accurate and comprehensive account of patient care with clear treatment plans and relevant interventions. To record the chronology of events, problems that arise, and response to them. Written evidence of health service to keep record and guarantee continuity of care between professionals. To meet legal , professional requirements. Clinical records Must be: accurate, legible, permanent, confidential. Has to be maintained for each patient so it can be easily: -read -retrieved -copied -printed Identification that is unique to each patient must appear on every page of that patient’s clinical record. All entries in a clinical record must be chronological, record the date of the entry, and identify the physical therapist making the entry. Clinical records should contain Record identification number Key demographic data such as full name, NHI number, date of birth, gender, ethnicity, contact details. Identification details of the workplace. The date Any relevant family or personal history Analysis of the patient’s signs and symptoms. Treatment plan all procedures and the date and time they took place. Progress made and discharge plan Information given to the patient Reports from referring health professionals Name, signature and of the PT responsible Electronic health records Records in in a structured digital format Softwares systems for general practitioners for PT. - Generally accepted best way to store the patient’s medical data. Clinical reports in Physiotherapy Communication between people involved in th patient health issues: -Medical-legal report -Assessment/Diagnostic report -Status TOPIC 5: DATA STANDARIZATION AND PT DIAGNOSIS Assessment in Physiotherapy Implies the recording of information and clinical data. Need to structure and organise all information: 1.Filiation 2.Subjective data: symptoms, red flags, yellow flags, etc … 3. Objective data: visual, joint mobility, muscle function, palpation. 4.Clinical reasoning 5.Diagnosis 6.Goals 7.Treatment plan Assessment and Clinical Reasoning -Subjective: History taking -Objective: scales -Analysis. SOAP -Plan realistic Our goals are: -Specific -Measurable -Agreed. SMART -Realistic: multiple factors must be considered -Timing PT Diagnosis PTD is the result of a process of clinical reasoning using a problem-oriented hypotico-deductive model. It has a patient-centric approach. WHO classifications of health status ICD-10 (International classification of diseases): it bases on the etiology in order to establish medical diagnosis. ICF: functional diagnosis ICD-10 The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. Classify diseases and other health problems recorded on many types of health and vital records. ICF model Concepts Impairment Any loss or abnormality of psychological, physiological or anatomical structure or function. Disability: Any restriction or lack of ability to perform an activity in th manner or within the range considered normal for a human being. Handicap: - A disadvantage for a given individual that limits or prevents the fulfillment of a social role that is normal. TOPIC 6: METHODOLOGY OF ASSESSMENT IN PHYSICAL THERAPY Assessment in physical therapy 1st step in every serious and skilled assistance Systematised for every patient. Every patient’s information must be compiled and carefully read and listen order to determine the patient’s state of health. Describe capabilities and problems that can be addressed from a PT perspective. Main sources of information: -Patient -Family -Clinical history and other professional health recordings. Filiation Name and Surname Age Contact data occupation Hobbies Medical diagnosis Reason for consultation Current medication Subjective Assessment AGE (correlation regarding the patient’s health problem) -Is the age of onset correlated to the pathology? -How does age affect in the treatment techniques selection? -Symptoms fit patient’s age? Gender (correlation regarding the patient’s health problem) -Is gender correlated with the age? -Does gender explain the problem onset? Crucial for ruling out SERIOUS PATHOLOGY * Professional and Leisure Activities -Learn rehabilitation strategies —> Return to normal life. -Detect harmful maintained positions and movements Familiar and Socio-Economic Data -Eduction level -Health insurance coverage Medical History and Current Diseases (Bring up your Questions Gently) Current Medication Pain Cardinal symptom to assess. Most frequent cause of consultation in Physiotherapy. LOCATION