Assessment And Clinimetrics Topic 1-9 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 TOPIC 7: PAIN ASSESSMENT * original model Onset # Sudden or insidious Associated with trauma? If affirmative … -Any twinge (ligament) or click (meniscus) perceived? -Was there immediate inflammation (outside) or deferred (inside)For how long did it last? If negative… -What triggers the pain? 6 -Associated with some concrete activity? E -Related to OVERUSE? Clinical features of Pain Neuropathic Pain Caused by irritation of the nerve roots and dorsal (sensory linked to hypoesthesia) ganglion. High-intensity, throbbing, electrical , burning. Goes over the affected nerve tour (occasionally to fingertip) Occasional dysesthesia and/ or paresthesia. * Somatic Pain - Dull, non-electric, diffuse and difficult location. Highly variable intensity. Distinguish differential aspects involving every affected tissue. Visceral Pain Deep and diffuse Often mislead with somatic pain. Associated with viscera function * Pain behaviour Continuous - Does not occur with specific positions or rest. Chemical irritation, bony tumor, visceral. If not increased with mechanical tests. Intermittent - Present or absent depending on its triggers. Mechanical if originated at the musculo-skeletal system. Persistent Constant with variations Inflammatory and mechanical shades - Tdisce Previous treatments Crucial to focus on a new treatment according to those made previously and prognosis establishment. * Signs or symptoms that may alert of major pathology: - Severe or Ominor trauma (if there is history of osteoporosis) -History of cancer/tumours family) ~ dat -Older than 50 or younger than 20 - -Recent infection - > -Fever -General asthenia -Sudden weight loss -Immunosuppression -Night or constant pain not associated with clearly variation sin the relief -Saddle pareses or anesthesia o -Bilateral neurological symptoms involving the lower limb + back pain 2CN5 -Sudden decrease in muscle strength -Dorsal or lumbar pain associated with any particularfood or diet - Psychosocial factors that increase the risk of developing long-term disability -Belief —> “the injury is harmful” -Fear from specific movements and avoidance behaviours hinssophobic -Tendency to despair and social isolation > - older and hroni -Expectations that passive treatments are more helpful than the active training Objective assessment Visual inspection 1st phase —> Started in the 1st visual contact with the patient. P info GAIrcycle - Is he/she protecting the affected area? Technical aids to mobility? Family overprotection? Limping ? How does he/ she get undressed? -Skin colour -Postural standing -Muscle atrophy different types -Scar C -Deformities -Odemeas, bruises - Flexion wrinkles -Pupillary appearance Mobility and muscle strength exploration Active mobility & -Always before passive assessment -OJO —> The contractile component rules the whole examination -Physiological movements —> Combined movement scanning -Movement ⑳ Quality -Muscle testing if necessary —> to evaluate muscle strength and O pain during contraction u Passive Mobility O Partive retainer -Inert components of the musculoskeletal system -Physiological and accessory passive movements u - Final movement sensation: # sliding -CAPSULAR (I.e feeling of flexion of the wrist or knee extension) -OSSEOUS (sharp and irreducible) -ELASTIC (I.e dorsal flexion of ankle with the knee extended) -IN SPRING ( I.e#knee-fibrocartilage meniscal injury) -COMPRESSIVE (I.e maximum knee flexion) -THICK ( I.e capsular inflammation) -SPASM (I.e reactive response in the opposite direction to the movement) -VACUUM (I.e absence of final feeling, absence of reactive spasm) -HARD MECHANICAL ( jammed) Specificity Tests: -According to patient’s complaint and body region -Provocation tests, neurological study, osteoarthritis- tendinous reflexes Palpation: -At the end of the scan -Search for sensation, painful points, tissue temperature Finally 6 - - (goals Clinical reasoning in Physical therapy “Mental process and decision making that takes place during the process of evaluation, diagnosis and treatment of the patient’s pathology”. Crucial to guarantee our true professional autonomy (PT’s are responsible for our own actions and are able to adopt responsible, timely, accurate, and independent clinical decisions) Initial models Hypothetical-deductive reasoning. -Based on the relationship between clinical patterns and diagnosis. Jones (1992) adapted the HDR and proposed a Category hypothesis system (shows numerous interrelated components of the patient’s condition; 7 categories) 1.Functional limitation or disability 2.Pathobiologic mechanisms 3.Physical and psychological disorders 4.Contributing factors 5.Precautions and contraindications 6.Management and treatment 7.Prognosis Collaborative Models Patient Centered Model -Highlights the importance of the patient specific problem context within the clinical reasoning process. -Depends on the W role of each patient in the decision-making process. W plausible Dialecting reasoning less used -Holystic & [ - -Faces thought and actions towards the understanding of the person, instead of only his/her physical problem u -“Interaction between quantitative and qualitative reasoning models” Collaborative Clinical Reasoning Model -Highlights the patient’s cooperation on the CR process. -Helps PTs to delve into the patient’s condition and patients to improve their understanding and condition acceptance, - in order to increase the therapeutic process efficiency. -This collaboration leads to the improvement of patient’s perspectives and treatment outcomes. Edwards (2000-2004) Diagnosis: Diagnostic reasoning —> Functional impairments Narrative reasoning —> Understand the patient’s interpretation of his/her condition. z Treatment: un Reasoning of the & procedure —> Define therapeutic procedures O Interactive reasoning —> Establishment of the PT- patient relationship - m Collaborative reasoning —> PT- patient treatmentE decision-making - ~ Predictive reasoning —> take into accountS future shifts and their consequences. Teaching reasoning —># Explanation of the PTP —> higher patient implication ~ - TOPIC 8: SCIENTIFIC VALIDATION OF TEST AND SCALES. RELIABILITY AND VALIDITY Tests A medical test is a kind of medical procedure performed to detect, diagnose, or monitor diseases, susceptibility and determine a course of treatment. It must be a reliable and valid instrument. Reliability The extent to which an experiment, test, or measuring procedure yields the same results on repeated trials. What determines the variability of a test? -Measuring instrument -Evaluator interpretation -Own patient variability -Randomness Determining the reliability of a test Test-rest reliability: measure of reliability obtained by administering the same test twice over a period of time. Intra-rater reliability: degree of an agreement among repeated administrations of a diagnostic test performed by a single rater. Inter-rater reliability: is the degree of agreement among raters Different procedures based on the nature of the assessment variable: -Qualitative variables: no natural sense of order. Deal with descriptions. E.g: sex/ hair Color/ positive-negative test… -Quantitative variables: numbers. E.g: 1-10 VAS. Reliability: Cohen’s kappa Agreement between two measures of a qualitative variable: Validity of a test Test validity is the extend to which a test accurately measures what it purports to measure. For tests classifying the subject (E.g: healthy/ill) Confirmation based on a gold standard test result. A test is valid in case of adequate values of: Sensitivity Specificity Reliability Predictive values Gold standard test is the best test available, it is often invasive or expensive. A new test is, for example, a new screening test or a less expensive diagnostic test. 8 ** Sensitivity and specificity Assume a population of 1000 people 900 do not have the disease A screening test is used to identify the 100 people with the disease. The results of the screening are in this table. # Validity of a test Positive predictive value (PPV) The proportion of patients whose test is positive and have the disease. # Negative predictive value (NPV) The proportion of patients whose test is negative and are free of the disease * # * TOPIC 9: BALANCE AND GAIT ASSESSMENT Balance The human being has the ability to maintain positions and move Adapting to intrinsic and extrinsic changes in posture under the influence of gravity Balance is the basis for all those movements. Orientation —> Interpretation by the CNS of afferent stimuli, to maintain a proper body alignment according to the physical environment and tasks performed on it. 3 major Afferent Systems: Visual, Vestibular, Somatosensory Stability Processing afferent efferent information and mechanisms. Resist + anticipate disturbances (feedback & feedforward) Maintain a stable static position and allow movement at the same time. Integrative system —> Cerebellum (process and modulate all information) Static Information about a body segment relative to one another in a stability. Dynamic Information about the movement speed and direction of one or several body segments. Balance disorders Direct way Injury to the major afferent systems and integrative system: -Deafferentation (afferent nerve fibers injury) going with anatomical structure injury (bones, ligaments, muscles) -Damage of sensors or nerves -Alteration of the CNS Indirect way Impairment of the nerve signal transduction (nerve transduction inhibition) that comes with bony-joint trauma and or prolonged immobilization periods. Balance assessment Functional assessment tools (tests or scales) -Define deficits, establish a treatment plan -Achieve the greatest possible patient functional independence Functional test must take into account three aspects: -Functional skills -Motor and sensory strategies used to maintain postural control in several tasks. -Sensory, motor and cognitive deficiencies that limit the posture control. It’s mandatory to preserve the patient’s integrity ( protect them from falling at all times!!) Use at least 2 tests, each one will provide different information about how to act. Assessment of functional skills Examine how the patient performs many daily tasks requiring postural control V Are there underlying motor, sensory and cognitive impairments contributing to got the imbalance? Limitations: -Don’t evaluate change of context situations -Don’t evaluate the movement quality Most commonly used tests: -Balance ability Self assessment: number of recent falls allows to define what postural control key aspects are affected. -Activities-specific Balance Confidence (ABC) Scale -Falls Efficacy Scale-International (FES-I) Scales for the Measurement of Balance Skills Time Up and Go test (TUG) Reach Test Multi-directional reach test BERG BALANCE TEST Berg Balance test Measures balance in elderly and neurological patients Consist of an assessment of functional tasks 14 time scale Equipment: Ruler, 2 chairs, stool, stopwatch Time: 15-20 min Scoring: assess,emit between 0 and 4, Total= 56 points Interpretation: 41-46 —> low fall risk 21-40 —> medium fall risk 0-20 —> high fall risk Evaluation of the Equilibrium Strategies 1. Motor strategies: 1.1.Alignement —> Sitting and standing position -Plumb line -Static force plates -Scales 1.1.Movement Strategies -Patient ability to maintain postural control -Performed while the patient changes positions -Movements of the center of gravity at all levels must be controlled 2. Sensitive strategies Romberg Test Dynamic posturography Sensory Organization Test (SOT) 3. Visual Strategies Ability to organise and select sensory information in response to changing visual conditions GAIT Is a neuromuscular & musculoskeletal action of the whole body that requires the coordination of both legs and a large number of joints and muscles working together Problems with mobility management are crucial to solve when regaining functional independence. GAIT Assessment Functional assessment tools ↓ Define deficits, establish a treatment plan (short and long term-term goals) ↓ Achieve the greatest possible patient functional independence. Functional test must take into account three aspects: -Functional skills -Motor and sensory strategies used to maintain postural control in several contexts and tasks -Sensory, motor and cognitive deficiencies that limit the posture control GAIT Assessment part 2 Cadence: Steps/min = 111-117/min Speed: Normal speed on flat ground = 82 m/min (adult) Monitorizing Stopwatch Podometer Step watch activity monitor Assessment of functional skills Dynamic Gait Index Functional gait assessment Figure of 8 walk test Gillette functional assessment Questionnaire Evaluation of the Gait Strategies Visual Analysis Functional Ambulation classification Rancho Los amigos Walking Ability Questionnaire Rivermead Visual Gait Assessment Motor Assessment Scale Scales limitations Mobility, balance, or general motor control does not snot provide information about the way in which the activity occurs. These measure do not delve into the underlying deficits that require treatment. Scales covering a wider range of gait abilities, especially in community living, are required. Evaluation of sensory, motor, and cognitive deficiencies that limit the posture control and gait PT needs to adopt a flexible position to evaluate and interpret posture, balance and gait in each patient, deciding the most significant component. OJO. Any of the individual factors can be altered ↓ Correlated systems will try to compensate the deficit to achieve the task. Assessment of functional skills Hoffer Functional Ambulation Scale Figure of 8 walk test Gillette Functional Assessment Questionaire Evaluation of the Gait Strategies Functional Ambulation Classification Ranches Los MAigos Walkign Ability Questionnaire (RLAH) Rivermead Visual Gait Assessment (RVGA) Motor Assessment Scale Scales Limitations Mobility, balance, or general motor control does not provide information about the way in which the activity occurs. These measures do not delve into the underlying deficits that require treatment. Scales covering a wider range of gait abilities, especially in community living, are required Evaluation of sensory, motor, and cognitive deficiencies that limit the posture control and gait PT may need to adopt a flexible position to evaluate and interpret posture, balance and gait in each patient, deciding the significant component OJO Any of the individual factors can be altered ↓ Correlated systems will try to compensate the deficits to achieve the task. TOPIC 7: PAIN ASSESSMENT V2 Nociception Encoding and processing of harmful stimuli in the nervous system. Nociceptor High threshold sensory receptor that is capable of transducing and encoding noxious stimuli. -Thermal -Mechanical -Chemical -Silent -Polimodal TOPIC 10: ACTIVITIES OF DAILY LIVING Dependency assessment Multidisciplinary Personal life Family Social Health Economic Care Physiotherapy: Motor-functional aspects —> MSK problems Geriatry: Cognitive-physiological aspects —> Senescense, dementia. Family medicine and palliative care: Symptom control and quality of life Evaluating medicine: Graduation for obtaining compensation and access to services. Social work: Domestic aspects, the environment and support for caregivers. Why assess dependency? A metric for a variety of services and programs related to caring for the elderly and those with disabilities. Determine type of assistance Set goals of treatment Determine patient health status Dependency grades Grade I: Moderate dependency Help to perform ADLs at least once a day, or intermittent or limited support needs for personal autonomy. Grade II: Service dependency Help to perform various ADLs twice or three times a day, but does not want permanent support from a caregiver or has significant support needs for personal autonomy. Grade III: High dependency Help to perform several ADLs several times a day, because of total loss of physical, mental, intellectual or sensory autonomy, needs the indispensable and continuous support of another person. Disabilities components assessed with dependency scales Activities of daily living (ADLs) Set of behaviors that a person performs every day or almost every day in order to live autonomously and integrated in his environment and to fulfill his social role. Measures of function: Generic VS Specific tools General health status questionnaires Not specific to any pathology or diagnosis Overall aspects of functional capacities Could evaluate physical function alone (+) Goof measurement properties (-) Miss out specific problems of each pathology. Not sensitive with functional changes Specific: Health-related quality of life for a specific pathology Generic: Not related to any type of disease. Applicable to the gernal population and to group of patients. 3 subgroups: single item measures, health profiles and utility measures. ICF Barthel index EUROQo-5D SF-36 Barthel index functional assessment Mainly used in rehabilitation, geriatrics and residential admissions. Is to establish degree of independence from any help, however minor and for whatever reason. A patient’s performance should be established using the best available evidence. Ask patient and their friends/ relatives for usual source. 10 sections: 8 sections (11 activities): -7 self care: Feeding, washing the whole body, dressing, personal hygiene, toilet use. -4 mobility: Body transfers, mobility in a wheelchair, going up and down stairs. 2 sections: -Stooling and urination Objectives Functional capacity assessment Detect the degreee of deterioration Objectively control the clinical evolution Design care and rehabilitation plans in an interdisciplinary way Severity levels 1. Independent, but requires technical aids, prostheses or orthoses. 2. Help is required, but patient performs at least 50% of the activity. 3. Patient requires a lot of help. 4. Total incapacity or major help to perform the activity. Barthel index interpretation Multiply each item score x10 -80-100 => Able to live independently -60-79 => Minimally dependent -40-59 => Partially dependent -20-39 => Very dependent - Total dependence EUROXoL-5D Quality of life health related measurement tool European consensus Two parts: 1. Descriptive System: Mobility, Personal care, Daily activities, Pain/discomfort, anxiety/depression -1) = No problem -2)= Some problems/ moderate problems -3) = Many problems/ unable 2. Vertical VAS (20 cm) “Worst health you can imagine” “Best health you can imagine” SF- 36 Health Survey Developed from the medical outcomes study questionnaire battery. SF-20 and SF-12 versions. 8 health concepts Physical function Physical role Body pain General health Standard version: 4 weeks Vitality Acute version: 1 week Social function Emotional role Mental health 1 Transition item: Change in health status from previous year. Not use in scoring Measures of function Specific tools Pathology-specific” Items generated specifically with a given pathology Body part specific: Region specific; items about tasks using the involved body part. Patient-specific: Each patient identifies his or her own set of disabilities. Measures of function. Generic vs specific Specific tools Positive (+): Able to detect specific limitations associated to certain pathologies. Positive (+): Sensitive to detect functional changes in response to treatment. Negative (-): not able to detect general psychosocial or health related quality of life status. TOPIC 11: CERVICAL SPINE ASSESSMENT Cervical Spine Impairment Prevalence —> At least 70% Next Year —> 40% of the population will suffer from neck pain Up to 60% of the cases are persistent several years after the first episode. Reliability: Intraclass Correlation Coefficient (ICC) # Inclinometry: Flexo-Extension -Calibrate 1 Inclinometry: Side Bending et * Inclinometry: Rotation Using CROM (magnet), goniometer ( analogical and digital (more reliable) * * Association between neck pain and deep cervical flexors weakness follows craniocervical instability. Device: Stabilizer or Manometer Lying in supine position; Gestured answer “Yes”/ Maintain. Baseline —> 200mmHg Progression level 5s each: 22, 24, 26, 28 up to 30 mmHg. Training —> 10s each, 10 repetitions maintaining lower progression levels higher progression level. OJO Keep a close eye on the superficial flexors activation!! ICC= 0.81 when assessing muscle activation ICC= 0.93 when assessing muscle contraction maintenance Signs test is positive: Patient quits test. Arrow is shaking Patient reaches the level but cannot hold it. Evaluate for how long is the patient able to maintain both head and neck lifting above the table in a receding chin position. Lifting height= 2.5 cm Norm Value: t= 30-40 s STOP if the patient touches our hand for longer than 1s or flexion creases get lost. Signs of positive: Quits test Detachment of chin Touching the fingers on back of head - * Signs of positive: When you worsen someone’s symptoms the test is positive. When you decrease symptoms the test is considered positive. Patient is placed in ipsilateral side bending and then slight extension with compression axially. Supine, relieving symptoms would be a positive test. Sitting position Deep breathing Exhalation with the glottis closed for 2-3 sec Positive if radicals symptoms are reproduced tests the median nerve (stretch Positive if: -Reproduces patient’s symptoms -Decreasing in elbow or wrist ROM -Ameliorates with isilateral CC side bending -Worsen with contralateral CC side bending. Assesses the integrity of the transverse ligament of the atlas by testing atlantoaxial stability. If sublux> 4mm —> CC Flex worsted the symptoms —> Sublux. Reduction by posterior pushing —> Symptoms amelioration —> Positive test. Steps 1. Stabilize the C2 spinous process with the 1st interdigital space. 2. Mild craniocervical flexion (30) 3. Place the other hand on the patient’s forehead 4. Posteriorly directed force. Directly proportional relationship between neck pain and disability Chronic neck pain —> Motor, Sensitive and psychological impact. Neck Disbaility Index Widely translated into several languages Self administered , 4 min lasting 10 items, 6 options each, scoring 0 to 5 Total score=50 Conclusions the most reliable methods to assess cervical mobility are CROM and Inclinometry In a clinical point of view, root canal and instability tests show better specificity, than sensitivity, therefore are better for ruling out the pathology than for diagnosing, except for the ULTT. The most valid scale for assessing disability associated to neck pain is the NDI. TOPIC 12: ASSESSMENT OF UPPER LIMB Shoulder biomechanics Overhead movements: GH mobility (0-60) Scapular tilt -Rib sliding + clavicular lift -AC joint -SC joint Active/passive range of motion Noncontractlile Dysfunction: -Active and passive movement produce symptoms and are restricted in the same direction and at the same point in the range. Contractile Dysfunction: -Passive joint play movements are normal and symptom free. -Resisted movement produce symptoms. Signs and Symptoms Pain during -Certain activities -Certian positions -Night Weakness Decreased ROM Restricted activities Shoulder pathology Impingement Rotator cuff tears Dislocations Sprains Subacromial disorders Subacromial space => 9-10mm -Subacromial syndrome Anatomic structures involved: -Rotator cuff -Bursa -Tendons -Ligaments and capsule Shoulder assessment Profile: Age, sex, job, sports… Chronology of events Pain Visual assessment Mobility: Active and Passive Muscular strength Specific tests Palpation Visual inspection Swelling Skin discoloration Bruising Muscle atrophy Scars Deformity posture Winging of the scapulae