BMS150 Student Version Practical Lab Manual Week 2.pdf

OHIPMNRS MODEL FOR ORTHOPEADIC ASSESSMENT Observe: • Patient’s general appearance, posture & gait (how do they walk into the office?) • Emotional status (happy, sad) – are they comfortable? History (Basic Considerations) • Where is the problem? Point to it exactly. When did it start? • What makes it...

OHIPMNRS MODEL FOR ORTHOPEADIC ASSESSMENT Observe: • Patient’s general appearance, posture & gait (how do they walk into the office?) • Emotional status (happy, sad) – are they comfortable? History (Basic Considerations) • Where is the problem? Point to it exactly. When did it start? • What makes it better or worse? Prior treatment or injuries? • Quality of issue? (numbness, tingling, sharp, ache) • Severity (scale from 0-10)? Gradual or sudden onset? Inspection (Visual) • Posture, gait, bony deformity, trouble with activities of daily living (ADLs) • Obvious discomfort (painful expression, unable to sit comfortably, limp) • Bony & soft tissues (deformity, bruising, swelling, colour, sweat/dry, scars, calluses, bunions, atrophy, ulcers) • Foot wear (supportive, wear patterns on shoes, assisting devices such as orthotics or braces) Palpation (360 Degrees Around Joint/Painful Area) • Please NOTE: Temperature, Texture, Tone, Tenderness (4 Ts) • 360 Degrees around the joint • A bit above and a bit below the site of injury/complaint • Apply enough pressure to feel deeper tissues and recreate pain • Anatomy review (bone, tendons, ligaments, fascia, blood vessels, nerves, lymph, viscera) Motion: AROM/PROM/RROM • Start with AROM - Full Ranges (Note any issues) • Move to PROM - Full Ranges with Over Pressure at the end for End Feel • Move to RROM - Full Strength but fully isometric (neutral/relaxed position) Neurovascular Screen • Dermatomes • Myotomes • Deep Tendon Reflexes • Pulses, capillary refill, temperature Referred Pain (screen adjacent areas) • Is there pain in other areas Special Tests (Orthopedic Tests) • Start with tests for the specific area of pain/concern • Keep in mind nerve referral pathways. So, if appropriate, perform specials tests above and below the site of pain/ concern. Cervical Spine Assessment *What follows is key anatomy, ranges of motion, neurological testing and special orthopaedic tests* PALPATION Bony Palpation • Anterior aspect o Thyroid cartilage (C4-C5) o Cricoid Cartilage(C6) • Posterior aspect o Occiput o Inion (EOP) o Mastoid process o SP of the cervical vertebrae (C2-7) o Facet joints Soft tissue palpation • Anterior o SCM o Lymph Node Chain o Supraclavicular fossa • Posterior o Trapezius Muscle o Lymph Nodes o Levator Scapulae Lower Dermatomes Myotomes Must be held at least 5 seconds and done BILATERAL Spinal level Resisted action C1-C2 Neck flexion • Head slightly flexed • Pressure to forehead with stabilizing hand between the scapula • Be sure neck does not extend when applying pressure C3 Neck side flexion • One hand above patients ear • Stabilize with other hand on opposite shoulder C4 Shoulder elevation • Bring shoulders up to about half of full elevation • Apply a downward force while patient tries to keep in place • If done seated have patient push up on thighs C5 Shoulder abduction • Elevate arms to 70-80 degrees, elbows at 90 degrees • Apply downward force on humerus • To prevent rotation place examiners forearms over the patients forearms C6 Elbow flexion • Arm at the side, elbow at 90 degrees • Forearm neutral • Apply downward force C7 Elbow extension • Arm at the side, elbow at 90 degrees • Forearm neutral • Apply upward force C8 Thumb extension • Extend the thumb to just short of full range • Apply pressure to bring into flexion T1 Squeeze patients abducted fingers together T2 Pull patients adducted fingers apart Spinal level Resisted action L2 Hip flexion • With Knee Bent • Pressure to thigh while patient tries to resist downward pressure L3 Knee Extension • With Knee Bent • Hand on Tibia and patient will resist knee flexion L4 Ankle Dorsiflexion • With Knee bent • Hand on dorsal of foot and patient resists dorsiflexion L5 Great Toe Extension • Patient resists big toe extension S1 Hip Extension but also Ankle Plantar Flexion and Eversion • Patient can stand on toes and hold or, while sitting, plantar flex into examiners hand • This also adds hip extension, so get patient to lie prone with knee bent and resist hip extension S2 Knee Flexion • With knee bent patient resists knee flexion Deep Tendon Reflex Testing Reflex Site of Stimulis Spinal level Biceps Biceps Tendon C5-C6 Brachioradialis Brachioradialis tendon or just distal to the musculotendinous junction C5-C6 Triceps Distal triceps tendon above the olecranon process C7-C8 Patellar Patellar Tendon L3-L4 Achilles Achilles Tendon S1-S2 Special Test (Orthopaedic Testing) Cervical Distraction Test (Pain Relief Test) • • • • Examiner places one hand under the patients chin and the other around occiput Examiner than slowly lifts the patients head Positive o pain is relieved or decreased Indicates o relief from pressure on a nerve root by widening the neural foramen; decreasing pressure on the facet joint; relaxing contracted muscles Spurling’s OR Foraminal compression Test • • • Examiner presses straight down on the head in 3 stages, each of which is increasingly provocative. If symptoms are produced, one does not need to progress to the next stage. o Stage 1 = compression of head in neutral o Stage 2 = compression of head in extension o Stage 3 = compression of head in extension and rotation Positive o pain radiating into the arm toward which the head is side flexed during compression Indicates o the test narrows the IVF to bring out facet joint symptoms, stenosis, herniation, osteophytes Maximal foraminal compression Test • • • • Pa#ent Extends, Lateral Flexes, and Rotates to same side Examiner than compresses the head in this position Positive o pain radia#ng to arm Indicates o Concave side pain = nerve root or facet joint pathology o Convex side pain = muscle strain Valsalva Test • • • Have pa#ent hold breath and bear down as if he is having a bowel movement Positive o pain in the cervical spine or dermatome related to the cervical spine injury secondary to increased pressure Indicates o a space occupying lesion (E.g. tumor, herniated disc) is present in the cervical canal Shoulder Depression Test • • • • Examiner side flexes the pa#ent’s head to one side while applying a downward pressure on the opposite shoulder Positive o increased pain to either side Indicates o pain to compressed side = compression of nerve roots, foraminal encroachment (osteophytes) Indicates o pain to stretched side = adhesions around the dural sleeves of the nerve on the side being stretched Vertebral Artery Test • • • • Pa#ent supine, examiner passively places the head and neck into extension and side flexion Once in this posi#on the examiner rotates the neck to the same side and holds it for 30 seconds Positive o dizziness or nystagmus Indicates o Vertebral artery compression Chvostek’s Test • • • • • Evaluates for a CN 7 pathology Irritation to CN 7 will often refer pain to the area of the TMJ Examiner taps on the parotid gland and observes patients reaction Positive o facial muscles twitch as a result of the tapping Indicates o Cn 7 palsy or injury or Low blood calcium Jaw Reflex • A stretch reflex involving the masseter and the temporalis muscles • Patient gently opens his mouth while the examiner places her thumb on his chin • Examiner uses a reflex hammer to tap the thumb • Normal reflex response is closing the mouth • Positive o absence or hyperactivity is considered loss of the jaw reflex • Indicates o CN. 5 injury if absent, UMN lesion if brisk Soto-Hall Test • • • • Patient lies supine with legs straight Patient then actively flexes neck by putting their chin to their chest Positive o Lightening like pain Indicates o Dural or meningeal irritation in the cervical spine No Picture available Brachial Stretch Tests/Upper Limb Tension Tests (ULTT) 1. ULTT - Median Nerve Dominant • Places tension on C5,6, and 7 nerve roots (Median nerve dominant test) • Not specific to any given single given nerve root • Positive test indicates irritation or compression of any 1,2 or 3 of the involved nerve roots which • • • • • contribute to the median nerve Each portion of the maneuver must be done carefully and gently Communicate with the patient to determine whether radicular symptoms are reproduced and at what point Performed Test on Right Side o Patient is supine along the right edge of the examining table, scapula projects past the lateral edge of the table o Examiner stands at the head of the table on right side, facing the patient’s feet o Examiner’s left thigh rests against the superior aspect of the patients right shoulder o Examiner’s left hand holds the patient’s right elbow o Examiner’s right hand holds the patient’s right wrist o Examiner depresses the patient’s shoulder girdle with his thigh o Patient’s shoulder is abducted 10 degrees, so arm is clear of the table o Extend the elbow and externally rotate the upper limb at the shoulder o Examiner’s right hand grasps the patient’s fingers and extends the wrist and MCP joints o Abducting the shoulder to 90 degrees while maintaining shoulder depression further increases nerve root irritation Stretching or aching sensation in the antecubital fossa in almost all subjects. This is NOT an abnormal response. Positive Test = Radicular pain to median nerve distribution of C6 and C7. 2. ULTT – Radial Nerve Dominant • Tests for irritation of C6 and 7 (Radial nerve dominant) • Performed with patient lying supine • Each portion of the maneuver must be done carefully and gently • Communicate with the patient to determine whether radicular symptoms are reproduced and at what point • Perform Test on Right Side o Patient is supine, positioned on an angle so their scapula projects past the edge of the table o Examiner is on right side of the table near patients head, but facing their feet o Examiners left thigh rests against the superior aspect of the patients right shoulder, depressing the patients right shoulder. o Extend patients elbow o Examiner internally rotates the entire upper extremity at the shoulder o Examiners right hand flexes the patients right hand, wrist, thumb and fingers • Positive test = Radicular pain in the radial nerve distribution of C6 and C7. 3. ULTT – Ulnar Nerve Dominant • Irritation of C8 and T1 nerve roots • Ulnar nerve dominant • Because of the relative hypomobility of the cervical/thoracic junction, lesions of these • • lower nerve roots are harder to assess Perform Test of Right Side o Patient is supine and examiner is on the right side of the table facing towards the patient head o Patients flexed right elbow is rested against the examiners pelvis just below the ASIS o Examiners left hand grasps the patients right fingers o Examiners right hand is holds the patients superior right shoulder against the table to prevent elevation o Patients wrist is extended and the forearm supinated o Maximally flex patients elbow and with examiners right hand depress patients shoulder o Patients shoulder is externally rotated and abducted ! approximating the patients hand to their ear o Ask patients to laterally bend their head: o Away from side being tested = increase tension o Towards side being tested = relax tension o Response o Normally a tugging sensation in the axilla is felt Positive test = radicular pain along the ulnar nerve distribution of C8 and T1 Group Case This part of the practical is designed to have your TA lead a group OHIPMNRS assessment with 1 student as patient and 1 student as doctor. The doctor is allowed to ask the entire group for help and guidance with each step or swap out completely with another member of the group to continue the assessment. The TA will provide positive findings, feedback on the assessment, and the diagnosis at the end. The idea is so that this case is taken up in a group setting so that by the end of the practical session, all students will have a firm understanding on how to perform an OHIPMNRS assessment, special tests, and reaching a diagnosis. There is nothing to submit. Taking notes is optional. J.D (22yoa, Female) J.D came into your clinic last week with a chief complaint of deep aching pain in the neck and shoulders and down her left arm with periodic tingling into the hand. She tells you it began as a low grade pain six months ago and has been getting significantly worse over the past few months. She also reveals that over the past two years she has been getting headaches on the right side of her head, they seem to come on at the end of long days. Past history reveals that she was in a moderate motor vehicle accident 8 or 9 months ago. Occupation: Student, works part-time as a receptionist and swims competitively EXTRA INFORMATION • Tingling radiates into medial palm (C7, C8 dermatomes), aggravated by prolonged sitting and looking down to study • Headaches start at the occiput behind the right ear and radiate forward to the right forehead • History taking reveals she has been a student for two years, headaches only come on weekdays after attending classes, and are generally not present during summer break • During school she sits near the front of a large classroom to the right of the room where she must look up and to left to see the presentation Please perform an OHIPMNRS style assessment and be sure to incorporate ALL of the special tests learned in today’s practical session. 14 References: 1. Magee, David J. Orthopedic Physical Assessment, 5th Edition, Elsevier 2008,ISBN 978-1-4160-6851-8 15