Clinical Assessment Day 1 PDF

T2 Clinical Assessment- Introduction Clinical Assessment Massage Therapists are often perceived by the public to only perform relaxation massage. Not to detract from the many potential health benefits of relaxation massage but, most RMT’s provide many of thei...

T2 Clinical Assessment- Introduction Clinical Assessment Massage Therapists are often perceived by the public to only perform relaxation massage. Not to detract from the many potential health benefits of relaxation massage but, most RMT’s provide many of their patients with specific treatment for impairments and general wellness. To do this an RMT must possess the skills to conduct a basic health history and musculoskeletal assessment so that a safe and effective treatment plan can be formulated. If we don’t know what’s wrong, how can we attempt to fix it? Assessment provides us with an objective means to identify an injury or dysfunction and to monitor the effectiveness of a treatment plan. The purpose of the assessment is to find the cause of the patient’s pain or dysfunction so that the treatment plan can be directed towards rectifying the cause of the problem. Otherwise treatment can only offer temporary or short term symptom relief. Hence the following clinical assessment mantra: FIND THE CAUSE – THEN TREAT THE CAUSE Diagnosis Term denoting the disease or syndrome a person has or is believed to have (Taber’s) Identification of a disease by history, physical examination, laboratory studies, and radiological studies (Taber’s) Identification and naming of a disease or pathology Protected act under the ‘Regulated Health Professions Act’ (RHPA) Professions able to communicate a diagnosis have access and training to interpret diagnostic tests Assessment An appraisal or evaluation of a patient’s condition….(Taber’s) An educated evaluation of a patient’s condition and physical basis for their symptoms (Rattray/Ludwig) A means to fully understand the patient’s problems, from the patient’s perspective as well as the clinician’s, and the physical basis for the symptoms that have caused the patient to complain (Magee) Impairment Any loss or abnormality of psychological, physiological, or anatomical structure or function Impairment of patient’s body structure or function Can occur as a result of a medical condition, pathology or injury Can be applied to the wellness model of care as well 1 T2 Clinical Assessment- Introduction WHY ASSESS? 1. Gather information necessary to devise a safe treatment plan Identify possible red flags (serious underlying pathology) Previous injury that may contraindicate certain techniques. Medications Underlying pathology or health condition that may contraindicate treatment 2. Gather information necessary to devise an effective treatment plan Identify patients goals Identify impairments Establish goals of treatment Facilitates treatment that has direction and intent Ensures that you are treating the cause of the complaint, otherwise treatment will yield poor results 3. A tool to monitor the progress/effectiveness of treatment Objective means to monitor results of treatment, self care, function Provides information for informed clinical decision making 4. A means to communicate with other health care professionals Must be able to speak the language other practitioners will understand (doctors, physiotherapists, chiropractors, etc…) Professional image 5. Required by law CMTO standards, RHPA, MTA 2 T2 Clinical Assessment- Introduction “SOAP” notes A very common assessment recording method used by many health care professionals is the problem- oriented medical records method, which uses “SOAP” notes. SOAP is an acronym that stands for the four parts of the assessment: Subjective data, Objective data, Assessment, and Plan. This method is especially useful in helping the practitioner solve a problem. The product of this format is a well organized assessment that is easily recorded, and easy to understand when referred to in the future. Subjective Data Patient’s perception of the current symptoms and their health history ( what they tell you) On the initial visit this would include the health history and answers to the questions asked by the therapist during the interview This information is VERY IMPORTANT to the assessment process, and should not be overlooked On subsequent visits this section should include how the patient has been doing since the last visit – have their symptoms or level of function changed? Compliance with self-care? Objective Data The practitioners observations, testing, and physical findings This will include postural observations, palpation, functional/ROM testing and special orthopaedic tests. Assessment The examiners diagnosis or assessment of the condition, what you believe the cause of the complaint to be An interpretation of the Subjective & Objective data In student clinics this would be referred to as your ‘clinical impression’. This should be a concise statement that may include more than one finding It is not necessary to repeatedly state the clinical impression from treatment to treatment on a single treatment plan. However this is the section where the clinician would comment on progress to date and whether the treatment plan needs revision or not. Plan This is treatment plan or what the therapist will do to treat the problem Treatment aims/goals are stated along with the strategies to attain them All treatment plans should include o Treatment goals or aims of treatment o Techniques used to achieve an effect (includes type of massage, stretching, TrP therapy, self-care, hydrotherapy, patient education) o What structures those techniques are applied to and how long or how often o Number & Frequency of future treatments & when to re-examine 3 T2 Clinical Assessment- Introduction ASSESSMENT PROTOCOL Generally an assessment should progress in the following sequence. This sequence is adaptable to the body part being assessed and will help you arrive at a logical explanation for your patient's complaint. 1. Case history 2. Observation 3. Palpation 4. Rule Outs 5. Functional Tests (ROM tests AF,PR,AR) 6. Special Tests 7. Muscle Tests 8. Neurological Tests 9. Joint Play examination 10. Lesion site palpation GENERAL GUIDELINES OF CLINICAL ASSESSMENT 1. Observe and test BILATERALLY (all observations and functional/ROM testing) 2. Test the UNAFFECTED SIDE FIRST Provides a baseline for comparison 3. Do the most PAINFUL TESTS LAST Modify the order of your testing so that the test you expect to provoke pain be done last A pain producing test performed early in the assessment can skew the results 4. If your patient experiences pain during a particular movement or test have them STOP and identify the LOCATION and NATURE of the pain. The location and nature of the pain is important information that will guide your testing Don’t aggravate the injury by moving through the pain 5. Take a thorough case history saves you time by avoiding unnecessary testing 6. Always support the limb in a secure and neutral position 7. Rule out the proximal and distal joints Ensures that you are in fact assessing the proper joint The complaint may be the result of dysfunction at another joint or referred pain 8. Be aware referred pain Neurological, Trigger Point, or Visceral 4 T2 Clinical Assessment- Introduction Testing Positions In addition to supine and prone, note the following descriptions of other commonly used testing positions: High Seated Hips and knees are at 90° flexion Long Seated Hips at 90° flexion, knees extended Hook lying Supine, hips at 45° flexion, knees at 90° flexion Case History Taking An assessment should be thorough, systematic and conducted in an efficient manner (PRACTICE and a PLAN is the key) To achieve this goal it is essential to conduct a thorough ‘case history’ as this significantly reduces the amount of time required to conduct the rest of the assessment By the end of the case history the therapist should have a good idea as to what the cause of the complaint is – all you have to do is LISTEN TO THE PATIENT and ASK THE RIGHT QUESTIONS. VERY IMPORTANT – the information gathered in the case history will dictate the proper order of functional testing Pointers on Communication Be polite - it’s not an interrogation; you need to build a rapport with the patient Respect privacy – don’t start the intake on the way to the treatment area Body language – use an open posture Maintain eye contact Think before you speak Speak confidently EMPATHY Paraphrase to clarify Slow down LISTEN to the patient 5 T2 Clinical Assessment- Introduction Case History Guidelines Don’t ask any leading questions; try to keep questions open ended as this will help you gather the information you need from the patients perspective However at times it may be necessary to ask some specific closed ended questions that will help you gather important information and keep the interview focused. Generally the following information should be gathered during the intake: Presenting Complaint Why is the patient coming to see you What is the chief/primary complaint What are their goals/expectations of treatment This will give you direction to your assessment and determine if the patient's goals are realistic General Health Information from health history form Pay particular attention to things that may have an influence on the primary complaint; and also things that may require modification to treatment Age – many conditions occur within certain age ranges Identify ‘Red Flags’; something that would require referral to a physician Occupation What do they do for a living and any hobbies/sports Key is to identify any repetitive motions or prolonged postures that may be contributing factors to the complaint. This can help identify the location or the source of the problem. Functional requirements of the job M.D. & Meds Have they seen a doctor about their complaint o Test results and/or a diagnosis can be extremely helpful Medications o Inquire about any medications being used, and are they helping o May require modification to treatment (steroidal drugs, pain killers, muscle relaxants, mood altering drugs) Previous Injury Have they had this injury before – and how was it treated Have they had an injury to the same joint in the past or to a joint above or below the injury site 6 T2 Clinical Assessment- Introduction Present complaint may be the result of the poor healing or rehab of a previous injury Pain Questions regarding the patient's pain or discomfort Will help you gain a thorough understanding of what the patient is experiencing Function Is the complaint interfering with any activities of daily living (ADL)?...such as household chores or driving etc… Therapies Is the patient receiving any other treatment for the current complaint, or have they received treatment in the past for a similar condition. Did the therapy/treatment help? You may want to communicate with any other healthcare practitioners providing care to the patient; a team approach is usually the best approach Current symptoms How does the patient feel today? (can limit the amount or type of testing) 7 T2 Clinical Assessment- Introduction PAIN - A physical and emotional response to tissue irritation, derangement, damage, or tissue death. - The most common symptom for which patients seek care. PAIN: An unpleasant sensation associated with actual or potential tissue damage Mediated by specific nerve fibres to the brain Conscious appreciation may be modified by various factors INFLAMMATORY: Pain results from the release of chemical irritants of inflammation Pain also a result of swelling / edema that compresses nociceptors MECHANICAL: Pain results from the stretch or compression of pain sensitive structures These structures contain nociceptors, when they are stimulated, produce painful sensations ACUTE PAIN: Pain provoked by noxious stimulation produced by injury/disease CHRONIC PAIN: Pain that persists beyond the usual course of healing CHRONIC PAIN SYNDROME: A clinical syndrome in which patients present with high levels of pain that is chronic in duration Involves functional limitations and often times depression NEUROGENIC PAIN: Pain as a result of non-inflammatory dysfunction of the peripheral or central nervous system that does not involve nociceptor stimulation or trauma REFERRED PAIN: Pain that is felt at another location of the body that is distant from the tissues that have caused it Occurs because the same or adjacent neural segments supply the referred site Usually reported as pain that is in a generalized area, felt deeply, radiates segmentally without crossing the midline, and has indistinct boundaries 8 T2 Clinical Assessment- Introduction RADICULOPATHY: Also known as radicular or nerve root pain Involves a spinal nerve or spinal nerve root Pain that is felt in a dermatome, myotome, or sclerotome DERMATOMAL PAIN: A dermatome is an area of skin supplied by one dorsal nerve root Injury can cause sensory alteration to the skin, or pain (usually burning or electric) MYOTOMAL PAIN: A myotome is a group of muscles supplied by one nerve root SCLEROTOMAL PAIN: An area of bone or fascia innervated by a nerve root VISCERAL PAIN: Nerve roots also supply the viscera Pain can be felt in a dermatome as a result of visceral injury TRIGGER POINT PAIN: Referred pain arising from a trigger point Patient often feels the pain at a distance that is entirely remote from the area of the trigger point Untreated trigger points can be associated with pain syndromes that include but are not limited to: radiculopathy, tension headaches, frozen shoulder, tennis elbow… After determining your patient’s chief complaint and their mechanism of injury, the largest portion of your case history taking will be questions regarding their pain or dysfunction. To help you understand the patient’s experience of pain/dysfunction you will need to ask some very important questions as part of your subjective assessment. Here are a couple acronyms or guides to help you: Onset & Duration – Site & Spread – Behaviour & Symptoms LOFDSAQ or SOFDSAQ Note: Every individual has a different pain threshold, which can be influenced by physiological, cultural, emotional or psychological factors. Usually, the worse the pain the more severe the injury is. However, this is not always true. Example: complete tear of muscle or ligament may be painless due to the rupture of the associated neural structures. 9 T2 Clinical Assessment- Introduction 1. LOFDSAAQ LOCATION ⮚ Where is the pain and does it travel/radiate anywhere? ⮚ Generally: as a lesion worsens, the area of pain enlarges and moves distally from the original lesion. This concept is referred to as _________________________. peripheralization If resolving, the area decreases and becomes localized, this is called ______________________. centralization ⮚ Do they point to a specific spot or to a general area Superficial or less severe injuries are usually easier to identify (they can usually point to specific spot) Deeper structures give rise to pain that refers and is more difficult to localize. Local: - Usually indicates a lesion to a superficial structure such as: o Superficial muscles and tendons (ex. hamstrings strain or tendonitis) o Superficial ligaments (ex. MCL)…most ligaments are deep and do not cause superficial pain o Bursa; such as at the greater trochanter or olecranon o Superficial periosteum; such as at iliac crest contusion. Diffuse: - Pain that is not localized and can occur with injuries to the following: o A deep somatic or neural structure o Joint subluxation or dislocation o Severe hematoma o Fractures; sometimes described as deep boring pain o Trigger points and local cutaneous nerves ONSET ⮚ Was there a Mechanism of Injury (MOI) Applied to anatomy, gives a great indication as to what may be injured ⮚ How quickly did the pain/dysfunction begin Immediate onset – traumatic injury (quicker onset may indicate more serious injury) Example: fracture, subluxation, severe muscle or joint injury Gradual or ____________________ insideous onset Often occurs with overuse and repetitive strain injury 10 T2 Clinical Assessment- Introduction These injuries are associated with repeated microtrauma FREQUENCY & DURATION ⮚ How frequently and for how long do the symptoms occur? ⮚ Is the pain constant or intermittent? ⮚ Is the condition improving or worsening? ⮚ Are there any patterns (morning or evening pain, pain with activity?) All the time: ⮚ Usually indicates a severe injury or an active inflammatory state When repeating the mechanism: ⮚ Suggests local lesion, either ligamentous or muscular. ⮚ Ligaments cause pain when ________________. strech ⮚ Muscles cause pain when _________________________________. tear / contracted Morning: ⮚ Sometimes caused by adaptive shortening (ex. Plantar Fasciitis) ⮚ If accompanied by stiffness may indicate intracapsular swelling that builds overnight due to inactivity (common with degenerative joint pathologies or arthritis) End of day: ⮚ Suggests inflammation due to overuse (excessive stress on structures through the day) ⮚ Postural strain or TrPs due to muscle fatigue Weight bearing: ⮚ Pain only on with weight bearing suggests articular (joint surface) or muscular injury SEVERITY ⮚ Verbal pain scale (1-10) ⮚ Visual analogue scale ⮚ Mild/moderate/severe ⮚ Good way to monitor progress AGGRAVATING/RELIEVING 11 T2 Clinical Assessment- Introduction ⮚ What makes it better or worse Can give information regarding the nature of the injury Are there any specific movements or positions that reproduce the pain Can help order your ROM/functional testing QUALITY ⮚ Can you describe or put a word to the pain? Remember not to lead them…if they are having trouble you can offer a few quick options. ⮚ The description of the pain can offer great clues as to the source of pain Sharp: Skin and fascia (eg. Laceration) Superficial muscle (eg. Strain) Superficial ligament (eg. MCL or LCL) Acute inflammation Periosteum (acute lateral epicondylitis) Radicular Pain is sometimes referred to as sharp. May also have decreased ‘muscle strength’ and ‘deep tendon reflex’. Dull Ache: Joints Deep muscles (gluteus medius) Chronic muscle injuries (chronic hamstring strain) Subchondral bone (patellofemoral syndrome, chondromalacia) Chronic inflammation Deep or peripheral nerve Trigger points Referred pain Tingling or Paresthesia: Nerve injury Circulatory problems Numbness: Can be caused by damage or impingement of a nerve innervating a particular area Ex. ulnar border of hand/forearm caused by injury/impingement to ulnar nerve or C8-T1 nerve root. Twinge: 12 T2 Clinical Assessment- Introduction Twinges with a movement that repeats the mechanism of injury could be caused by injury to a local muscle or ligament. Sensation similar to plucking on a string Noises and/or sensations: Clicking and/or snapping can be caused by a tendon flipping over a bone, thickened bursa, meniscal tear, or synovial plica (a fold in the synovium of a joint) Grating is most commonly caused by osteoarthritic changes to a joint (chondromalacia, or calcium in a joint) Sound of tearing at time of injury may indicate muscle or ligament tear Locking or catching suggests a loose body within the joint Giving way or instability is commonly caused by severe joint damage, especially to primary stabilizing ligaments Popping can be caused by negative pressure within a tendon synovial sheath, a tendon flipping over a bony prominence, or possibly by rupture of ligament or tendon 2. OBSERVATIONS - Observations are things we see with our eyes. They should begin the moment you set your eyes on your patient. - Swelling - Altered function - Redness - Deformities - Imbalances - Postural assessment - Pay attention to things like how they enter the room, remove clothing, and sit. 3. PALPATION - Things we feel - Texture - Tone - Tenderness - TEMPERATURE - NOTE: Do not palpate the lesion site at this point of the assessment as it may distort the rest of your assessment. Only check for heat (indicates inflammation) 4. RULE OUTS - Check the joints immediately above and below the affected area to eliminate them as possible sources of dysfunction 13 T2 Clinical Assessment- Introduction - Quick scans of joints using ‘Active Free’(AF) movements followed by overpressure of some or all of the ranges of a joint. - If a rule out is positive at a given joint – then that joint must also be assessed 5. FUNCTIONAL TESTS Active Free (AF) Amount of joint motion that can be achieved by the patient during the performance of unassisted voluntary joint motion. Passive Relaxed (PR) Amount of joint motion available when an examiner moves a joint through its anatomical or physiological range, without assistance from the patient, while the patient is relaxed. Active Resisted (AR) Used to determine the status of the contractile unit with the use of controlled isometric contractions, along the normal planes of movement of a given joint. By the time you get to the functional tests you will likely have a sense of what the nature of the injury is, but you use functional testing to confirm or refute that educated guess. Remember we are trying to arrange the testing order so that the most _______________________ is done last. Example: if you suspect that passive testing will be most painful, do it last. Passive testing engages inert tissue and (passively) elongates contractile tissue. Resisted testing (done isometrically) engages contractile tissue only. We are trying to reproduce the pain/dysfunction. AF movements are always done first then followed by either PR or AR movements. (depending on the suspected nature of the injury) ACTIVE FREE MOVEMENTS (AF) Active Free movements are always done first. They are referred to by Magee as “a functional test of the anatomic and dynamic aspects of the body and joints”. Active Free movements do not differentiate between contractile or inert tissue. Document the following when testing AF movements: ▪ Patient’s willingness to move the joint ▪ Patient’s mobility or available ROM (shows functional ROM vs. anatomical ROM) 14 T2 Clinical Assessment- Introduction ▪ Amount of observable restriction ▪ Whether movements cause pain o Range at which it occurs o Location, intensity and quality Also observe: ▪ Quality of movement ▪ Compensatory movements (i.e. increasing cervical lateral flexion by elevating the shoulder) ▪ Apprehension about doing the movement ▪ Painful arc ▪ Crepitus After taking the case history you should have a strong indication of whether the tissue involved with the injury is inert or contractile in nature. After you have completed the active free movements of the physical examination you must determine if passive relaxed movements or active resisted tests should be done next. The order of testing is done so the most painful of the two is done last. Examples: Text If you believe your patient has a strain of the semitendinosis then your order of testing would be_________________________________________________________________. A/F P/R A/R If you believed the injury was to the medial collateral ligament the order of your testing would be _________________________________________________________. A/F A/R P/R PASSIVE RELAXED MOVEMENTS (PR) When doing Passive Relaxed Movements it is important to encourage your patient to remain as relaxed as possible, allowing you to put the joint through as full a range as possible until an end feel or end range is felt. Must use enough force to determine the patient’s limitations and determine their end feel/range - without seriously exacerbating their condition Passive Relaxed Movements test the inert joint structures Contractile tissue may also cause pain, especially end of range as it is stretched However contractile tissue will also cause pain with ___________________ A/R P/R testing while the inert tissue should not. Along with noting all the points already given under the Active Free movement, you should also observe and document any of the following with Passive Relaxed movements: 15 T2 Clinical Assessment- Introduction ▪ Hypermobility (which allows a joint to be susceptible to ligamentous sprain, tendonitis, early arthritis, dislocations and subluxations) ▪ Hypomobility (can suggest conditions such as muscle strains, nerve compression syndromes, and cartilaginous damage due to constant compression forces) ▪ If, when, and where they feel pain (ask them) ▪ The END FEEL OVERPRESSURE (passive forced) Used primarily to clarify the end feel or end range. It may also provoke the symptoms if they do not show during AF or PR movements. When performing an overpressure the therapist takes the joint to the end of its range and notes how the tissue feels at the end of the particular movement. End Feel The quality of motion or sensation that clinician “feel” in the joint during overpressure at the end of passive range of motion Cyriax defines six end feels: 1. Tissue Approximation ▪ Movement is stopped by the compression of tissue (ex. calf against posterior thigh on knee flexion) (mushy feel) ▪ Normal end feel 2. Bone to Bone ▪ When bone touches another bone (ex. elbow extension) ▪ Can be normal or abnormal (abnormal if it occurs before normal end range) 3. Tissue Stretch Hard or firm (springy) type of movement with a slight give Occurs toward the end range of motion Feeling of springy or elastic resistance Normal end feel “rising tension or stiffness” Most common type of normal end feel Found when the capsule and ligaments are providing resistance to movement 4. Muscle Spasm sudden dramatic arrest of movement, often accompanied by pain described as “sudden and hard” ▪ Usually the result of protective reflex designed to splint a joint and prevent further movement/injury ▪ Often seen in acute or severe injuries (ex. ligament sprain, acute capsulitis) ▪ Abnormal end feel 16 T2 Clinical Assessment- Introduction 5. Capsular Very similar to tissue stretch Does not occur where one would expect it (ie. early in ROM) Tends to have a “thicker” feeling to it ROM is obviously reduced Usually indicated that the capsule is at fault Some divide this into ‘hard’ or ‘soft’ 6. Springy block ▪ Usually indicates an internal derangement within a joint ▪ May be caused by a loose body within a joint (ex. bone chip, meniscal tear) ▪ A slight rebound may be noted at the end of range ▪ Abnormal end feel 7. Empty end feel ▪ Patient stops the movement due to the intensity of the pain ▪ Movement is stopped before end of range is felt ▪ Abnormal end feel A common end feel not described above is a ‘Muscular’ end feel. Often described as rubbery (ex. tension felt in the hamstrings during a straight leg raise) ACTIVE RESISTED TESTS (AR) Active Resisted tests are done to determine the status of the ________________________: Muscle belly Musculotendinous junction Tendon Tendoperiosteal junction Nerve that supplies the muscle The muscles crossing the joint are contracted isometrically (no movement), in a neutral position (minimizes the tension placed on the associated inert structures). From the neutral/mid-range position the patient is asked to slowly build up to a full contraction over a 5 second period and slowly relax. Conversely you may supply the force while asking the patient to maintain the position of the joint. Try to determine whether the contraction is weak or strong, painful or pain free. You may also wish to use the ‘Oxford muscle testing scale’. Cyriax notes four possible finding with resisted testing: 17 T2 Clinical Assessment- Introduction 1. Strong and Painless No lesion or neurological deficit in the muscle or tendon Normal 2. Strong and Painful 1st or 2nd degree muscle strain A minor lesion of the musculotendinous unit 3. Weak and Painless Interruption of nerve supply compression syndromes etc. Complete rupture of a muscle or tendon 4. Weak and Painful Partial rupture of a muscle or tendon Painful inhibition caused by pathology such as a neoplasm, fracture or acute inflammation of tissue Note: Pain with repetitive movements may indicate a problem with the vascular supply to the region. Oxford Manual Muscle Testing Scale 5 Normal – overcomes maximal resistance 4 Able to overcome some resistance 3 Able to overcome gravity but not resistance 2 Able to produce movement with gravity eliminated 1 Slight contraction – muscle tightens but no movement produced 0 No contraction 6. Special Tests used to confirm or rule out injury to specific structures there are many of them and each have a specific name 7. Muscle Testing Length and strength tests for specific muscles Used to determine if a muscle is weak or strong Used to determine if a muscle is short or long 8. Neurological Test 18 T2 Clinical Assessment- Introduction Used to confirm or rule out neurological involvement Dermatomes Myotomes Deep Tendon Reflexes 9. Joint Play Examination Tests accessory joint motion within a joint Not under voluntary control Essential for full and pain free ROM 10. Palpation Finally the lesion site should be palpated Palpation should be systematic and purposeful Using Palpation in Patient Examination Skilled palpation is an art Prerequisite skill for the execution of all massage techniques Skill in palpation is required when performing orthopedic tests Valuable skill for assessment and reassessment o Performed formally (at assessment points) o Performed continuously during a treatment There are many ways to perform palpation. How you palpate is dictated by the purpose of your palpation Basic Principles of Palpation Palpation is a moving inquiry Should be unhurried, un-abrupt, and the therapist must be present Seek answers to a variety of questions when palpating o What is the structure? o What is the quality? o How does it differ from others I’ve palpated? o How does this finding relate to the patient’s history? o How does this structure reflect the patient's demonstrated or reported function? With practice you will no longer need to consciously think of these things and you will develop ‘intelligent touch’ Objects of Palpation 19 T2 Clinical Assessment- Introduction Therapists can identify many impairments through the palpation of specific ‘objects of palpation’ Objects are – the focus of the therapists attention during palpation Not necessarily physical objects What you intend to palpate will dictate the method of palpation to use Contact Surfaces Hands should be supple and relaxed Dominant hand is usually more sensitive Both hands can be used simultaneously to compare (ex. Left vs. Right) Hands may be used to perform different tasks (ex. Moving a body part and palpating) Can use fingers, thumbs, palms, thenar/hypothenar eminence, or back of hand (select according to what you are palpating) Force of Palpation Force should also be applied according to the task at hand Force can vary in rate, pressure, direction, duration 1. Rate of Palpation Scanning/stroking over a large area o Relatively quick o Collect information from a large area o Ex. Tissue contours, resting muscle tone of the entire back Static palpation o No movement of the palpating hand o Best used for palpating movement phenomenon (pulse, respiratory rhythm) 2. Pressure of Palpation Lack of concentration, too much pressure, too much movement are the most common errors when palpating Use the minimum pressure required to contact the intended tissue or structure Use a light force and steadily increase the force as needed to palpate the different layers of tissue Touch should be firm, not tentative or abrupt 3. Direction of Palpation ‘Force of palpation’ can be applied as a shearing force shear can be applied perpendicular (vertical) OR parallel (horizontal) to the tissue Forces can be applied separately or in combination Most often there is some degree of combination involved 20 T2 Clinical Assessment- Introduction Tension along a tissue layer and drag occur when force is applied in a horizontal direction to the tissues Drag is a term used to describe both the therapists palpation and the tissue layers resistance to lengthening in response to the force o Assessment of drag is integral to the examination of connective tissues such as fascia & skin Shearing forces can be applied to different tissue layers to evaluate the movement between them (vertical layers or adjacent layers) Shearing forces in combination with compression are also used to assess muscle tone and bulk All palpation/massage techniques combine elements of compression, drag, and shear o Generally the direction used to palpate the tissue is usually the same used to treat the tissue 4. Duration of Palpation Palpation should not take more than a few seconds (can alter the results of examination) Assessing Objects of Palpation Temperature Provides info about status of inflammation and circulation Direct contact on skin when using back of hand; use very light pressure Palm of hand, approx. 10 mm from surface of skin; use continuous motion to assess Contour and Bulk Refer to the gross shape and size of the patient’s body Use fast scanning palpation & large contact surfaces (palmar surface of hand) Correlate the palpation with visual observation Texture and Consistency Variations in the density of tissues, regardless of the depth of the layer the tissues lie Can be described in superficial tissues (skin), deep tissues (hamstring attachment at isch. Tub.) Can describe tissue hardness or softness o Tissue hardness (descriptors include ropy, stringy, hard, etc…) can be attributed to chronic inflammation that results in the deposit of collagen in the tissues o Tissue softness (descriptors include distended, spongy, boggy, etc…) may be attributed to acute inflammation and the associated presence of fluid in the tissues Fluid Status 21 T2 Clinical Assessment- Introduction Palpation can be used to measure turgidity (fluid pressure or fluid tension) Used to determine the amount of excess fluid in an area and the location (intra/extra- capsular) Viscosity (thickness or stickiness) of semi-liquid materials (connective tissues and muscle) o Muscle and connective tissue viscosity is altered by neuromuscular or connective tissue techniques Palpating Soft Tissue Layers (“Layer Palpation”) Epithelium, connective tissues, contractile tissue Skin Use minimal force Compare thickness, elasticity, tightness of the attachment Neurological dysfunction may be determined by assessing the skin (ex. Dermatomes) Superficial Fascia Turgor (fluid pressure) can be gauged Mobility can be assessed (skin rolling) Deep Layer or Investing Layer Smooth, firm, and continuous and lies between the superficial fascia and the muscle Requires more refined palpation skills (there is more intervening tissue) Muscle Resting muscle tension is assessed by noting a muscle’s response to compressive and shearing forces May compress the whole muscle or bow it; conversely you can try sinking into the muscle and attempt to tease the fibres apart Muscle tension is a variable state and will vary from one person to the next and on segment to another Spasm is more dramatic and more readily palpated Elevated resting tone can result from a variety of clinical conditions including injury, degenerative disease, and stress May also try to note high fluid pressure within muscles Periosteum Thin, dense, spongy layer overlying the bone Only accessible at areas where there is no overlying muscle 22 T2 Clinical Assessment- Introduction Tissue Mobility and Restrictive Barriers Normal Soft Tissue Range of Motion Soft tissues have an available range of motion (comparable to joint range of motion) Within this range are three barriers or resistances o Physiological barrier ▪ Range of motion available of normal circumstances ▪ Midrange is the range with least amount of resistance o Elastic barrier ▪ Felt at the end of range and beyond (end-feel) this is when the tissue is engaged at end of passive range o Anatomical barrier ▪ Final resistance to normal range; any further motion will cause injury to the tissue (ligament, muscle, fascia, bone) Restrictive Barriers occurs when there is soft tissue dysfunction (skin, fascia, muscle. ligament, capsule or any combination of). located anywhere between the physiological barriers and will alter the midrange of the tissue potential to alter/limit the available range of motion Palpation of Tissue Mobility compression and/or drag forces used to observe the resulting movement note any restrictive barriers, quality of movement, and when barriers are engaged Anatomical Structures essential to assessment and treatment the accuracy of your palpation will directly influence the outcomes of treatment need to reliably be able to palpate the appropriate structure and layer of tissue that you intend to treat of assess Body Rhythms pulses and respiratory rhythms static palpation is used with minimal to moderate compression Tremors and Fasciculations 23 T2 Clinical Assessment- Introduction Fasciculations are localized, subconscious muscle contractions that do not involve the whole muscle; result from the contraction of the muscle cells innervated by a single motor axon Tremors are rhythmic movements of a joint that result from involuntary contractions of agonist and antagonist muscle groups both are palpated statically with minimal to moderate compression Vibration crepitus is a vibration associated with roughened gliding surfaces of a tendon, tendon sheath, articulating surface; crepitus is often audible in addition to being palpable "Red Flags" Findings in Patient History That Indicate Need for Referral to Physician (Magee) Cancer Persistent pain at night Constant pain anywhere in the body Unexplained weight loss (10-15 lbs. in 2 weeks or less) Loss of appetite Unusual lumps or growths Unwarranted fatigue Cardiovascular Shortness of breath Dizziness Pain or a feeling of heaviness in the chest Pulsating pain anywhere in the body Constant and severe pain in lower leg (calf) or arm Discoloured or painful feet Swelling (no history of injury) Frequent or severe abdominal pain Gastrointestinal/Genitourinary Frequent heartburn or indigestion Frequent nausea or vomiting Change in or problems with bladder function (e.g., urinary tract infection) Unusual menstrual irregularities Miscellaneous Fever or night sweats Recent severe emotional disturbances Swelling or redness in any joint with no history of injury Pregnancy Neurological Changes in hearing 24 T2 Clinical Assessment- Introduction Frequent or severe headaches with no history of injury Problems with swallowing or changes in speech Changes in vision (e.g., blurriness or loss of sight) Problems with balance, coordination, or falling Sudden weakness 25 T2 Clinical Assessment- Introduction WHY ASSESS? 1. Gather information necessary to devise a safe treatment plan Identify possible red flags (serious underlying pathology) Previous injury that may contraindicate certain techniques. Medications Underlying pathology or health condition that may contraindicate treatment 2. Gather information necessary to devise an effective treatment plan Identify patients goals Identify impairments Establish goals of treatment Facilitates treatment that has direction and intent Ensures that you are treating the cause of the complaint, otherwise treatment will yield poor results 3. A tool to monitor the progress/effectiveness of treatment Objective means to monitor results of treatment, self care, function Provides information for informed clinical decision making 4. A means to communicate with other health care professionals Must be able to speak the language other practitioners will understand (doctors, physiotherapists, chiropractors, etc…) Professional image 5. Required by law CMTO standards, RHPA, MTA 2 T2 Clinical Assessment- Introduction “SOAP” notes A very common assessment recording method used by many health care professionals is the problem- oriented medical records method, which uses “SOAP” notes. SOAP is an acronym that stands for the four parts of the assessment: Subjective data, Objective data, Assessment, and Plan. This method is especially useful in helping the practitioner solve a problem. The product of this format is a well organized assessment that is easily recorded, and easy to understand when referred to in the future. Subjective Data Patient’s perception of the current symptoms and their health history ( what they tell you) On the initial visit this would include the health history and answers to the questions asked by the therapist during the interview This information is VERY IMPORTANT to the assessment process, and should not be overlooked On subsequent visits this section should include how the patient has been doing since the last visit – have their symptoms or level of function changed? Compliance with self-care? Objective Data The practitioners observations, testing, and physical findings This will include postural observations, palpation, functional/ROM testing and special orthopaedic tests. Assessment The examiners diagnosis or assessment of the condition, what you believe the cause of the complaint to be An interpretation of the Subjective & Objective data In student clinics this would be referred to as your ‘clinical impression’. This should be a concise statement that may include more than one finding It is not necessary to repeatedly state the clinical impression from treatment to treatment on a single treatment plan. However this is the section where the clinician would comment on progress to date and whether the treatment plan needs revision or not. Plan This is treatment plan or what the therapist will do to treat the problem Treatment aims/goals are stated along with the strategies to attain them All treatment plans should include o Treatment goals or aims of treatment o Techniques used to achieve an effect (includes type of massage, stretching, TrP therapy, self-care, hydrotherapy, patient education) o What structures those techniques are applied to and how long or how often o Number & Frequency of future treatments & when to re-examine 3 T2 Clinical Assessment- Introduction ASSESSMENT PROTOCOL Generally an assessment should progress in the following sequence. This sequence is adaptable to the body part being assessed and will help you arrive at a logical explanation for your patient's complaint. 1. Case history 2. Observation 3. Palpation 4. Rule Outs 5. Functional Tests (ROM tests AF,PR,AR) 6. Special Tests 7. Muscle Tests 8. Neurological Tests 9. Joint Play examination 10. Lesion site palpation GENERAL GUIDELINES OF CLINICAL ASSESSMENT 1. Observe and test BILATERALLY (all observations and functional/ROM testing) 2. Test the UNAFFECTED SIDE FIRST Provides a baseline for comparison 3. Do the most PAINFUL TESTS LAST Modify the order of your testing so that the test you expect to provoke pain be done last A pain producing test performed early in the assessment can skew the results 4. If your patient experiences pain during a particular movement or test have them STOP and identify the LOCATION and NATURE of the pain. The location and nature of the pain is important information that will guide your testing Don’t aggravate the injury by moving through the pain 5. Take a thorough case history saves you time by avoiding unnecessary testing 6. Always support the limb in a secure and neutral position 7. Rule out the proximal and distal joints Ensures that you are in fact assessing the proper joint The complaint may be the result of dysfunction at another joint or referred pain 8. Be aware referred pain Neurological, Trigger Point, or Visceral 4 T2 Clinical Assessment- Introduction Testing Positions In addition to supine and prone, note the following descriptions of other commonly used testing positions: High Seated Hips and knees are at 90° flexion Long Seated Hips at 90° flexion, knees extended Hook lying Supine, hips at 45° flexion, knees at 90° flexion Case History Taking An assessment should be thorough, systematic and conducted in an efficient manner (PRACTICE and a PLAN is the key) To achieve this goal it is essential to conduct a thorough ‘case history’ as this significantly reduces the amount of time required to conduct the rest of the assessment By the end of the case history the therapist should have a good idea as to what the cause of the complaint is – all you have to do is LISTEN TO THE PATIENT and ASK THE RIGHT QUESTIONS. VERY IMPORTANT – the information gathered in the case history will dictate the proper order of functional testing Pointers on Communication Be polite - it’s not an interrogation; you need to build a rapport with the patient Respect privacy – don’t start the intake on the way to the treatment area Body language – use an open posture Maintain eye contact Think before you speak Speak confidently EMPATHY Paraphrase to clarify Slow down LISTEN to the patient 5 T2 Clinical Assessment- Introduction Case History Guidelines Don’t ask any leading questions; try to keep questions open ended as this will help you gather the information you need from the patients perspective However at times it may be necessary to ask some specific closed ended questions that will help you gather important information and keep the interview focused. Generally the following information should be gathered during the intake: Presenting Complaint Why is the patient coming to see you What is the chief/primary complaint What are their goals/expectations of treatment This will give you direction to your assessment and determine if the patient's goals are realistic General Health Information from health history form Pay particular attention to things that may have an influence on the primary complaint; and also things that may require modification to treatment Age – many conditions occur within certain age ranges Identify ‘Red Flags’; something that would require referral to a physician Occupation What do they do for a living and any hobbies/sports Key is to identify any repetitive motions or prolonged postures that may be contributing factors to the complaint. This can help identify the location or the source of the problem. Functional requirements of the job M.D. & Meds Have they seen a doctor about their complaint o Test results and/or a diagnosis can be extremely helpful Medications o Inquire about any medications being used, and are they helping o May require modification to treatment (steroidal drugs, pain killers, muscle relaxants, mood altering drugs) Previous Injury Have they had this injury before – and how was it treated Have they had an injury to the same joint in the past or to a joint above or below the injury site 6 T2 Clinical Assessment- Introduction Present complaint may be the result of the poor healing or rehab of a previous injury Pain Questions regarding the patient's pain or discomfort Will help you gain a thorough understanding of what the patient is experiencing Function Is the complaint interfering with any activities of daily living (ADL)?...such as household chores or driving etc… Therapies Is the patient receiving any other treatment for the current complaint, or have they received treatment in the past for a similar condition. Did the therapy/treatment help? You may want to communicate with any other healthcare practitioners providing care to the patient; a team approach is usually the best approach Current symptoms How does the patient feel today? (can limit the amount or type of testing) 7 T2 Clinical Assessment- Introduction PAIN - A physical and emotional response to tissue irritation, derangement, damage, or tissue death. - The most common symptom for which patients seek care. PAIN: An unpleasant sensation associated with actual or potential tissue damage Mediated by specific nerve fibres to the brain Conscious appreciation may be modified by various factors INFLAMMATORY: Pain results from the release of chemical irritants of inflammation Pain also a result of swelling / edema that compresses nociceptors MECHANICAL: Pain results from the stretch or compression of pain sensitive structures These structures contain nociceptors, when they are stimulated, produce painful sensations ACUTE PAIN: Pain provoked by noxious stimulation produced by injury/disease CHRONIC PAIN: Pain that persists beyond the usual course of healing CHRONIC PAIN SYNDROME: A clinical syndrome in which patients present with high levels of pain that is chronic in duration Involves functional limitations and often times depression NEUROGENIC PAIN: Pain as a result of non-inflammatory dysfunction of the peripheral or central nervous system that does not involve nociceptor stimulation or trauma REFERRED PAIN: Pain that is felt at another location of the body that is distant from the tissues that have caused it Occurs because the same or adjacent neural segments supply the referred site Usually reported as pain that is in a generalized area, felt deeply, radiates segmentally without crossing the midline, and has indistinct boundaries 8 T2 Clinical Assessment- Introduction RADICULOPATHY: Also known as radicular or nerve root pain Involves a spinal nerve or spinal nerve root Pain that is felt in a dermatome, myotome, or sclerotome DERMATOMAL PAIN: A dermatome is an area of skin supplied by one dorsal nerve root Injury can cause sensory alteration to the skin, or pain (usually burning or electric) MYOTOMAL PAIN: A myotome is a group of muscles supplied by one nerve root SCLEROTOMAL PAIN: An area of bone or fascia innervated by a nerve root VISCERAL PAIN: Nerve roots also supply the viscera Pain can be felt in a dermatome as a result of visceral injury TRIGGER POINT PAIN: Referred pain arising from a trigger point Patient often feels the pain at a distance that is entirely remote from the area of the trigger point Untreated trigger points can be associated with pain syndromes that include but are not limited to: radiculopathy, tension headaches, frozen shoulder, tennis elbow… After determining your patient’s chief complaint and their mechanism of injury, the largest portion of your case history taking will be questions regarding their pain or dysfunction. To help you understand the patient’s experience of pain/dysfunction you will need to ask some very important questions as part of your subjective assessment. Here are a couple acronyms or guides to help you: Onset & Duration – Site & Spread – Behaviour & Symptoms LOFDSAQ or SOFDSAQ Note: Every individual has a different pain threshold, which can be influenced by physiological, cultural, emotional or psychological factors. Usually, the worse the pain the more severe the injury is. However, this is not always true. Example: complete tear of muscle or ligament may be painless due to the rupture of the associated neural structures. 9 T2 Clinical Assessment- Introduction 1. LOFDSAAQ LOCATION ⮚ Where is the pain and does it travel/radiate anywhere? ⮚ Generally: as a lesion worsens, the area of pain enlarges and moves distally from the original lesion. This concept is referred to as _________________________. peripheralization If resolving, the area decreases and becomes localized, this is called ______________________. centralization ⮚ Do they point to a specific spot or to a general area Superficial or less severe injuries are usually easier to identify (they can usually point to specific spot) Deeper structures give rise to pain that refers and is more difficult to localize. Local: - Usually indicates a lesion to a superficial structure such as: o Superficial muscles and tendons (ex. hamstrings strain or tendonitis) o Superficial ligaments (ex. MCL)…most ligaments are deep and do not cause superficial pain o Bursa; such as at the greater trochanter or olecranon o Superficial periosteum; such as at iliac crest contusion. Diffuse: - Pain that is not localized and can occur with injuries to the following: o A deep somatic or neural structure o Joint subluxation or dislocation o Severe hematoma o Fractures; sometimes described as deep boring pain o Trigger points and local cutaneous nerves ONSET ⮚ Was there a Mechanism of Injury (MOI) Applied to anatomy, gives a great indication as to what may be injured ⮚ How quickly did the pain/dysfunction begin Immediate onset – traumatic injury (quicker onset may indicate more serious injury) Example: fracture, subluxation, severe muscle or joint injury Gradual or ____________________ insideous onset Often occurs with overuse and repetitive strain injury 10 T2 Clinical Assessment- Introduction These injuries are associated with repeated microtrauma FREQUENCY & DURATION ⮚ How frequently and for how long do the symptoms occur? ⮚ Is the pain constant or intermittent? ⮚ Is the condition improving or worsening? ⮚ Are there any patterns (morning or evening pain, pain with activity?) All the time: ⮚ Usually indicates a severe injury or an active inflammatory state When repeating the mechanism: ⮚ Suggests local lesion, either ligamentous or muscular. ⮚ Ligaments cause pain when ________________. ⮚ Muscles cause pain when _________________________________. Morning: ⮚ Sometimes caused by adaptive shortening (ex. Plantar Fasciitis) ⮚ If accompanied by stiffness may indicate intracapsular swelling that builds overnight due to inactivity (common with degenerative joint pathologies or arthritis) End of day: ⮚ Suggests inflammation due to overuse (excessive stress on structures through the day) ⮚ Postural strain or TrPs due to muscle fatigue Weight bearing: ⮚ Pain only on with weight bearing suggests articular (joint surface) or muscular injury SEVERITY ⮚ Verbal pain scale (1-10) ⮚ Visual analogue scale ⮚ Mild/moderate/severe ⮚ Good way to monitor progress AGGRAVATING/RELIEVING 11 T2 Clinical Assessment- Introduction ⮚ What makes it better or worse Can give information regarding the nature of the injury Are there any specific movements or positions that reproduce the pain Can help order your ROM/functional testing QUALITY ⮚ Can you describe or put a word to the pain? Remember not to lead them…if they are having trouble you can offer a few quick options. ⮚ The description of the pain can offer great clues as to the source of pain Sharp: Skin and fascia (eg. Laceration) Superficial muscle (eg. Strain) Superficial ligament (eg. MCL or LCL) Acute inflammation Periosteum (acute lateral epicondylitis) Radicular Pain is sometimes referred to as sharp. May also have decreased ‘muscle strength’ and ‘deep tendon reflex’. Dull Ache: Joints Deep muscles (gluteus medius) Chronic muscle injuries (chronic hamstring strain) Subchondral bone (patellofemoral syndrome, chondromalacia) Chronic inflammation Deep or peripheral nerve Trigger points Referred pain Tingling or Paresthesia: Nerve injury Circulatory problems Numbness: Can be caused by damage or impingement of a nerve innervating a particular area Ex. ulnar border of hand/forearm caused by injury/impingement to ulnar nerve or C8-T1 nerve root. Twinge: 12 T2 Clinical Assessment- Introduction Twinges with a movement that repeats the mechanism of injury could be caused by injury to a local muscle or ligament. Sensation similar to plucking on a string Noises and/or sensations: Clicking and/or snapping can be caused by a tendon flipping over a bone, thickened bursa, meniscal tear, or synovial plica (a fold in the synovium of a joint) Grating is most commonly caused by osteoarthritic changes to a joint (chondromalacia, or calcium in a joint) Sound of tearing at time of injury may indicate muscle or ligament tear Locking or catching suggests a loose body within the joint Giving way or instability is commonly caused by severe joint damage, especially to primary stabilizing ligaments Popping can be caused by negative pressure within a tendon synovial sheath, a tendon flipping over a bony prominence, or possibly by rupture of ligament or tendon 2. OBSERVATIONS - Observations are things we see with our eyes. They should begin the moment you set your eyes on your patient. - Swelling - Altered function - Redness - Deformities - Imbalances - Postural assessment - Pay attention to things like how they enter the room, remove clothing, and sit. 3. PALPATION - Things we feel - Texture - Tone - Tenderness - TEMPERATURE - NOTE: Do not palpate the lesion site at this point of the assessment as it may distort the rest of your assessment. Only check for heat (indicates inflammation) 4. RULE OUTS - Check the joints immediately above and below the affected area to eliminate them as possible sources of dysfunction 13 T2 Clinical Assessment- Introduction - Quick scans of joints using ‘Active Free’(AF) movements followed by overpressure of some or all of the ranges of a joint. - If a rule out is positive at a given joint – then that joint must also be assessed 5. FUNCTIONAL TESTS Active Free (AF) Amount of joint motion that can be achieved by the patient during the performance of unassisted voluntary joint motion. Passive Relaxed (PR) Amount of joint motion available when an examiner moves a joint through its anatomical or physiological range, without assistance from the patient, while the patient is relaxed. Active Resisted (AR) Used to determine the status of the contractile unit with the use of controlled isometric contractions, along the normal planes of movement of a given joint. By the time you get to the functional tests you will likely have a sense of what the nature of the injury is, but you use functional testing to confirm or refute that educated guess. Remember we are trying to arrange the testing order so that the most _______________________ is done last. Example: if you suspect that passive testing will be most painful, do it last. Passive testing engages inert tissue and (passively) elongates contractile tissue. Resisted testing (done isometrically) engages contractile tissue only. We are trying to reproduce the pain/dysfunction. AF movements are always done first then followed by either PR or AR movements. (depending on the suspected nature of the injury) ACTIVE FREE MOVEMENTS (AF) Active Free movements are always done first. They are referred to by Magee as “a functional test of the anatomic and dynamic aspects of the body and joints”. Active Free movements do not differentiate between contractile or inert tissue. Document the following when testing AF movements: ▪ Patient’s willingness to move the joint ▪ Patient’s mobility or available ROM (shows functional ROM vs. anatomical ROM) 14 T2 Clinical Assessment- Introduction ▪ Amount of observable restriction ▪ Whether movements cause pain o Range at which it occurs o Location, intensity and quality Also observe: ▪ Quality of movement ▪ Compensatory movements (i.e. increasing cervical lateral flexion by elevating the shoulder) ▪ Apprehension about doing the movement ▪ Painful arc ▪ Crepitus After taking the case history you should have a strong indication of whether the tissue involved with the injury is inert or contractile in nature. After you have completed the active free movements of the physical examination you must determine if passive relaxed movements or active resisted tests should be done next. The order of testing is done so the most painful of the two is done last. Examples: If you believe your patient has a strain of the semitendinosis then your order of testing would be_________________________________________________________________. If you believed the injury was to the medial collateral ligament the order of your testing would be _________________________________________________________. PASSIVE RELAXED MOVEMENTS (PR) When doing Passive Relaxed Movements it is important to encourage your patient to remain as relaxed as possible, allowing you to put the joint through as full a range as possible until an end feel or end range is felt. Must use enough force to determine the patient’s limitations and determine their end feel/range - without seriously exacerbating their condition Passive Relaxed Movements test the inert joint structures Contractile tissue may also cause pain, especially end of range as it is stretched However contractile tissue will also cause pain with ___________________ testing while the inert tissue should not. Along with noting all the points already given under the Active Free movement, you should also observe and document any of the following with Passive Relaxed movements: 15 T2 Clinical Assessment- Introduction ▪ Hypermobility (which allows a joint to be susceptible to ligamentous sprain, tendonitis, early arthritis, dislocations and subluxations) ▪ Hypomobility (can suggest conditions such as muscle strains, nerve compression syndromes, and cartilaginous damage due to constant compression forces) ▪ If, when, and where they feel pain (ask them) ▪ The END FEEL OVERPRESSURE (passive forced) Used primarily to clarify the end feel or end range. It may also provoke the symptoms if they do not show during AF or PR movements. When performing an overpressure the therapist takes the joint to the end of its range and notes how the tissue feels at the end of the particular movement. End Feel The quality of motion or sensation that clinician “feel” in the joint during overpressure at the end of passive range of motion Cyriax defines six end feels: 1. Tissue Approximation ▪ Movement is stopped by the compression of tissue (ex. calf against posterior thigh on knee flexion) (mushy feel) ▪ Normal end feel 2. Bone to Bone ▪ When bone touches another bone (ex. elbow extension) ▪ Can be normal or abnormal (abnormal if it occurs before normal end range) 3. Tissue Stretch Hard or firm (springy) type of movement with a slight give Occurs toward the end range of motion Feeling of springy or elastic resistance Normal end feel “rising tension or stiffness” Most common type of normal end feel Found when the capsule and ligaments are providing resistance to movement 4. Muscle Spasm sudden dramatic arrest of movement, often accompanied by pain described as “sudden and hard” ▪ Usually the result of protective reflex designed to splint a joint and prevent further movement/injury ▪ Often seen in acute or severe injuries (ex. ligament sprain, acute capsulitis) ▪ Abnormal end feel 16 T2 Clinical Assessment- Introduction 5. Capsular Very similar to tissue stretch Does not occur where one would expect it (ie. early in ROM) Tends to have a “thicker” feeling to it ROM is obviously reduced Usually indicated that the capsule is at fault Some divide this into ‘hard’ or ‘soft’ 6. Springy block ▪ Usually indicates an internal derangement within a joint ▪ May be caused by a loose body within a joint (ex. bone chip, meniscal tear) ▪ A slight rebound may be noted at the end of range ▪ Abnormal end feel 7. Empty end feel ▪ Patient stops the movement due to the intensity of the pain ▪ Movement is stopped before end of range is felt ▪ Abnormal end feel A common end feel not described above is a ‘Muscular’ end feel. Often described as rubbery (ex. tension felt in the hamstrings during a straight leg raise) ACTIVE RESISTED TESTS (AR) Active Resisted tests are done to determine the status of the ________________________: Muscle belly Musculotendinous junction Tendon Tendoperiosteal junction Nerve that supplies the muscle The muscles crossing the joint are contracted isometrically (no movement), in a neutral position (minimizes the tension placed on the associated inert structures). From the neutral/mid-range position the patient is asked to slowly build up to a full contraction over a 5 second period and slowly relax. Conversely you may supply the force while asking the patient to maintain the position of the joint. Try to determine whether the contraction is weak or strong, painful or pain free. You may also wish to use the ‘Oxford muscle testing scale’. Cyriax notes four possible finding with resisted testing: 17 T2 Clinical Assessment- Introduction 1. Strong and Painless No lesion or neurological deficit in the muscle or tendon Normal 2. Strong and Painful 1st or 2nd degree muscle strain A minor lesion of the musculotendinous unit 3. Weak and Painless Interruption of nerve supply compression syndromes etc. Complete rupture of a muscle or tendon 4. Weak and Painful Partial rupture of a muscle or tendon Painful inhibition caused by pathology such as a neoplasm, fracture or acute inflammation of tissue Note: Pain with repetitive movements may indicate a problem with the vascular supply to the region. Oxford Manual Muscle Testing Scale 5 Normal – overcomes maximal resistance 4 Able to overcome some resistance 3 Able to overcome gravity but not resistance 2 Able to produce movement with gravity eliminated 1 Slight contraction – muscle tightens but no movement produced 0 No contraction 6. Special Tests used to confirm or rule out injury to specific structures there are many of them and each have a specific name 7. Muscle Testing Length and strength tests for specific muscles Used to determine if a muscle is weak or strong Used to determine if a muscle is short or long 8. Neurological Test 18 T2 Clinical Assessment- Introduction Used to confirm or rule out neurological involvement Dermatomes Myotomes Deep Tendon Reflexes 9. Joint Play Examination Tests accessory joint motion within a joint Not under voluntary control Essential for full and pain free ROM 10. Palpation Finally the lesion site should be palpated Palpation should be systematic and purposeful Using Palpation in Patient Examination Skilled palpation is an art Prerequisite skill for the execution of all massage techniques Skill in palpation is required when performing orthopedic tests Valuable skill for assessment and reassessment o Performed formally (at assessment points) o Performed continuously during a treatment There are many ways to perform palpation. How you palpate is dictated by the purpose of your palpation Basic Principles of Palpation Palpation is a moving inquiry Should be unhurried, un-abrupt, and the therapist must be present Seek answers to a variety of questions when palpating o What is the structure? o What is the quality? o How does it differ from others I’ve palpated? o How does this finding relate to the patient’s history? o How does this structure reflect the patient's demonstrated or reported function? With practice you will no longer need to consciously think of these things and you will develop ‘intelligent touch’ Objects of Palpation 19 T2 Clinical Assessment- Introduction Therapists can identify many impairments through the palpation of specific ‘objects of palpation’ Objects are – the focus of the therapists attention during palpation Not necessarily physical objects What you intend to palpate will dictate the method of palpation to use Contact Surfaces Hands should be supple and relaxed Dominant hand is usually more sensitive Both hands can be used simultaneously to compare (ex. Left vs. Right) Hands may be used to perform different tasks (ex. Moving a body part and palpating) Can use fingers, thumbs, palms, thenar/hypothenar eminence, or back of hand (select according to what you are palpating) Force of Palpation Force should also be applied according to the task at hand Force can vary in rate, pressure, direction, duration 1. Rate of Palpation Scanning/stroking over a large area o Relatively quick o Collect information from a large area o Ex. Tissue contours, resting muscle tone of the entire back Static palpation o No movement of the palpating hand o Best used for palpating movement phenomenon (pulse, respiratory rhythm) 2. Pressure of Palpation Lack of concentration, too much pressure, too much movement are the most common errors when palpating Use the minimum pressure required to contact the intended tissue or structure Use a light force and steadily increase the force as needed to palpate the different layers of tissue Touch should be firm, not tentative or abrupt 3. Direction of Palpation ‘Force of palpation’ can be applied as a shearing force shear can be applied perpendicular (vertical) OR parallel (horizontal) to the tissue Forces can be applied separately or in combination Most often there is some degree of combination involved 20 T2 Clinical Assessment- Introduction Tension along a tissue layer and drag occur when force is applied in a horizontal direction to the tissues Drag is a term used to describe both the therapists palpation and the tissue layers resistance to lengthening in response to the force o Assessment of drag is integral to the examination of connective tissues such as fascia & skin Shearing forces can be applied to different tissue layers to evaluate the movement between them (vertical layers or adjacent layers) Shearing forces in combination with compression are also used to assess muscle tone and bulk All palpation/massage techniques combine elements of compression, drag, and shear o Generally the direction used to palpate the tissue is usually the same used to treat the tissue 4. Duration of Palpation Palpation should not take more than a few seconds (can alter the results of examination) Assessing Objects of Palpation Temperature Provides info about status of inflammation and circulation Direct contact on skin when using back of hand; use very light pressure Palm of hand, approx. 10 mm from surface of skin; use continuous motion to assess Contour and Bulk Refer to the gross shape and size of the patient’s body Use fast scanning palpation & large contact surfaces (palmar surface of hand) Correlate the palpation with visual observation Texture and Consistency Variations in the density of tissues, regardless of the depth of the layer the tissues lie Can be described in superficial tissues (skin), deep tissues (hamstring attachment at isch. Tub.) Can describe tissue hardness or softness o Tissue hardness (descriptors include ropy, stringy, hard, etc…) can be attributed to chronic inflammation that results in the deposit of collagen in the tissues o Tissue softness (descriptors include distended, spongy, boggy, etc…) may be attributed to acute inflammation and the associated presence of fluid in the tissues Fluid Status 21 T2 Clinical Assessment- Introduction Palpation can be used to measure turgidity (fluid pressure or fluid tension) Used to determine the amount of excess fluid in an area and the location (intra/extra- capsular) Viscosity (thickness or stickiness) of semi-liquid materials (connective tissues and muscle) o Muscle and connective tissue viscosity is altered by neuromuscular or connective tissue techniques Palpating Soft Tissue Layers (“Layer Palpation”) Epithelium, connective tissues, contractile tissue Skin Use minimal force Compare thickness, elasticity, tightness of the attachment Neurological dysfunction may be determined by assessing the skin (ex. Dermatomes) Superficial Fascia Turgor (fluid pressure) can be gauged Mobility can be assessed (skin rolling) Deep Layer or Investing Layer Smooth, firm, and continuous and lies between the superficial fascia and the muscle Requires more refined palpation skills (there is more intervening tissue) Muscle Resting muscle tension is assessed by noting a muscle’s response to compressive and shearing forces May compress the whole muscle or bow it; conversely you can try sinking into the muscle and attempt to tease the fibres apart Muscle tension is a variable state and will vary from one person to the next and on segment to another Spasm is more dramatic and more readily palpated Elevated resting tone can result from a variety of clinical conditions including injury, degenerative disease, and stress May also try to note high fluid pressure within muscles Periosteum Thin, dense, spongy layer overlying the bone Only accessible at areas where there is no overlying muscle 22 T2 Clinical Assessment- Introduction Tissue Mobility and Restrictive Barriers Normal Soft Tissue Range of Motion Soft tissues have an available range of motion (comparable to joint range of motion) Within this range are three barriers or resistances o Physiological barrier ▪ Range of motion available of normal circumstances ▪ Midrange is the range with least amount of resistance o Elastic barrier ▪ Felt at the end of range and beyond (end-feel) this is when the tissue is engaged at end of passive range o Anatomical barrier ▪ Final resistance to normal range; any further motion will cause injury to the tissue (ligament, muscle, fascia, bone) Restrictive Barriers occurs when there is soft tissue dysfunction (skin, fascia, muscle. ligament, capsule or any combination of). located anywhere between the physiological barriers and will alter the midrange of the tissue potential to alter/limit the available range of motion Palpation of Tissue Mobility compression and/or drag forces used to observe the resulting movement note any restrictive barriers, quality of movement, and when barriers are engaged Anatomical Structures essential to assessment and treatment the accuracy of your palpation will directly influence the outcomes of treatment need to reliably be able to palpate the appropriate structure and layer of tissue that you intend to treat of assess Body Rhythms pulses and respiratory rhythms static palpation is used with minimal to moderate compression Tremors and Fasciculations 23 T2 Clinical Assessment- Introduction Fasciculations are localized, subconscious muscle contractions that do not involve the whole muscle; result from the contraction of the muscle cells innervated by a single motor axon Tremors are rhythmic movements of a joint that result from involuntary contractions of agonist and antagonist muscle groups both are palpated statically with minimal to moderate compression Vibration crepitus is a vibration associated with roughened gliding surfaces of a tendon, tendon sheath, articulating surface; crepitus is often audible in addition to being palpable "Red Flags" Findings in Patient History That Indicate Need for Referral to Physician (Magee) Cancer Persistent pain at night Constant pain anywhere in the body Unexplained weight loss (10-15 lbs. in 2 weeks or less) Loss of appetite Unusual lumps or growths Unwarranted fatigue Cardiovascular Shortness of breath Dizziness Pain or a feeling of heaviness in the chest Pulsating pain anywhere in the body Constant and severe pain in lower leg (calf) or arm Discoloured or painful feet Swelling (no history of injury) Frequent or severe abdominal pain Gastrointestinal/Genitourinary Frequent heartburn or indigestion Frequent nausea or vomiting Change in or problems with bladder function (e.g., urinary tract infection) Unusual menstrual irregularities Miscellaneous Fever or night sweats Recent severe emotional disturbances Swelling or redness in any joint with no history of injury Pregnancy Neurological Changes in hearing 24 T2 Clinical Assessment- Introduction Frequent or severe headaches with no history of injury Problems with swallowing or changes in speech Changes in vision (e.g., blurriness or loss of sight) Problems with balance, coordination, or falling Sudden weakness 25