Systematic Evaluation Process PDF

Systematic Evaluation Process - What needs to be known for successful evaluation and impression? - ANATOMY - Pathomechanics - Biomechanics of Sport - Pathologies - Many different ways - Must stay systematic so that information is not...

Systematic Evaluation Process - What needs to be known for successful evaluation and impression? - ANATOMY - Pathomechanics - Biomechanics of Sport - Pathologies - Many different ways - Must stay systematic so that information is not missed - Must be a Sequential Process - Two Types - Off-Field (Clinical) - In an athletic training clinic or a clinical facility - On-Field - More condensed than the clinical Clinical Evaluations Off-Field Systematic Evaluation Process - History - The most important part of the evaluation - Communication Skills - Simple Open-Ended Questions - Tips for taking a good history - Listen - Verbal vs Nonverbal Communication - Avoid slang and jargon language - Maintain eye contact - Be calm and reassuring History Question Examples - Present Condition - Mechanism - #1 question - What, when, how, where? - Forces - Acute vs chronic - Limb position - Able to continue - Location of Symptoms - Description of Symptoms - Change in Symptoms - Sounds and Sensations - Pain - Rating Scales - McGill Pain Questionnaire  - Oswestry low backscale - OPQRST - Onset - When did the pain start - Anything that provokes the pain - Anything that makes pain worse or better - Provocation/palliation - Quality - Dull, sharp, aching - Radiating or Referred Pain - Ex of radiating hit funny bone and fingers tingle - Ex of Referred heart attack has pain in the neck or shoulder - Can tell us nerve issues and Psychological issues - Severity - Timing - Is it constant or does it come and go - Worse at night or worse in the morning - Paresthesia - Cold, Heavy - Give out - Treatment to Date - Previous Injury or Illness - AMPLE? - Allergies - Allergies to medication, food - Medications - Are they on any meds - Previous illness - Diabetes - The last thing taken by mouth - Events leading up to the present condition Off-Field Systematic Evaluation Process - Observation (Inspection) - Begins when the patient enters the athletic training clinic - Gait - Posture - Functional Movement - Always so a bilateral comparison - Compare the injured side to the non-injured side - See what works how for the person - Look at the skin - Palpate the skin - Bleeding  - First step in first aid - Control the bleeding - Posture - Body Position Gait - Gross and Subtle - Deformities - Gross and Subtle - Skin Color - Ecchymosis (need to know it and know how to spell it) - Discoloration - Bruising - Redness - Swelling - Effusion vs Edema - Effusion is swelling inside a joint - Edema ankle sprain swelling around the joint - Localized vs Diffuse - Bilateral Symmetry - Deformities - Atrophy - The muscle reducing in size usually underactive muscles - Spasm - The body's way of splinting itself - Skin - Scars, ecchymosis, temp, color - Signs of Inflammation - Redness - Heat - Pain - Swelling - Loss of function - If Suspect head injury - Eye movement - Facial expressions - Palpation - Detects pathologies cannot see - Visual Anatomy - Feeling For - Point tenderness - Trigger points - Tissue density - Deformities/Symmetry - Crepitus - Gapping  - Muscle tension/spasm - Temperature - Swelling (edema/effusion) - Palpation Procedures - Injured vs noninjured - Start away from the injured part - Bony tissue first - Ligament structures second - Muscle tissue third - Range of motion (ROM) - Active ROM (AROM) - Willingness to move - Evaluated first unless contraindicated - Contraindications - Passive ROM (PROM) - Quantity of movement - Endfeeks - Normal vs Abnormal - Manual Muscle tests - Isolate muscles - Break tests - Differentiate pain related to muscles or non-contractile tissue - Restive ROM (RROM) - Asses gross strength of muscle group - Contractions - Grading system - 5 minimal - 4 some strength loss - 3 can extend against resistance - 2 gravity independence (gravity independent position) - 1 Trace - 0 no movement - Joint Stability Tests (Ligament and Capsular) - Stress test - Isolate specific ligaments - Asses joint laxity - Bilateral comparison - Joint play - Accessory Motions - Joint Laxity - Firm (normal) - Slight stretching of the ligament with little, if any, tearing of the fibers. Pain is resent, but the degree of laxity is roughly compared with that of the opposite extremity.  - Soft - Partial tearing of the fibers. There is increased play of the joint surfaces upon one another or the joint line “opens up” significantly when compared with the opposite side - Empty - Complete tearing of the ligament. The moton is excessing and becomes restricted by secondary restraints, such as tendons - Selective Tissue Tests (special Tests) - Bilateral comparison - Specific to a structure, joint, or body part - Neurological tests - Sensory - Dermatomes - Sensory discrimination - Sensory input - Motor - Myotomes - Break Tests - Reflex Testing - Functional Activity Tests - Use only for mild injuries - Use very simple skills - Walking, reaching, etc - Progress to very complex - Running, cutting, throwing - Begin each skill at half speed progressing to full - Do not allow any activity that causes pain - Immediate Plan of Care - Observe performance - Looking for smooth, fluid motion - Question the patient concerning pain or other abnormal feelings - Make a decision based on the evidence - Take emotion out on the decision - Clinical Decision - Based on evidence - Nature and severity of injury - Courses of action - Provide immediate emergency first aid - ICER - Refer to a physician if needed - Via ambulance or other transport  - Confirms evaluation - Xray other lab tests - Recommends/administers definitive treatment - Final Step - Re-evaluate - Throughout rehabilitation process - Record Findings - If it's not written down, it didn’t happen On Field Evaluation Initiation of On-Field Evaluation - Emergency Planning - Emergency action plan (EAP) - Clear Communication System - Know the rules regarding on-field assessments - Instruct coaches and athletes not to move injured patients On-Field Systematic Evaluation - Focus Decision Making on - Acute management of injury - Safest removal method - Urgency of referral - Must Rule out - Cardiovascular or respiratory failure - Life Threatening head or spinal injury - Profuse bleeding - Fractured - Joint dislocation - Peripheral nerve injury - Other On-Field Evaluation Process On-Field Systematic Evaluation - Components - Size up the scene - Primary survey - Is the scene safe - Identify life-threatening injures - Unconscious - Always treat them as though they have head and spine injury  - Attempt to arouse if unconscious - ABC’s - Secondary Survey - History - Brief compared to clinical evaluation - Mechanism of injury - Location of injury - Location of pain - OPQRST - Noises - Snap, crack, or pop - Previous injury - Always rule out head and spine - Observation (inspection) - Questions to ask yourself as you approach a patient - Is the athlete moving - Conscious or unconscious - Position of athlete - How are they reacting to the injury - Do they have bleeding from the head or other signs of injury - Deformity, swelling, or discoloration? - Abormal postiioning of head, neck or extremities - Defomalities - Skin color - Sweating - Asses for shock - Observe for internal injuries - Bilateral comparison - Screening - Palpation - Tips - Tell athletes may cause pain and why - Begin gently and gradually increase the pressure - Watch athlete's reactions to palpation - Correlate the two - ROM - AROM - Most important - RROM - PROM - Contraindications - Ligament and Special Tests - Usually single plane tests  - Gives immediate impression - Neurovascular Tests - IF suspect fracture - Check pulse in the injured part - Sensory and Motor Tests - If the suspect spine injury - Dermatomes - Myotomes - Immediate Action Plan - Decisions, Decisions, what should you do - Fractures, dislocations, gross joint, instability, spinal injury - Decision Guidelines - No splinting needed - patient walks off the field with no assistance - No splinting needed - patients is assisted off the field - No splining needed - the patient is transported directly to the hospital - Splinting is needed - splint but the patient may walk off the field (ie upper extremity injury) - Splinting is needed - splint but the patient is assisted off the field (ie lower extremity injury) - Splinting is needed - the patient is transported immediately to a hospital Ways to Remove - Walk assit - 1 and 2 person - Stretcher - Cart - Sequence for getting someone up - Sit up first - question - Stand up - question - Give instructions how will remove Return to play decision - Concussion = never on the same day - May need to consult a physician - Final determination - Evaluation - Functional testing - No emotion all based on facts of evaluation Head Injuries Oh no, What do I do? - Stay Calm  - “Know that you are in control of the controllable but you CAN NOT DICTATE THE OUTCOME” - Be the leader - Practice, Practice, and more PRACTICE - Someone's life may be in your hands Managing the Unconscious Athlete - Why is this so scary - You cant get signs or symptoms so you do not know what could be wrong - Can not collect symptoms so much rely on signs - Always treat them as though they have cervical spine injury - Always stay calm Mechanisms for Rendering an Athlete Unconscious - Blow to the head - Diabetic Coma - Hypoglycemia - Electric Shock - Heat Illness - Heat stroke - Drowning - Psychogenic Shock - Fainting - Syncope - Illness - Substance Abuse - Epileptic Seizures - Rhabdomyolysis - Proteins released in blood stream can be life-threatening - Others? Remember what you have learned thus far - Check - Remember C-spine - In line stabilization - Establish the level of consciousness - Glasgow coma scale - Patient Position - Posturing - Body position - Decorticate rigidity - Arms are flexed, legs are extended - Decerebrate rigidity - Arms and legs are extended - Determine Quality of Life - Pulse - Reparations  - Pupils - Blood pressure - Record with time taken - Call - No signs of life = immediately - Signs of life = unresponsive for > 2 minutes - Hand signals - Care - Conduct life-saving skills - Severe bleeding - CPR and AED General Head Evaluation History - C-spine pain - Head pain - Mechanisms of injury - LOC - Previous concussions - Complaints of weakness - Persistent symptoms - Know your patient's medical history Inspection - Head Position - C-spine - Body Position - Decorticate rigidity - Arms are flexed, legs are extended - Decerebrate rigidity - Arms and legs are extended - Mastoid Process - Battle’s sign - Indication of skull fracture - Raccoon eyes - Black and blue around eyes - Indication of skull fracture - Swelling, Deformity, Bleeding, Discoloration - Eyes - General - Nystagmus - Improper tracking of eyes - Eyes are studdering - Strabismus  - Most likely something worse than a concussion - Are eyes tracking together - One forward one side - Pupil size - Anisocoria - Pupil reaction - Nose and ears - Otorrhea - Otto - ear - Is blood coming out? - Rhinorrhea - Riho - sinus/nose - Is blood coming out? - CSF - Halo test - Yellow fluid separates from the blood, and cereveral spinal fluid Palpation - Head-to-toe evaluation - General information seeking - Head structures - Cervical structures - Upper extremities Functional Tests - Behavior - Analytical skills - Information processing - Memory - Neuropsychological testing - Balance and coordination Neurological Assessment - Cranial nerve assessment - Cervical spine - If suspect injury - Dermatomes - Myotomes - Reflexes Maintain your Cool - PRACTICE! - Know that you are in control of the controllable but can not control the outcome - Be the leader Sports-related concussion (AKA: TBI) Articles to read - Amsterdam consensus statement on concussions  - SCAT6 Definition - “Sport-related concussion (SRC) is a traumatic brain injury caused by a direct blow to the head, neck or body resulting in an impulsive force being transmitted to the brain that occurs in sports and exercise-related activities” Common Features - “This initiates a neurotransmitter and metabolic cascade, with possible axonal injury, blood flow change, and inflammation affecting the brain” - “Symptoms and signs may present immediately, or evolve over minutes or hours, and commonly resolve within days, but may be prolonged” - “Sports-related concussion results in a range of clinical symptoms and signs that may or may not involve loss of consciousness” - “The clinical symptoms and signs of concussion cannot be explained solely by (but may occur concomitantly with) drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction) or other comorbidities (such as physiological factors or coexisting medical conditions)” - “No abnormality is seen on standard structural neuroimaging studies (computed tomography or magnetic resonance imaging t1 and t2 weighted images, but in research setting, abnormalities may be present on functional, blood flow or metabolic imaging studies. Mechanism - Direct blow - Coup injury - Indirect blow - Cotrecoup injury - Types of Forces Causing Brain Injury Sideline evaluation (details) - Rapid screening for SRC - Key contributing factors - Clear-in-field signs - Significant impact - Sideline objective assessments Diagnosis of Acute SRC symptoms - Somatic - Headache - Cognitive impairment - Feeling in fog - Slowed reaction times - Mental confusion/disorientation - Balance impairment - Gait unsteadiness - Dizziness - Behavioral changes - Irritability  - Physical - Loc - loss of consciousness - Amnesia - Anterograde can't remember after injury - Retrograde can’t be remembered before injury - Very common with concussions - Neurological deficits - Tinnitus - Nystagmus - Visual acuity - Nausea - Pulse - BP - Respirations Post-traumatic phase symptoms - Photophobia - Sensitivity - Seeing stars or flashing lights - Poor concentration - Irritability - Depression - Anxiety - Fatigue - Headache - Sleep disturbance - Cant sleep or want to sleep all the time Persistent symptoms - Failure of normal clinical recovery - Adults - Children Post-concussion assessment - Mental testing assessments - Postural-stability tests - Neuropsychological tests Mental status testing - SCAT6 - On the field or sidelines - Red flags - Observation signs - Cognitive screening - Glasgow coma scale - Cervical spine assessment - Coordination and oculomotor screen - Office or ATC  - Athletes background - Symptom evaluation - Cognitive screening - Orientation - Immediate memory - Concentration - Coordination and balance examination - Modified BESS - Timed tandem - Dual-task gait - Delayed REcall Quiz onfield off field and what was touched on concussions including cranial nerves name and what they asses