Chapter 8 The Examination and Evaluation

Overview The examination process involves a complex relationship between the clinician and patient The examination process involves a complex relationship between the clinician and patient The aim of the examination process is to provide an efficient and effective exchange, and to develop a rapport between the clinician and patient The aim of the examination process is to provide an efficient and effective exchange, and to develop a rapport between the clinician and patient The success of this interaction involves a myriad of skills The success of this interaction involves a myriad of skills

The Patient The patient serves as perhaps the most valuable resource to the clinician The patient serves as perhaps the most valuable resource to the clinician Each interaction with a patient is an opportunity to increase knowledge, skill, and understanding Each interaction with a patient is an opportunity to increase knowledge, skill, and understanding

Communication Communication between the clinician and patient begins when the clinician first meets the patient, and continues throughout any future sessions Communication between the clinician and patient begins when the clinician first meets the patient, and continues throughout any future sessions Communication involves interacting with the patient using terms he or she can understand Communication involves interacting with the patient using terms he or she can understand

The examination and evaluation The success of any rehabilitation intervention depends on the quality and accuracy of the examination and the subsequent evaluation The success of any rehabilitation intervention depends on the quality and accuracy of the examination and the subsequent evaluation An examination refers to the gathering of data and information concerning a topic An examination refers to the gathering of data and information concerning a topic An evaluation refers to the making of a value judgment based on the collected data and information An evaluation refers to the making of a value judgment based on the collected data and information

The Examination The examination consists of three components of equal importance: The examination consists of three components of equal importance: –The history –The systems review –The tests and measures

Observation Throughout the history, systems review, and tests and measures, collective observations form the basis for diagnostic deductions Throughout the history, systems review, and tests and measures, collective observations form the basis for diagnostic deductions

Examination History History –The history usually precedes the systems review and the tests and measures components of the examination, but it may also occur concurrently –It is estimated that 80% of the necessary information to explain the presenting patient problem can be provided by a thorough history

Examination History of current condition History of current condition –This portion of the history taking can prove the most challenging, and involves the gathering of both positive and negative findings, followed by the dissemination of the information into a working hypothesis

Examination Systems review Systems review –The systems review is the part of the examination that identifies possible health problems that require consultation with, or referral to, another health care provider

Examination Scanning examination Scanning examination –The purpose of the scanning examination is to help rule out the possibility of symptom referral from other areas, and to ensure that all possible causes of the symptoms are examined –Used when there is no history to explain the signs and/or symptoms, or when the signs and/or symptoms are unexplainable

Examination Tests and measures Tests and measures –The tests and measures component of the examination, which serves as an adjunct to the history and systems review, involves the physical examination of the patient –The decision about which tests to use should be based on the best available research evidence

Tests and measures Pain Pain –Pain is a disturbed sensation that causes suffering or distress –The following factors must be investigated: Onset Onset Intensity Intensity Location Location Perception Perception Quality Quality Behavior Behavior Nature Nature

Tests and measures Range of motion Range of motion –The range of motion examination should determine the exact directions and types of motion that elicit the symptoms –Active –Passive

Active range of motion Active range of motion testing gives the clinician information about: Active range of motion testing gives the clinician information about: The quantity of available physiological motion The quantity of available physiological motion The presence of muscle substitutions The presence of muscle substitutions The willingness of the patient to move The willingness of the patient to move The integrity of the contractile and inert tissues The integrity of the contractile and inert tissues The quality of motion The quality of motion Symptom reproduction Symptom reproduction The pattern of motion restriction The pattern of motion restriction

The pattern of motion restriction Cyriax gave us the terms capsular and non- capsular pattern of restriction Cyriax gave us the terms capsular and non- capsular pattern of restriction –Capsular: a limitation of pain and movement in a joint specific ratio, which is usually present with arthritis, or following prolonged immobilization –Non-capsular: a limitation in a joint in any pattern other than a capsular one. May indicate the presence of either a derangement, a restriction of one part of the joint capsule, or an extra-articular lesion, that obstructs joint motion

Passive Range of Motion Passive range of motion testing gives the clinician information about the integrity of the contractile and inert tissues, and the end-feel Passive range of motion testing gives the clinician information about the integrity of the contractile and inert tissues, and the end-feel Pain that occurs at the end-range of active and passive movement is suggestive of a capsular contraction, or scar tissue that has not been adequately remodeled Pain that occurs at the end-range of active and passive movement is suggestive of a capsular contraction, or scar tissue that has not been adequately remodeled

Passive versus active ROM According to Cyriax, if active and passive motions are limited/painful in the same direction, the lesion is in the inert tissue, whereas if the active and passive motions are limited/painful in the opposite direction, the lesion is in the contractile tissue According to Cyriax, if active and passive motions are limited/painful in the same direction, the lesion is in the inert tissue, whereas if the active and passive motions are limited/painful in the opposite direction, the lesion is in the contractile tissue

End feel Cyriax introduced the concept of the end-feel, which can be defined as the quality of resistance felt by the clinician at end range Cyriax introduced the concept of the end-feel, which can be defined as the quality of resistance felt by the clinician at end range The end-feel can indicate to the clinician the cause of the motion restriction The end-feel can indicate to the clinician the cause of the motion restriction

Joint mobility testing Joint integrity and mobility testing can provide valuable information as to the status and the mobility of each joint and its capsule Joint integrity and mobility testing can provide valuable information as to the status and the mobility of each joint and its capsule One of three conclusions can be drawn from the passive mobility tests: One of three conclusions can be drawn from the passive mobility tests: –The joint is determined to be normal –The joint motion is determined as being excessive –The joint motion is determined as being reduced

Strength testing According to Cyriax, strength testing can provide the clinician with the following findings: According to Cyriax, strength testing can provide the clinician with the following findings: –A weak and painless contraction –A strong and painless contraction –A weak and painful contraction –A strong and painful contraction

Strength testing A number of grading systems exist to test muscle strength using manual resistance A number of grading systems exist to test muscle strength using manual resistance

Reflex integrity Reflex integrity is defined as the intactness of the neural path involved in a reflex Reflex integrity is defined as the intactness of the neural path involved in a reflex –Deep tendon reflex. Deep tendon reflex (DTR) tests utilize the muscle spindle to determine the state of both the afferent and efferent peripheral nervous systems, and the ability of the CNS to inhibit the reflex –Pathological. The presence of pathological reflexes is suggestive of CNS (upper motor neuron) impairment, and requires an appropriate referral

Sensory integrity Sensory integrity is the intactness of cortical sensory processing. It includes: Sensory integrity is the intactness of cortical sensory processing. It includes: –Proprioception –Pallesthesia (the ability to sense mechanical vibration) –Stereognosis (the ability to perceive, recognize and name familiar objects) –Topognosis (the ability to localize exactly a cutaneous sensation)

Posture Like ‘good movement’, ‘good posture’ is a subjective term based on what the clinician believes to be correct based on ideal models Like ‘good movement’, ‘good posture’ is a subjective term based on what the clinician believes to be correct based on ideal models Good posture may be defined as ‘the optimal alignment of the patient’s body that allows the neuromuscular system to perform actions requiring the least amount of energy to achieve the desired effect.’ Good posture may be defined as ‘the optimal alignment of the patient’s body that allows the neuromuscular system to perform actions requiring the least amount of energy to achieve the desired effect.’

Palpation Palpation is performed to: Palpation is performed to: Check for any vasomotor changes such as an increase in skin temperature that might suggest an inflammatory process Check for any vasomotor changes such as an increase in skin temperature that might suggest an inflammatory process Localize specific sites of swelling Localize specific sites of swelling Identify specific anatomical structures and their relationship to one another Identify specific anatomical structures and their relationship to one another Identify sites of point tenderness Identify sites of point tenderness Identify soft tissue texture changes or myofascial restriction Identify soft tissue texture changes or myofascial restriction Locate changes in muscle tone resulting from, trigger points, muscle spasm, hypertonicity, or hypotonicity Locate changes in muscle tone resulting from, trigger points, muscle spasm, hypertonicity, or hypotonicity Determine circulatory status by checking distal pulses Determine circulatory status by checking distal pulses Detect changes in the moisture of the skin Detect changes in the moisture of the skin

Special Tests These tests are only performed if there is some indication that they would by helpful in arriving at a diagnosis These tests are only performed if there is some indication that they would by helpful in arriving at a diagnosis The tests are used to help confirm or implicate a particular structure and may also provide information as to the degree of tissue damage The tests are used to help confirm or implicate a particular structure and may also provide information as to the degree of tissue damage

Neuromeningeal Mobility Tests The neurodynamic mobility tests examine for the presence of any abnormalities of the dura, both centrally and peripherally The neurodynamic mobility tests examine for the presence of any abnormalities of the dura, both centrally and peripherally These tests, which employ a sequential and progressive stretch to the dura until the patient’s symptoms are reproduced, are used if a dural adhesion or irritation is suspected These tests, which employ a sequential and progressive stretch to the dura until the patient’s symptoms are reproduced, are used if a dural adhesion or irritation is suspected

Imaging Studies The results from imaging studies should be used in conjunction with other clinical findings The results from imaging studies should be used in conjunction with other clinical findings In general, imaging tests have a high sensitivity (few false negatives), but low specificity (high false-positive rate) In general, imaging tests have a high sensitivity (few false negatives), but low specificity (high false-positive rate)

The Evaluation According to Grieve, an evaluation is the level of judgment necessary to make sense of the clinical findings in order to identify a relationship between the symptoms reported and the signs of disturbed function According to Grieve, an evaluation is the level of judgment necessary to make sense of the clinical findings in order to identify a relationship between the symptoms reported and the signs of disturbed function One of the problems for the clinician is how to attach relevance to all of the information gleaned from the examination One of the problems for the clinician is how to attach relevance to all of the information gleaned from the examination

Clinical Decision Making This judgment process can be viewed as a continuum. At one end of the continuum is the novice who uses very clear-cut signposts, while at the other end there is the experienced clinician who has a vast bank of clinical experiences from which to draw This judgment process can be viewed as a continuum. At one end of the continuum is the novice who uses very clear-cut signposts, while at the other end there is the experienced clinician who has a vast bank of clinical experiences from which to draw

Physical therapy diagnosis Making a physical therapy diagnosis involves a combination of hypothesis testing and pattern recognition Making a physical therapy diagnosis involves a combination of hypothesis testing and pattern recognition –The physical therapy diagnosis is a label ascribed to a cluster of signs and symptoms. A diagnosis can only be made when all potential causes for the symptoms have been ruled out A diagnosis can only be made when all potential causes for the symptoms have been ruled out

Prognosis The prognosis is the predicted level of function that the patient will attain within a certain time frame The prognosis is the predicted level of function that the patient will attain within a certain time frame This prediction helps guide the intensity, duration, and frequency of the intervention, and aids in justifying the intervention This prediction helps guide the intensity, duration, and frequency of the intervention, and aids in justifying the intervention