Be a good historian

The most cost-effective component of an evaluation is a good history. For specialists in physical medicine and rehabilitation, this is not always easy. Aside from the chief complaint, mechanism, or onset of injury, aggravating factors or aspects that have improved activity, one has to take into account the patient’s goals to achieve an optimal outcome. The history taken should include the patient’s function levels before, during, and after the disease or injury.

There are often distracters within the patient’s history. The history becomes further complicated secondary to multiple interventions from other providers who treat neuromusculoskeletal problems. Physical and occupational therapy, massage, chiropractic care, osteopathic manipulation, injections, surgery, and psychological services all are designed to assist a patient in their recovery. The response to these interventions becomes important in providing further information regarding diagnosis and treatment. One must also be sensitive to the patient’s history in that often it is modulated by friends, family, coaches, fans, and supervisors. Other limitations of the history-taking process include language barriers, education, and culture.

Is the physical examination accurate?

Along with the history, the clinical examination completes the evaluation to arrive at a working diagnosis or diagnoses. Unfortunately, the universal use of the clinical examination has led to a less rigorous scientific evaluation of the examination technique than that which has been applied to other aspects of medicine, such as imaging modalities. Many components of the neuromusculoskeletal examination can be assessed for validity using a variety of parameters, such as specificity, sensitivity, and accuracy. The straight leg raising sign has been shown to be helpful in the diagnosis of a lumbosacral radiculopathy. The Lachman maneuver has been analyzed for its sensitivity and specificity for anterior cruciate ligament insufficiency. Hegedus and coworkers found very few physical examination signs for the shoulder that seemed to be diagnostically discriminatory, and most were not useful in the clinic. It is common to require a patient’s “subjective response” when performing a specific clinical test for it to be considered positive or negative. The pain response from the “objective test” can confound the overall diagnosis and subsequent treatment. When performing the neuromusculoskeletal examination, palpation of soft tissues, motion of body parts, and strength testing assists one in further understanding a patient’s overall impairment and limitations. These components of the examination are further pronounced when one is able to compare the symptomatic area with the asymptomatic side. It is rare that a static examination of muscles and joints is helpful.

Is the physical examination accurate?

Along with the history, the clinical examination completes the evaluation to arrive at a working diagnosis or diagnoses. Unfortunately, the universal use of the clinical examination has led to a less rigorous scientific evaluation of the examination technique than that which has been applied to other aspects of medicine, such as imaging modalities. Many components of the neuromusculoskeletal examination can be assessed for validity using a variety of parameters, such as specificity, sensitivity, and accuracy. The straight leg raising sign has been shown to be helpful in the diagnosis of a lumbosacral radiculopathy. The Lachman maneuver has been analyzed for its sensitivity and specificity for anterior cruciate ligament insufficiency. Hegedus and coworkers found very few physical examination signs for the shoulder that seemed to be diagnostically discriminatory, and most were not useful in the clinic. It is common to require a patient’s “subjective response” when performing a specific clinical test for it to be considered positive or negative. The pain response from the “objective test” can confound the overall diagnosis and subsequent treatment. When performing the neuromusculoskeletal examination, palpation of soft tissues, motion of body parts, and strength testing assists one in further understanding a patient’s overall impairment and limitations. These components of the examination are further pronounced when one is able to compare the symptomatic area with the asymptomatic side. It is rare that a static examination of muscles and joints is helpful.

How does one have more confidence in the diagnosis?

Once the history and clinical examination have been completed, and the diagnosis is made, treatment should be implemented. If there are questions regarding the diagnosis, however, which can lead to alterations in treatment, one looks to tests to complete the diagnosis. In the case of systemic diseases presenting as musculoskeletal complaints these tests may include blood and urine analysis, soft tissue biopsy, electrophysiologic examinations, and imaging studies. In the face of a neuromusculoskeletal injury, one must have some understanding of the sport or job and the mechanism of injury to make recommendations regarding further imaging. Often because of the unique training within physiatry, one can be called on to address causality issues; further treatment options; and the extent of impairment in relationship to work, sport, or activities of daily living. This requires knowledge in the differences between age-related changes within the neuromusculoskeletal system, pathology that is consistent for a specific injury, and the extent of healing and recovery given a specific diagnosis. These challenges can be seen with low back pain and the present knowledge of the natural degeneration of the lumbar spine. Yamaguchi and coworkers used ultrasound to demonstrate that there was a high incidence of asymptomatic rotator cuff tears in the general population. A side-to-side analysis was used. The clinician is faced with the everpresent possibility that one may be treating a patient with no pathology, or treating a patient who has significant pathology.

Although the ultimate goal is to return a patient to his or her highest level of functioning, or as close to the preinjury state as possible, today’s health care system has generated interest in the various applications of imaging modalities in musculoskeletal medicine. Plain radiography depicts most bony anatomic details. Different projections can help to demonstrate specific disorders. Plain radiographs are the first-line imaging modalities in most acute musculoskeletal trauma. Although the images are static, they have been used to correlate with soft tissue injuries. One example is elevation of the humeral head relative to the glenoid and decrease of the acromiohumeral distance in rotator cuff disease. Unless there is significant soft tissue damage, however, plain radiographs usually are not effective in helping to determine muscle or tendon pathology.

To obtain greater detail of bony structures, CT scanning creates high-resolution images. A CT scan exposes the patient to lower doses of radiation within a shorter examination time. Three-dimensional reconstruction is helpful in anatomic arrangements and malunions.

Arthrography has been used in detecting injuries to the articular cartilage, fibrocartilage tissue, capsules, ligaments, and tendon integrity. It can be used with CT to enhance the ligamentous-bony interface. Like all invasive procedures, there is risk of infection, allergic reaction to the contrast media, and pain with possible loss of function.

MRIs have been an enormous asset and a hindrance to the physiatrist. With imaging of the shoulder, despite the lack of an ability to have the patient move within the scanner, studies do demonstrate rotator cuff pathology in an asymptomatic population. There are potential hazards with the use of MRI. Another example of significant problems that can occur with MRI imaging is in the lumbar spine. Over the age of 50 years, significant abnormalities are seen in an asymptomatic population. Clinicians have all experienced the difficulty in trying to explain the abnormalities within the MRI of the lumbar spine or shoulder and the fact that it may not necessarily correlate with the patient’s history and clinical examination. Unfortunately, despite the incredible advances in CT and MRI imaging, they do carry a high expense. These studies are primarily performed at imaging centers, and they can take a considerable amount of time. They lack the ability to place the area of study in dynamic motion. These technologic modalities are most useful as complementary to less costly, fast, and readily available imaging procedures.