Musculoskeletal assessment



Musculoskeletal assessment


Lynne Gaskell




Introduction


Students are often in awe of qualified clinicians who assess and make complex clinical reasoning decisions in real time with apparently little effort. Becoming competent in patient assessment, like most things in life, takes practice, refinement and reflection, and it looks easy when performed by an expert. The ability to effectively examine and assess patients is an essential skill for physiotherapists to possess. This chapter introduces some important principles of musculoskeletal assessment. It provides an illustrated guide to many of the important techniques and tests that are valuable tools in the arsenal of the chartered physiotherapist. Furthermore, it provides some assessment templates for specific joints of the body. The objectives of this chapter are:



This chapter includes templates for assessment of the lumbar spine (including a biopsychosocial assessment), the cervical spine, the shoulder, the hip, the knee, the ankle and the foot.



General issues


Since 1977, chartered physiotherapists in the UK have been able to work as autonomous practitioners, making treatment decisions independently of other medical professionals. This professional autonomy makes the profession stimulating and exciting, but with it comes a great deal of responsibility. Upon qualifying, physiotherapists are legally responsible for their actions and treatments. Increasing numbers of physiotherapists now work in the primary care setting and this trend is likely to continue. Allowing patients direct access to physiotherapists could relieve other medical practitioners of considerable workload.


Recent years have seen the introduction of extended-scope practitioners, clinical specialist and consultant physiotherapy posts. Physiotherapists in these roles are assessing patients usually referred by general practitioners (GPs) who would otherwise have been examined by a consultant orthopaedic surgeon. These practitioners are required to possess excellent assessment skills, a wide experience of different clinical conditions and pathologies, and to be able to recognise the appropriate course of action for that particular patient. Audits of these interventions have been encouraging; Gardiner and Turner (2002) found that the extended-scope practitioners showed more consistency between clinical diagnosis and arthroscopic findings in the knee than did their medical counterparts. In the present climate, these posts, along with the newly established consultant physiotherapist role, are likely to expand and in doing so will deservedly raise the profile of the physiotherapy profession.



When should physiotherapists assess patients?




• On first patient contact, it is essential to perform an initial assessment to determine the patient’s problems and to establish a treatment plan.


• During the treatment, assessment is particularly appropriate while performing treatments such as mobilisations and exercises when the patient’s signs and symptoms may vary quite rapidly. Be aware of any improvement or deterioration in the patient’s condition as and when it occurs.


• Following each treatment, the patient should be reassessed using subjective and objective markers in order to judge the efficacy of the physiotherapy intervention. Assessment is the keystone of effective treatment without which successes and failures lose all of their value as learning experiences. Subjective and objective markers are explained later in this chapter.


• At the beginning of each new treatment, assessment should determine the lasting effects of treatment or the effects that other activities may have had on the patient’s signs and symptoms. In reassessing the effect of a treatment, it is essential to evaluate progress from the perspective of the patient, as well as from the physical findings.





Aims of the objective assessment


The objective assessment aims to seek abnormalities of function, using active, passive, resisted, neurological and special tests of all the tissues involved. This may be guided by the history. However, it is important to conduct all tests objectively and equally, and not attempt to bias the findings in an attempt to make the hypothesis fit.


Objective examination is concerned with performing and recording objective signs. It aims to:




Subjective assessment


Initial questioning


Subjective assessment needs to include the name, address and telephone number of the patient, and the patient’s hospital number, if appropriate. Both the age and the date of birth of the patient should be recorded. The medical referrer’s name and practice should also be recorded for correspondence, discharge letters, etc.


It is also essential for the physiotherapist to obtain sufficient details of the patient’s employment. Is the patient currently working? If not, determine the reasons for this. Is it because the person is unable to cope with the physical demands of the job? Do heavy lifting, repetitive movements or inappropriate sustained postures increase the symptoms? These factors may be precursors of poor posture and muscle imbalance, which may accentuate degenerative disease and increase symptoms. However, it is equally important to recognise that withdrawing from normal activities of daily life can result in deconditioning of musculoskeletal structures that may lead to degenerative disease and an increase in symptoms (Waddell 1992; Frost et al. 1998).


Identify the patient’s hobbies or interests. Is she/he able to participate in a sport if desired? If not, determine the reasons. Identify the length of time the patient has been off work or has been unable to participate in physical activities. Evaluate the progression of symptoms. If the person has not been participating in physical activities, and if no improvement has occurred it may be appropriate to advise a return to light training in order to prevent devitalisation of tissues and fear avoidance issues.



Present condition






Aggravating and easing factors



Positional factors

Most musculoskeletal pain is mechanical in origin and is therefore made better or worse by adopting particular positions or postures that either stretch or compress the structure that is giving rise to the pain. Moreover, aggravating and easing movements may provide the physiotherapist with a clue as to the structure that is causing the pain. Various body or limb positions place different structures on stretch or compression and the resultant deformation produces an increase in severity of the pain. The aggravating and easing factors can be recorded on the pain chart, as in Figure 11.1. It is also necessary to record the length of time that engaging in aggravating activities produces an increase in symptoms or, alternatively, takes to settle down. This indicates the irritability of the patient’s condition.



Time factors

It is useful to record the behaviour of signs and symptoms over a 24-hour period – the diurnal pattern. Do the symptoms keep the patient awake or awaken the person regularly during the night? Is this because of a particular sleeping posture or to other, unrelated factors? On arising, how are the symptoms for the first hour or so of the day and, moreover, do the symptoms vary from the morning to the afternoon and into the evening? Does this follow a particular pattern? This information can be included on the body chart.


Be careful not to confuse time of day with the performance of particular activities that the patient may undertake at that time. Certain pathologies tend to be more painful at characteristic times of the day. For example, chronic osteoarthritic changes are characteristically painful and stiff initially on arising from sleep, intervertebral disc related pain is often more painful on arising owing to the disc imbibing water during sleep and thus exerting pressure on pain-sensitive structures. Prolonged morning pain and stiffness, which improves only minimally with movement, suggests an inflammatory process (Magee 1992).



Determining the SIN factors


Once the severity of the symptoms and the aggravating and easing factors have been noted, it is then possible to determine the SIN factor of the condition: severity/irritability/nature. SIN factors are used to guide the length and firmness of the objective assessment and subsequent treatment.






History of the present condition








Investigations


Record the results of any investigations that the patient has undergone. Case notes, radiographic films and reports can be ordered and read, as patients may not always be a reliable source of the results of their investigations.



X-rays, MRI scans, CAT scans and bone scans

Scans are now commonly used to aid the diagnosis of musculoskeletal disorders. X-rays are useful in that they show the degree or extent of arthritis present at a joint. They are also useful in determining the extent of osteomyelitis (bone infection) and some malignancies and osteoporosis. Moreover, they are valuable following trauma to identify fractures or dislocations. Be aware, however, that there is a poor correlation between X-rays and spinal symptoms for non-specific low back and neck pain. What is identified as pathological on these tests may not always be the structure responsible for the patient’s signs and symptoms. Routine X-rays are not helpful in non-specific degenerative spinal disease (CSAG 1994).


Computerised axial tomography (CAT) scans may be used to identify the precise level and extent of disc prolapse and subsequent nerve impingement prior to discectomy. Magnetic resonance imaging (MRI) may be used to identify ligamentous and muscular injuries, particularly in athletes, as well as discogenic prolapse. Bone scans are sensitive to ‘hot spots’ or areas of inflammation present in bone and may detect malignancy or diseases such as ankylosing spondylitis, some fractures and infection sites.





Past medical history


Determine whether or not the patient is suffering, or has suffered, any major operations or illnesses. These may affect the vitality of the tissues and be a contraindication to particular treatments. Examples are respiratory or cardiac disease, diabetes, rheumatoid arthritis and epilepsy.


The prolonged use of oral steroid medication should be noted, as this affects bone density and produces a tendency towards bruising. This is commonly found in patients suffering chronic respiratory diseases, inflammatory bowel diseases or rheumatoid arthritis. Always identify cases of unexplained weight loss and general debility.





Objective assessment


Following the subjective assessment it is important to highlight the main findings and determine the SIN factor. A hypothesis may be reached as to the cause of the patient’s symptoms and the testing procedures are performed in order to support or refute the physiotherapist’s hypothesis.







Assessment of movement






Assessment of range of movement



Measurement of joint range using a goniometer

Active movement may be assessed by the use of a goniometer (Figure 11.3) or, alternatively, by visual estimation. It is measured in degrees and it is useful to practise using the goniometer by measuring the hip, knee and ankle joints in various positions. Either the 360° or 180° universal goniometers may be used. Ensure adequate stabilisation of adjacent joints prior to taking the measurements and locate the appropriate anatomical landmarks as accurately as possible. For details on specific joint measurements using the goniometer, refer to the appropriate joint assessment. Physiological and accessory passive movements are measured in terms of the above and by the end-feel respectively.




Differentiation tests


If a lesion is situated within a non-contractile structure such as ligament, then both the active and passive movements will be painful and/or restricted in the same direction. For example, both the active and passive movement of inversion will produce pain in the case of a sprained lateral ankle ligament. However, if a lesion is within a contractile tissue such as a muscle, then the active and passive movements will be painful and/or restricted in opposite directions (Cyriax 1982). For example, a ruptured quadriceps muscle will be painful on passive knee flexion (stretch) and resisted knee extension (contraction).





Assessment of muscle strength




Measurements using isokinetic machines

Objective measurements of strength throughout different joint angles and at different velocities are made more accurately using isokinetic machines, such as Cybex or Kin-Kom. These machines are particularly valuable in rehabilitative regimens such as anterior cruciate rehabilitation programmes and can determine the strength ratio of the quadriceps to the hamstrings, or the ratios of the operated versus the non-operated leg. Objective markers such as percentages of strength ratios or ratios of operated versus non-operated leg may be used in setting discharge protocols. Isokinetic machines have been found to be reliable and valid in measuring muscle torque, muscle velocity and the angular position of joints (Mayhew et al. 1994). However, they are limited in their use, and Wojtys et al. (1996) suggest that agility and functional exercises may be more beneficial than isokinetic machines in the strengthening of muscle.




Differentiation tests of muscles and tendons


These are contractile structures and are therefore tested by performing a contraction against resistance. A pain response and/or apparent weakness may indicate a strain of the muscle at any particular point of the range of movement. Full range should be checked as the muscle may be weak only at a particular point in the range. Muscle length may also be tested, particularly those muscles that are prone to become tight and then lose their extensibility. Muscles that pass over two joints and have mobiliser characteristics are particularly prone to tightness. Examples of these are the hamstrings, rectus femoris, gastrocnemius and psoas major. The length of the muscle is tested by passively moving the appropriate joints. The stretch is compared with the other side to determine reproduction of pain and/or restriction of movement.










Spinal assessments



The lumbar spine


Posture




Common deviations from normal posture (refer to Figure 11.6)




• Creases in the posterior aspect of the trunk and, particularly, adjacent to the spine may indicate areas of hypermobility or instability of that motion segment.


• Sway back comprises hyperextension of the hips, an anterior pelvic tilt and anterior displacement of the pelvis.


• Flat back consists of a posterior pelvic tilt and a flattening of the lumbar lordosis, extension of the hip joints, flexion of the upper thoracic spine and straightening of the lower thoracic spine.


• Kypholordosis consists of a forward-poking chin posture, elevation and protraction of the shoulders, rotation and abduction of the scapulae, an increased thoracic kyphosis, anterior rotation of the pelvis and an increased lumbar lordosis.


• Shifted posture (lateral shift) commonly arises from disc herniation or acute irritation of a facet joint. The shift is thought to result from the body finding a position of ease whereby the shoulders are displaced laterally in relation to the pelvis. Most commonly the shift occurs away from the painful side (Figure 11.7).




Movements


Assess not only the range of movement occurring and the pain response, but also localised areas of give and restriction occurring at specific motion segments.



Active movements







Repeated movements

Repeating movements several times may alter the quality and range of the movement and may give rise to latent pain. McKenzie (1981) advocates the use of repeating flexion and extension in both standing and lying to determine the movement that may centralise the patient’s symptoms (Figure 11.10). According to Palmer and Epler (1998), progressive worsening of pain on repeated movements indicates a disc derangement – the pain either becoming more intense or spreading more distally. Centralisation of symptoms means that the referred pain becomes more proximal, i.e. pain experienced at the medial aspect of the shin may centralise to the buttock. Thus, the exercise is believed to be reducing the patient’s symptoms and the disc derangement.




Combined movements

According to Edwards (1992): ‘Although the use of combining movements is not always necessary – adequate results being obtained by standard examination procedures – there are times when they are helpful. Often, with the more difficult mechanical problems, their use is essential.’


For example, lumbar spine extension may be performed and, while maintaining that extension, side flexion may be added. Symptoms are likely to vary with the addition of a second movement and this may indicate whether or not there is a regular or irregular stretch component to the signs and symptoms. For example, if a disc prolapse is aggravated by flexion, it would be reasonable to hypothesise that the addition of contralateral side flexion would also further increase the symptoms because both of the movements are stretching the posterior component of the disc and posterior longitudinal ligament. Combining ipsilateral side flexion to flexion would be expected to lead to a reduction in the patient’s symptoms as the ipsilateral side flexion is reducing the stretch component.




Assessing the sacroiliac joint




Compression tests




Neurological testing


Compression or traction of spinal nerve roots by disc trespass and/or osteophytes may give rise to referred pain, paraesthesia and anaesthesia, and also give positive neurological signs. Neurological signs should be carefully monitored as deterioration may indicate worsening pathology.





Reflexes





Adverse mechanical tension



Straight leg raise (SLR)

This is also known as Lasegue’s test. The patient is supine. The physiotherapist lifts the patient’s leg while maintaining extension of the knee (Figure 11.18). An abnormal finding is back pain or sciatic pain. The sciatic nerve is on full stretch at approximately 70 degrees of flexion, so a positive sign of sciatic nerve involvement occurs before this point (Palmer and Epler 1998). Any pain response and range of movement is noted and comparison made with the other side. Factors such as hip adduction and medial rotation further sensitise the sciatic nerve; dorsiflexion of the ankle will sensitise the tibial portion of the sciatic nerve; plantar flexion and inversion will sensitise the peroneal portion of the nerve.





Slump test

This tests the mobility of the dura mater. The patient sits with thighs fully supported with hands clasped behind the back. The patient is instructed to slump the shoulders towards the groin (Figure 11.20). The physiotherapist applies gentle overpressure to this trunk flexion. The patient adds cervical flexion, which is maintained by the therapist. The patient then performs unilateral active knee extension and active ankle dorsiflexion. The physiotherapist should not force the movement. The non-affected side should be assessed first.



Any symptoms are noted at the particular part in range. If the dura mater is tethered, symptoms will increase as each component is added to the slump test. The patient is instructed to extend the head – a reduction in symptoms on cervical extension is a positive finding, indicating abnormal neurodynamics.



Testing for lumbopelvic stability

Stability of the lumbar spine is necessary to protect the lumbopelvic region from the everyday demands of posture and load changes (Panjabi 1992). It is essential for pain-free normal activity (Jull et al. 1993) and should always be assessed.


With the patient in crook lying with the hips at 45 degrees flexion, he/she is instructed to maintain a neutral spine (it may be useful to tell the patient to maintain such a lordosis that an army of ants could just crawl through!). The person then performs an abdominal in-drawing by contracting the transversus abdominis muscle while attempting to maintain the spine in neutral. To challenge the transversus abdominis and multifidus stabilising muscles (and consequently the spinal position), the patient adds the leg load by alternately lifting the heels from the floor and sliding out the leg while maintaining a neutral spine position. The maintenance of a neutral spine posture can be assessed by using a biofeedback device. An inability to maintain the spine in neutral will result in the lumbar spine extending as the leg is lifted. The intra-abdominal pressure mechanism is controlled primarily by the diaphragm and transversus abdominis which provides a stiffening effect on the lumbar spine (Hodges and Richardson 1997).




Accessory spinal movements

The physiotherapist applies central posteroanterior pressures on the spinous processes and unilateral (one-sided) pressure over the articular pillar (Figure 11.21), noting areas of hyper- and hypomobility. Record any pain experienced by the patient and the corresponding spinal level.




Case study


Lumbar spine


A 30-year-old labourer was referred for physiotherapy following a lifting injury at work. He complained of left-sided low back and medial shin pain, and intermittent paraesthesia affecting his left great toe. The pain was aggravated by flexion and eased by standing and walking. On examination he had a marked shift to the right. Flexion was reduced to fingertips to knees and his left SLR was reduced to 50 degrees.


Owing to the rapid onset of symptoms associated with a lifting injury in a flexed posture, and the pain being aggravated by flexion and eased by extension activities, the injury was hypothesised to be discogenic. Clinical trials suggest that the most usual sources of low back pain are the intervertebral disc, the zygapophyseal (facet) joint and the sacroiliac joint (Maitland 2001).


The patient was treated by rotations to the right (as demonstrated on another patient in Figure 11.22), which centralised his pain. His shift was manually corrected on the first visit. He was prescribed repeated extension exercises in prone, as advocated by McKenzie (1985), to do at home every two hours. By the third visit his pain had centralised to left low back pain and his SLR was 80 degrees. He was then treated by unilateral mobilisations on the left at grade 4. This alleviated his symptoms and he regained full range of all movements.



Prior to discharge, he was given a programme of abdominal and multifidus exercises. He was also given postural and ergonomic advice prior to his return to work. The multifidus and the transverse abdominus muscles have been found to be primarily responsible for imparting local stability to the lumbar spine in the joint’s neutral zone (Panjabi 1992; Goel et al. 1993; Wilke et al. 1995; Hodges and Richardson 1996).

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Jan 7, 2017 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on Musculoskeletal assessment
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