Area of the symptoms

It is useful to record the area of the pain by using a body chart, because this affords a quick visual reference (Maitland 2001). The patient may complain of more than one symptom, so the symptoms may be recorded or referred to individually as P1 and P2 and so on. Areas of anaesthesia or paraesthesia may be recorded differently on the pain chart – they may be represented as areas of dots in order to distinguish them from areas of pain (Figure 11.1).

Severity of the symptoms

The severity of the pain may be measured on a visual analogue scale (VAS) (Figure 11.2) or on a numerical scale of 0–10 to quantify the pain, where 0 stands for no pain at all and 10 is perceived by the patient as the worst pain imaginable. The mark on a VAS can then be measured and recorded for future comparisons using a ruler. Although these measures are not wholly objective, they do allow changes to be monitored as the treatment progresses.

Duration of the symptoms

Establish whether the pain and symptoms are intermittent or constant. Is the pain present all of the time or does it come and go depending on activities or time of day?

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).

Severity

This can be quantified by the VAS, numerical scale or other valid pain questionnaire. It can be recorded as high (pain score of around 7–10), moderate (score around 4–6) or low (score around 1–3).

Irritability

This is the time that the person has to perform the activity to increase the pain and, conversely, how long it takes before the pain settles to its former intensity. It can be measured as either high (the aggravating factor causes the pain to increase very quickly or instantly and then the pain takes a long time to settle back), moderate (the aggravating factor takes longer to increase the symptom) or low (the aggravating factor can be performed for a long time before exacerbating the patient’s symptoms and then on stopping the activity the symptoms subside rapidly). An example of low irritablity would be that the knee pain is aggravated after jogging for one hour and then subsides after one minute of rest.

Nature

It is possible to hypothesise the nature of the condition following the subjective history, i.e. whether the patient’s condition has a predominantly inflammatory, traumatic, degenerative or mechanical cause.

Insidious onset

Insidious onset means that the patient’s symptoms appear without any obvious cause. An example of this would be a degenerative condition such as osteoarthritis. These types of conditions often begin with a small amount of stiffness and pain, which is characterised by exacerbation and remission but is, nonetheless, progressive.

Traumatic onset

Can the onset of symptoms be related to a particular injury? Identify if there was a definite cause for the patient’s symptoms. The mechanism of injury may be indicative of the structures damaged. For example, a valgus strain of the knee may stretch the medial collateral ligament of the knee, whereas forced rotation of the knee joint when in a semi-flexed weight-bearing position may tear the menisci.

Progression of the condition

Are the patient’s symptoms getting better or worse? Acute soft-tissue injuries normally undergo a period of inflammation and repair, and symptoms may subside rapidly within a few days or weeks. However, progressive arthritic diseases may have a history of exacerbation and remissions with a general increase in the severity or frequency of their symptoms, as the disease progresses.

Progression of the condition may indicate how quickly the patient’s symptoms will subside.

Chronicity or age of the condition

How long has the patient experienced the symptoms? Is the condition acute or chronic? If the injury is chronic or has not resolved completely, it may indicate a number of different causes, such as mechanical instability from a ligament disruption, functional instability because of weakened muscles, loss of proprioception (and therefore the loss of an inherently protective reflex mechanism at the joint) or malalignment. Furthermore, it may be developing into a degenerative condition. The physiotherapist should identify the following:

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.

Blood tests

These are used extensively for the confirmation of the diagnosis of particular diseases such as rheumatoid arthritis, ankylosing spondylitis, osteomyelitis and malignancy.

Other investigations

The patient may be undergoing investigations for other pathologies that could possibly relate to the musculoskeletal condition. These should be noted and recorded.

Active movements

These are movements performed by the patient’s voluntary muscular effort.

Passive movements

These are movements performed by an external source, such as the physiotherapist or a pulley system. There are two types of passive movements.

Resisted movements

These are performed against the resistance of the physiotherapist or weights by the patient’s own effort.

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.

End-feel

During passive movements, the end-feel is noted. Different joints and different pathologies have different end-feels. The quality of the resistance felt at the end of range has been categorised by Cyriax (1982). For example:

Symptoms arising from resisted contractions

The Oxford scale is relatively quick and easy to use, and is used widely in clinical practice. However, it is not very objective, functional or sensitive to change as the movements resisted are concentric contractions and the spaces between the grades are not linear. Nevertheless, it provides a guide to muscle strength and is somewhat sensitive to change.

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.

Passive insufficiency of muscles

This occurs with muscles that act over two joints (Figure 11.4a). The muscle cannot stretch maximally across both joints at the same time. For example, the hamstrings may limit the flexion of the hip when the knee joint is in extension as they are maximally stretched in this position. However, if the knee is flexed passively, then the hip will be able to flex further as the stretch on the hamstrings has been reduced.

Active insufficiency of muscles

This, too, occurs with muscles that act over two joints (Figure 11.4b). The muscle cannot contract maximally across both joints at the same time. An example is the finger flexors. If you are to make a strong fist, you may notice that the wrist is in a neutral or an extended position when you do this action. Now, if you attempt to actively flex your wrist joint whilst keeping your fingers flexed, you will find that the strength of the grip is greatly diminished. This is because the wrist and finger flexors are unable to shorten any further and so the fingers begin to extend or lose grip strength.

Differentiation tests of ligaments

Ligaments are non-contractile structures and are tested by putting the structure on stretch. Examples are a valgus strain of the knee to stretch the medial collateral ligament of the knee or passive inversion of the subtalar joint to stretch the lateral ligament of the ankle. A positive test would be a pain response or observation or feel of any excessive movement of the joint when compared with the other side.

Differentiation tests of bursae

Bursae are sacs of synovial fluid. Inflammation of these (bursitis) results in tenderness and/or heat on palpation. The tenderness is often very localised to the site of the inflamed bursa.

Differentiation tests of menisci

The history and mechanism of injury combined with anterior joint tenderness and the inability to passively hyperextend the knee are useful diagnostic markers of meniscal injury. Rotation on a semi-flexed weight-bearing knee is a common cause of injury.

A history of locking, whereby the joint momentarily locks and is unable to actively or passively release itself from the position, is also common. Objectively, the knee joint is unable to fully flex/hyperextend passively.

Characteristics of degenerative joint disease

Signs and symptoms may include:

Active movements

Flexion

Flexion should result in a smooth curve. Segmental areas of give or restriction appear as hinging (segmental hypermobility). Lack of movement in the lumbar spine may be compensated by flexion at the hips or thoracic spine flexion. The gross movement may be measured as fingertip-to-floor distance with a tape measure. Note any limitation of movement, lateral deviation and pain response (Figure 11.8).

Side flexion (Figure 11.9)

Normal movement should be observed as a smooth curve. Areas of give or restriction will be observed as hinging (segments of hypermobility) or plane lines (areas of hypomobility). Compare with the other side for symmetry. Note any ‘coupling’ of movements, i.e. the trunk may flex or rotate to compensate for restriction of side flexion.

Passive physiological intervertebral movements (PPIVMs)

These can be used to confirm any restriction of motion seen on active movement tests and to detect restriction of movement not discovered by the active movement tests. PPIVMs also detect segmental hypermobility (Magarey 1988; Maitland 2001).

Overpressure

If the plane movements have full range and are pain-free, then overpressure applied slowly and with care can be administered. At the end of the available range the physiotherapist may apply a small oscillatory movement to assess the quality and end-feel of the movement. Also, the range of further movement should be noted, as well as the pain response.

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.

Differentiation between the hip and lumbar spine as a source of symptoms

The hip joint may give rise to pain in the buttock or groin. In order to differentiate between pain arising as a result of spinal or hip pathology it is important that the therapist discounts the hip joint as a possible source of symptoms. With the patient supine, full flexion, medial and lateral rotation is performed actively and passively at the hip joint. These are the movements commonly painful or restricted by degenerative joint conditions such as osteoarthritis. If these movements are pain-free and full-range then it is unlikely that the hip is a source of symptoms. Compare both sides.

Assessing the sacroiliac joint

Compression tests

Posterior ligaments

These test the integrity of the posterior sacroiliac ligaments. The patient lies supine and the hip is passively flexed towards the ipsilateral shoulder (Figure 11.11). A downward thrust is applied along the line of the femur. Observe for pain response, clunk and difference in end-feel between both sides. The test is repeated for (oblique) hip flexion towards the contralateral shoulder and (transverse) hip flexion towards the contralateral hip.

Anterior ligaments – Faber test

Flexion plus abduction plus external rotation (the ‘Faber’ test) tests the integrity of the anterior sacroiliac ligaments. The test is also described as the ‘four test’ because of the position of the patient’s limb, a combination of flexion, abduction and external rotation. The physiotherapist pushes the leg downward, just proximal to the knee joint while stabilising the opposite hip with the other hand. A normal finding would be to lower the leg to the level of the opposite leg. Observe for pain response or limitation of movement (Figure 11.12).

Dermatomes

A dermatome is an area of skin supplied by a particular spinal nerve. Dermatomes may exhibit sensory changes for light touch and pin prick. Test each dermatome individually, on the unaffected and then the affected side.

Myotomes

A myotome is a muscle supplied by a particular nerve root level. These are assessed by performing isometric resisted tests of the myotomes L1–S1 in middle range, held for approximately three seconds. Test the unaffected side, then the affected: LI–L2 for the hip flexors (see Figure 11.13), L3–L4 for knee extensors (see Figure 11.14), L4 for foot dorsiflexors and invertors, L5 for extension of the big toe, S1 for plantar flexion (see Figure 11.15) and knee flexion, S2 for knee flexion and toe standing, and S3–S4 for muscles of the pelvic floor and the bladder.

Reflexes

• Test the non-affected first then affected side. Note: dull reflexes may indicate lower motor neurone dysfunction. Brisk reflexes may indicate an upper motor neurone dysfunction.

• L3 corresponds to the quadriceps. The patient sits with the knee flexed and the therapist hits the patellar tendon just below the patella (Figure 11.16).

• S1 corresponds to the plantarflexors. Dorsiflex the ankle and strike the Achilles tendon. Observe and feel for plantar flexion at the ankle (Figure 11.17).

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.

Prone knee bend (femoral nerve stretch)

The patient lies prone and the physiotherapist flexes the person’s knee and then extends the hip (Figure 11.19). Pain in the back or distribution of the femoral nerve indicates femoral nerve irritation or reduced mobility. Comparison is made with the other side.

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).

Palpation

Soft-tissue thickening over the articular pillar at one or more spinal levels is a common finding in cases of degenerative disease of the lumbar spine, as is hard bony thickening and prominence over the apophyseal joints. Note any general tightness or localised thickening of muscular tissue or ligamentous tissue. In general, the older the soft-tissue changes, the tougher they are; the more recent, the softer they are. However, a thickened or stiff area is not necessarily painful or the source of a patient’s symptoms (Maitland 2001).

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).