4. Musculoskeletal physiotherapy
Nick Southorn
• Initial subjective assessment47
• Initial objective assessment50
• Clinical semaphore52
• Treatments52
• Muscle energy techniques (MET)55
• In the clinic58
A glossary of terms may be useful to begin with: For a more comprehensive list of physiotherapy terms, The dictionary of physiotherapy (Porter 2005) is necessary.
• Abduction: movement away from the midline of the body.
• Accessory movement: a movement that can be done by the therapist, which makes up part of a gross overall movement. However, the patient cannot isolate and carry out this movement. For example, in shoulder abduction, the humeral head glides inferiorly in the articular surface of the glenoid cavity. A therapist can perform a passive accessory caudad glide to help improve the whole movement of abduction. The opposite is physiologic movement.
• Active movement: movement performed without facilitation.
• Adduction: movement towards the midline of the body.
• Cephalic: to do with the head (movement towards the head).
• Extension: a joint movement whereby the interior angle increases.
• Flexion: a joint movement whereby the interior angle decreases.
• Manipulation: high-velocity thrust moving a joint well into the limits of its range. The patient cannot stop this procedure.
• Mobilization: movement of a joint in such a way that the patient has total control and can stop the procedure if need be.
• Overpressure: the additional movement in a joint beyond the normal range that is applied by the therapist during assessment.
• Paradigm: a concept or belief.
• Passive movement: movement of a joint by the therapist.
• Physiologic movement: a movement of a joint such as shoulder abduction. It can be passive (i.e. no effort from the patient required as the therapist moves the joint) or active (the patient does all the work). The opposite is accessory movement.
So what is musculoskeletal therapy?
You will hear practitioners talk about the various ways in which to treat or assess a patient such as “orthopedic medicine,”“McKenzie,”“Maitland,”“Mulligan,” “Cyriax,” etc. Each of these techniques has slightly different approaches and theories behind it. There are people who will vigorously stick to one particular type of treatment and there are people who “cherry pick” aspects from each. Either way, as a student physiotherapist it is essential that you consider all of them to be within your learning remit. Below is a brief taster of some of the different techniques that physiotherapists employ in their practice. It is worth noting that none of these techniques is “physiotherapy” so they are regarded as part of your treatment arsenal and not your only trick! As a physiotherapist, you have legal license to carry out these techniques but you may see medical doctors, osteopaths and chiropractors also using them. Of course, certain types are preferred by certain professions; osteopathy and physiotherapy are becoming more alike in their treatments as the evidence base supports treatments and the professions take them on and concentrate on them.
Initial subjective assessment
Assessments are always made up of two parts – the subjective and the objective. The former involves information gathered by questioning and the latter is what is seen and/or measured by the clinician. The initial assessment is no different but it usually involves additional information.
The clerical questions are the standard name, address, general practitioner/family physician, date of birth and so on, so that you can be sure that you have the correct patient in front of you.
Some“special questions” are typically also asked at the start. These may include queries about:
• heart or lung problems, blood pressure
• asthma
• rheumatoid or osteo-arthritis (be prepared to explain the difference between them)
• steroid usage
• anticoagulant therapy
• allergies
• any recent significant weight loss that can’t be explained by dieting or increase in activity
• cancer.
Some questions may be guided by the type of condition, such as the cauda equina check for low back pain.
• Bladder retention/incontinence, bowel incontinence
• Saddle anesthesia
• Bilateral leg pain/weakness
Headings that may help gather a database of your patient are listed below. Something that may be of use to you is to work towards a SIN factor, which is the Severity, Irritability and Nature of the condition. While you read through these, have a think about some answers and which heading – severity, irritability or nature – they may contribute to.
PRESENTING CONDITION (PC)
• What is your main problem with your condition?
– This is sometimes referred to as “question 1.”
– The information you need is: how is this disease affecting the patient?
– This question will help you discover the actual effect on lifestyle and function as well as what the patient would like to regain.
– You can guide the answer but try not to direct the answer: “Is it loss of movement or strength, pain, or something else?” or “Is it preventing you from doing something you like or have to do?”, etc.
HISTORY OF PRESENTING CONDITION (HPC)
• Was there a major event that led to these symptoms (like a vehicle incident) or is it a result of microtrauma (such as repetitive strain injuries)? Perhaps it just came on (insidious onset).
– Try to gather information relating to the incident such as the mechanism of injury, were they driving or a passenger, were seatbelts worn, how far did they fall, how long before medical attention arrived, etc. Remember to be sensitive to psychologic/emotional implications relating to a major incident.
• How long have you noticed that something is not right/have you had the symptoms? Try to establish the age of the condition; is this one of many episodes or the only time this has happened?
• Did the symptoms come on immediately or develop over time?
• Are there any legal issues to consider?
• What other treatments or investigations have been used so far, if any (medical/surgical/complementary)?
LIST OF SYMPTOMS
Since you have asked about the main problem in question 1, they should have explained the whole story of that so now is a good time to ask what other symptoms/problems they can think of.
PAIN
• Do they have any?
• Is it constant or intermittent? Explain that constant means all the time, 24 hours of the day.
• Ask them to describe the pain – throbbing, sharp, dull, “toothache like,” shooting, etc.
• Can they rate it out of 10? The Numerical Rating Scale (NRS) is a 0–10 scale which is very useful as an objective measure. Ask for a number between 0 and 10 to describe when the pain is at its worst, least and right now.
• Is it the same intensity or variable?
• Aggravating/easing factors – remind them that rubbing, heat and rest are valid answers here. Also explore the length of time it takes for the pain to disappear.
• Is the pain so bad sometimes that they have to miss something (like work, hobbies)?
• Diurnal pattern.
– Do the symptoms appear worse at different times of the day (i.e. do they worsen/improve through the day or remain constant?)?
– Sleep patterns – are they aware of the symptoms when they awaken/on rising from bed/through the night (does it wake them)? If so, how many hours of unbroken sleep do they get?
PAST MEDICAL AND SURGICAL HISTORY (PMH)
Simply a list of conditions and operations that the patient has had in the recent past. Some things may appear insignificant to the pathology you face, such as the patient with adhesive capsulitis who tells you that they also have hypothyroidism or diabetes mellitus – the two have been likened to adhesive capsulitis (Siegel et al 1999).
DRUG HISTORY (DH)
Just a list of medication they take plus any other drugs they may wish to inform you of. Remind the patient that it is not only prescribed medications you need to be aware of – many people will buy their own from a pharmacy or herbalist.
SOCIAL HISTORY (SH)
• What do they do for a living?
• Hobbies
– Is this condition preventing them from pursuing their hobbies?
– Is it possible that their hobby has contributed to the condition?
• Home circumstances.
– Can they carry out activities of daily living (ADL)? Personal ADLs (PADLs) include washing, dressing, brushing teeth, etc. Domestic ADLs (DADLs) include cleaning, cooking, driving, etc. Establishing this will give you an indication not only about their ability to function but also their dependency on other people. This can be quite an emotive topic as sometimes it is quite humbling to have lost a certain degree of independence.
– Who do they live with? Do they have dependants? Is the person they have become dependent on capable of coping with this new situation?
– Do they have stairs and can they negotiate the stairs safely?
So there it is – the basic checklist of subjective questioning that will create for you a comprehensive database of the patient. Having asked these questions, you will have a good idea of the SIN factor, the patient’s motivation for recovery, the patient’s priorities, and the gross effect of this condition.
Initial objective assessment
The objective assessment is the method by which you discover the clinical signs of the pathology rather than just the symptoms. It is good practice to obtain information from the other side too and comment on whether anything you find (such as swelling) is of long standing or a new sign. As with the subjective assessment, it is always helpful to have a system in place. A detailed assessment is a thorough one that extends way beyond the realms of joint measurements. As a medical professional, you should note any other significant observations. Below is a brief guide to the objective assessment.
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