Download Examination and Evaluation

Chapter 8
The Examination and Evaluation
Overview
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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 success of this interaction involves a
myriad of skills
The Patient
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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
Communication
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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
The examination and
evaluation
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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 evaluation refers to the making of a value
judgment based on the collected data and
information
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The Examination
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The examination consists of three
components of equal importance:
– The history
– The systems review
– The tests and measures
Observation
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Throughout the history, systems
review, and tests and measures,
collective observations form the basis
for diagnostic deductions
Examination
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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
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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
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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
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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
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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
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Pain
– Pain is a disturbed sensation that causes
suffering or distress
– The following factors must be investigated:
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Onset
Intensity
Location
Perception
Quality
Behavior
Nature
Tests and measures
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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
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Active range of motion testing gives
the clinician information about:
The quantity of available physiological motion
 The presence of muscle substitutions
 The willingness of the patient to move
 The integrity of the contractile and inert
tissues
 The quality of motion
 Symptom reproduction
 The pattern of motion restriction
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The pattern of motion
restriction
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Cyriax gave us the terms capsular and noncapsular 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
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Passive range of motion testing gives the
clinician information about the integrity of
the contractile and inert tissues, and the
end-feel
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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
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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
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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
Joint mobility testing
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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:
– 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
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According to Cyriax, strength testing
can provide the clinician with the
following findings:
–A
–A
–A
–A
weak and painless contraction
strong and painless contraction
weak and painful contraction
strong and painful contraction
Strength testing
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A number of grading systems exist to
test muscle strength using manual
resistance
Reflex integrity
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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
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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
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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.’
Palpation
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Palpation is performed to:
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Check for any vasomotor changes such as an increase
in skin temperature that might suggest an
inflammatory process
Localize specific sites of swelling
Identify specific anatomical structures and their
relationship to one another
Identify sites of point tenderness
Identify soft tissue texture changes or myofascial
restriction
Locate changes in muscle tone resulting from, trigger
points, muscle spasm, hypertonicity, or hypotonicity
Determine circulatory status by checking distal pulses
Detect changes in the moisture of the skin
Special Tests
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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
Neuromeningeal Mobility
Tests
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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
Imaging Studies
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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)
The Evaluation
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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
Clinical Decision Making
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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
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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.
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A diagnosis can only be made when all
potential causes for the symptoms
have been ruled out
Prognosis
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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