Download Chapter 13: Off-the Field Injury Evaluation

Chapter 13: Off-the-Field
Injury Evaluation
Part I
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Evaluation of Injuries
• Essential skill for athletic trainers
• Four distinct evaluations
1. Pre-participation (prior to start of season)
2. On-the-field assessment
3. Off-the-field evaluation (performed in the
clinic/training room…etc)
4. Progress evaluation
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Clinical Evaluation &
Diagnosis
• Diagnosis
– Use of clinical or scientific methods to
establish cause and nature of patient’s illness
or injury and subsequent functional
impairment due to pathology
– Forms basis for patient care
• Physicians make medical diagnosis
– Ultimate determination of patient’s physical
condition
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• Athletic trainers and other health care
professionals use evaluation skills to
make clinical diagnoses
– Clinical diagnosis identifies pathology and
limitations/disabilities associated with
pathology
• Athletic trainers have academically-based
credential and in many states some form
of regulation which recognizes ability and
empowers clinician to make accurate
clinical diagnosis
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Basic Knowledge Requirements
• Athletic trainer must have general knowledge
of anatomy and biomechanics as well as
hazards associated with particular sport
• Anatomy
– Surface anatomy (Further info in HE 92)
• Topographical anatomy is essential
• Key surface landmarks provide examiner with
indications of normal or injured structures
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Body Planes & Anatomical
Directions
• Page 337 & 338
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– Body planes
• Points of reference
– Midsagittal planes- Left and right
– Transverse- Top and Bottom
– Frontal (coronal) – Front and back
– Anatomical directions
•
•
•
•
•
•
•
•
Anterior- in front
Posterior- in back
Superior- above
Inferior- below
Distal- further away
Proximal- closer to
Medial- towards the middle
Lateral- away from the middle
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– Abdominopelvic Quadrants
• Four corresponding regions of the abdomen
• Divided for evaluative and diagnostic purposes
• A second division system involves the
abdomen being divided into 9 regions
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– Musculoskeletal Anatomy
• Structural and functional anatomy
• Encompasses bony and skeletal musculature
• Neural anatomy useful relative to motion,
sensation, and pain
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Standard Terminology for
Bodily Position and Deviations
• Page 340 Table 13-1
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– Standard Terminology
• Used to describe precise location of structures
and orientation
• Abduction- to draw away or deviate from
midline
• Adduction- To deviate towards or draw towards
• Eversion- turning outward
• External (lateral) rotation- rotary motion in a
transverse plain away from midline
• Flexion- to bend; joint angle increases
• Internal (medial) rotation- Rotary motion in a
transverse plane towards the midline
• Inversion- turning inward
• Pronation- Applied to the foot- eversion &
abduction, lowering of medial foot; applied to
palm- turning downward
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• Supination- Applied to foot- raising the medial
arch; applied to the palm- turning the palm
upward
• Valgus- Deviation of part or portion of the
extremity distal to the joint away from the
midline
• Varus- Deviation of part or portion of the
extremity distal to the joint towards the midline
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Terminology Lab
• 6 Total groups; each group will draw the
terminology given
– Body planes
– Anatomical Directions
– Quadrants with organs (help pg 828)
– Nine regions with organs (help pg 828)
– Positions & Deviations (abduction,
adduction, eversion, extension, external
rotation, and flexion)
– Positions & Deviations (Internal rotation,
inversion, pronation, supination, valgus
and varus)
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• Biomechanics (foundation for
assessment)
– Application of mechanical forces which
may stem from within or outside the body
to living organisms
– Pathomechanics - mechanical forces
applied to the body due to structural
deviation - leading to faulty alignment
(resulting in overuse injuries)
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• Understanding the Activity
– More knowledge of activity allows for more
inherent knowledge of injuries associated
with activity resulting in more accurate clinical
diagnosis and rehab design with appropriate
functional aspects incorporated for return to
activity
– Must be aware of proper biomechanical and
kinesiological principles to be applied in
activity
– Violation of principles can lead to repetitive
overuse trauma
– Increased understanding = better
assessment and care
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Descriptive Assessment
Terms
• Page 339- 341
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• Descriptive Assessment Terms
– Etiology - cause of injury or disease
interchanged with mechanism of injury
– Mechanism – mechanical description of cause
– Pathology - structural and functional changes
associated with injury process
– Symptoms- perceptible changes in body or
function that indicate injury or illness
(subjective) patient describes them
– Sign - objective, definitive and obvious
indicator for specific condition
– Degree- grading for injury/condition from mild,
moderate and severe
– Diagnosis- denotes name of specific condition
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– Prognosis- prediction of the course of the
condition
– Sequela - condition following and resulting
from disease or injury (pneumonia resulting
from flu)
– Syndrome - group of symptoms and signs that
together indicate a particular injury or disease
– Differential diagnosis – systematic method of
diagnosing a disorder
•
•
•
•
Refers to a list of possible causes
Prioritizing of possibilities
Also referred to as hypothesis or working diagnosis
Utilize skills to make decision regarding condition
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Off-the-field Injury Evaluation
• Detailed evaluation on sideline or in clinic
setting
• May be the evaluation of an acute injury
or one several days later following acute
injury
• Divided into 4 components
– History, observation, palpation and special
tests
– HOPS
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• History
– Obtain subjective information relative to
how injury occurred, extent of injury, MOI
– Mechanism of Injury (MOI)- how, when,
what, did you hear or feel anything
– Injury location- localized or general
– Pain characteristics
• Nerve- sharp, bright or burning; Bone- local &
piercing; vascular- aching & referred; muscledull, aching and referred
– Joint- instability
– Acute or Chronic
– Previous or pre-extisting
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• Observations- bilateral comparison
– Asymmetries, postural mal-alignments or
deformities?
– How does the athlete move? Is there a
limp?
– Are movements abnormal?
– What is the body position?
– Facial expressions?
– Abnormal sounds?
– Swelling, heat, redness, inflammation,
swelling or discoloration?
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• Palpation
– Knowledgeable touching
• Light pressure to deeper pressure
• Away from site towards site of injury
– Bony tissue
• Abnormal gaps, misalignment
– Soft tissue
• Swelling, lumps, gaps, temperature
• Sensations- dysesthesia (diminished sensation),
anesthesia (numbness), and hyperesthesia
(increased sensation)
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• Special Tests
– Used to detect specific pathologies
– Compare inert and contractile tissues and
their integrity
– Assessment should be made bilaterally
• Start with uninjured side first for “normal”
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© 2011 McGraw-Hill Higher Education. All rights reserved.
Chapter 13: Off-the-Field
Injury Evaluation
Part II
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Special Tests
• Movement Assessment
– Contractile- muscles and tendons
• Lesion (tear)- pain with AROM in one direction
and pain with PROM in opposite
– Pain with active contraction and with stretch
– Inert- bones, ligaments, joint capsule,
fascia, nerves, bursae, nerve roots and
dura mater
• Pain with AROM and PROM in same direction
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• Active Range of Motion (AROM)
– Joint motion that occurs because of muscle
contraction
• Passive Range of Motion (PROM)
– Movement that is performed completely by
the examiner
• Endpoints- what the examiner “feel” during
special tests
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End Points
• Page 344-345
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• Normal endpoints
– Soft tissue- soft and spongy, gradual
painless stop (knee flexion)
– Capsular- abrupt, hard, firm with very little
give (hip rotation)
– Bone to bone- distinct, abrupt (elbow
extension)
– Muscular- springy with some associated
discomfort (shoulder abduction)
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• Abnormal Endpoints:
– Empty- movement is beyond the
anatomical limit, pain occurs before the
end range (ligament rupture)
– Spasm- involuntary muscle contraction that
prevents motion, also called guarding
(back spasm)
– Loose- extreme hypermobility (previous
sprained ankle)
– Springy block- a rebound endpoint
(meniscus tear)
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Measurements
• Goniometry- Measures the joint range
of motion
– Measure 0- 180 degrees
– Placed along the lateral surface with
patient in anatomical neutral; middle on the
joint, each end on axis using bony
landmarks
• Digital Inclinometer- measures the slope
of elevation
– Digital using gravity
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Joint
Shoulder
Action
Degrees of Motion
Flexion
Extension
Adduction
Abduction
Internal rotation
External rotation
180
50
40
180
90
90
Elbow
Flexion
Forearm Pronation
Supination
145
80
85
Wrist
Flexion
Extension
Abduction
Adduction
80
70
20
45
Hip
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
125
10
45
40
45
45
Knee
Ankle
Flexion
140
Plantar flexion
Dorsiflexion
Foot Inversion
Eversion
45
20
40
20
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Figure 13-4 A & B
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Manual Muscle Testing
• The ability of the injured patient to
tolerate varying levels of resistance
(usually caused by pain)
• Muscle is isolated and tested through
full ROM
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Manual Muscle Strength
Grading
• Page 346 Table 13-3
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TABLE 13-3 Manual Muscle Strength Grading
Grade
Percentage (%)
Qualitative Value
Muscle Strength
5
100
Normal
Complete range of motion (ROM)
against gravity with full
resistance
4
75
Good
Complete ROM against gravity
with some resistance
3
50
Fair
Complete ROM against gravity
with no resistance
2
25
Poor
Complete ROM with gravity
omitted
1
10
Trace
Evidence of slight contractility
with no joint motion
0
0
Zero
No evidence of muscle
contractility
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Neurological Examination
• Usually follows manual muscle testing
• Includes 6 major areas
– Cerebral Function
– Cranial Nerve Function
– Cerebellar Function
– Sensory Testing
– Reflex Testing
– Motor Testing
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• Cerebral Function
– Questions to assess general affect, level of
consciousness, intellectual performance,
emotional status, though content, sensory
interpretation & language skills
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LAB
• Get into groups of 2-3
• Using the SAC form check
– Orientation
– Immediate memory
– Concentration
– Delayed recall
• Each person should be tested and administer
the test
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• Normal: 25
points
• Need to get
back to
baseline to
return
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Cranial Nerve Functions
• Twelve total cranial nerves that can be
assessed through smell, eyes, facial
expressions, biting balance, swallowing,
tongue protrusion and shoulder shrugs
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Cranial Nerves & Their
Function
• Page 347 Table 13-4
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TABLE 13-4
Cranial Nerves
Function
I. Olfactory
Smell
II. Optic
Vision
III. Oculomotor
IV. Trochlear
Eye movement, opening of eyelid, constriction of
pupil, focusing
Inferior and lateral movement of eye
V. Trigeminal
Sensation to the face, mastication
VI. Abducens
Lateral movement of eye
VII. Facial
Motor nerve of facial expression; taste; control of
tear, nasal, sublingual salivary, and submaxillary
glands
Hearing and equilibrium
VIII. Vestibulocochlear
IX. Glossopharyngeal
X. Vagus
XI. Accessory
XII. Hypoglossal
Swallowing, salivation, gag reflex, sensation from
tongue and ear
Swallowing; speech; regulation of pulmonary,
cardiovascular, and gastrointestinal functions
Swallowing, innervation of sternocleidomastoid
muscle
Tongue movement, speech, swallowing
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Cranial Nerve Lab
• Class broken into 12 groups; 2-3 people
per group.
• Each group is given a cranial nerve.
• Make a drawing of the cranial nerve,
include the roman numeral, the name
and the function.
• On the back of the sheet, write how you
would test a patient for your assigned
nerve
• Give a presentation
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Mnemonics
• Some Say Marry Money, But My
Brother Says Big Business Makes
Money
– S: Sensory
– M: Motor
– B: Both
• OLd OPie OCcasionally TRies
TRIGonometry And Feels VEry
GLOomy, VAGUe, And HYPOactive
• Oh Once One Takes The Anatomy Final
Very Good Vacations Are Heavenly
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Cerebellar Function
• Controls purposeful coordinated
movements
• Tests include
– Touching finger to nose
– Touching patients finger to examiners
– Drawing alphabet in air with foot
– Heel-toe walking
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Sensory Testing
• Dermatome: area of skin innervated by
a single nerve
– Touch, pain, temperature, vibration,
position sense
• Myotomes: muscles or groups of
muscles innervated by a specific motor
nerve
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Figure 13-5
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Reflex Testing
• Reflex: involuntary response to a
stimulus
• Types
– Deep tendon (somatic), superficial, and
pathological
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• Motor- Manual muscle testing
• Joint Stability- discussed in HE 92
(chapters 18-25)
• Functional Performance- progression,
return to play
• Postural- malalignments
• Anthropomtric- measuring the human
body
• Volumetric- swelling, displacement of
water
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Figure 13-6
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PART III
OFF-THE-FIELD INJURY
EVALUTION
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Progress Evaluations
• The scope of the injury
• How the injury appears today vs past
• Still needs to go through HOPS
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Documenting Injury Evaluation
Information
• Complete and accurate documentation
is critical
• Clear, concise, accurate records is
necessary for third party billing
• While cumbersome and time
consuming, athletic trainer must be
proficient and be able to generate
accurate records based on the
evaluation performed
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• SOAP Notes
– Record keeping can be performed
systematically which outlines subjective &
objective findings as well as immediate and
future plans
– SOAP notes allow for subjective &
objective information, the assessment and
a plan to be implemented
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SOAP Notes
• Page 353
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– S (subjective)
• Statements made by patient - primarily history
information and patient’s perceptions including
time, mechanism and site of injury. Also the
type and course of pain
– O (Objective)
• Findings based on athletic trainer’s evaluation
including inspection, palpation and
assessments of range of motion. Also the
outcome of special tests
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– A (Assessment)
• Athletic trainer's professional opinion regarding
impression of injury
• May include suspected site of injury and
structures involved along with rating of severity
– P (Plan)
• Includes first aid treatment, referral information,
goals (short and long term) and examiner’s
plan for treatment
• Treatment should also include specific short
term goals
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Progress Notes
• Progress notes- written after each
progress evaluation written in SOAP
note form
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ASSIGNMENT
• Using the standard abbreviations and
symbols used in medical documentation
in Table 13-7 on page 352, rewrite the
sentences
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Additional Diagnostic Tests
• Due to the need to diagnose and design
specific treatment plans, physicians
have access to additional tools to
acquire additional information relative to
an injury
• There are a series of diagnostic tools
that can be utilized in order to more
clearly define and determine the
problem that exists
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• Plain Film Radiographs (X-ray)
– Used to determine presence of fractures bone
abnormalities and dislocations
– Can be used to rule out disease (neoplasm)
– Occasionally used to assess soft tissue
• Arthrography
– Visual study of joint via X-ray after injection of dye,
air, or a combination of both
– Shows disruption of soft tissue and loose bodies
• Arthroscopy (scope)
– Invasive technique, using fiber-optic arthroscope,
used to assess joint integrity and damage
– Can also be used to perform surgical procedures
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X-Ray
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Myelopgraphy, CT scan, Bone
Scan
• Page 356
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• Myelography
– Opaque dye injected into epidural space of spinal
canal (through lumbar puncture)
– Used to detect tumors, nerve root compression and
disk disease and other diseases associated with
the spinal cord
• Computed Tomography (CT scan)
– Penetrates body with thin, fan-shape X-ray beam
– Produces cross sectional view of tissues
– Allows multiple viewing angles
• Bone Scan
– Involves intravenous introduction of radioactive
tracer
– Used to image bony lesions (i.e. stress fractures) in
which there is inflammation
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CT Scan
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Bone Scan and DEXA Scan
Figure 13-8 F & G
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• DEXA Scan
– Dual energy X-ray absorptiometry
– Used to measure bone mineral density
• Greater mineral density = greater signal picked
up
– Documents small changes in bone mass
– Used on both spine and extremities
– Less expensive, less radiation exposure
– More sensitive and accurate for measuring
subtle bone density changes over time
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MRI & MRI Anthrography
• Page 356
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• Magnetic Resonance Imaging (MRI)
– Using powerful electromagnets, magnetic current
focuses hydrogen atoms in water and aligns them
– After current shut off, atoms continue to spin
emitting different levels of energy depending on
tissue type, creating different images
– While expensive, it is clearer than CT scan and
the test of choice for detecting soft tissue lesions
• MRI Arthrography
– Imaging study involving injection of contrast agent
into joint prior to MRI
– Allows for more detailed assessment of joint vs.
traditional MRI
– Contrast agent allows for highlighting of certain
areas
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Magnetic
Resonance
Imaging
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• Ultrasonography
– Diagnostic ultrasound of sonography
– Allows clinician to view location, measurement or
delineation of organ or tissue by measuring
reflection or transmission of high frequency
ultrasound waves
– Computer is able to generate 2-D image
– Advancements in technology are allowing for 3-D
imaging as well
• Musculoskeletal Ultrasound
– Allows for imaging and evaluation of soft tissue
structures
– Complimentary technique to MRI or CT
– Non-painful, non-invasive, cost effective
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• Doppler Ultrasound
– Used to examine blood flow in arms and legs
– Alternative to arteriography and venography
– Detects blood clots, venous insufficiency,
vessel closing, or altered blood flow
• Arteriogram
– Catheter inserted into blood vessel and
contrast medium is injected
– Using x-ray, images are taken to determine
path of fluid flow in vessels
• Venogram
– Radiographic procedure used to image veins
filled with contrast medium
– Used for detecting thrombophlebitis and for
tracing of venous pulse
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Figure 13-8
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• Echocardiography
– Uses ultrasound to produce graphic record of
cardiac structures (valves and dimensions of
left atrium and ventricles)
• Electroencephalography (EEG)
– Records electrical potentials produced in the
brain to detect changes or abnormal brain
wave patterns
• Electromyography (EMG)
– Graphic recording of muscle electrical activity
using surface or needle electrodes
– Observed with oscilloscope screen or graphic
recordings called electromyograms
– Used to evaluate muscular conditions
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• Electrocardiography
– Recording of electrical
activity of heart at
various stages in
contraction cycle
– Assesses impulse
formation, conduction,
depolarization and repolarization of atria and
ventricles
Figure 13-9
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• Nerve Conduction Velocity
– Used to determine conduction velocity of
nerves and can provide key information
relative to neurological conditions
– After applying stimulus to nerve, speed at
which the muscle reaction occurs is
monitored
– Delays may indicate nerve compression or
muscular/nerve disease
• Synovial Fluid Analysis
– Detect presence of infection in the joint
– Used to confirm diagnosis of gout and
differentiates between inflammatory and noninflammatory conditions (degenerative vs.
rheumatoid arthritis)
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Blood Tests
• Page 358
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• Blood Test
– Complete blood count (CBC) used to
screen for anemia (too few red blood cells),
infection (too many white cells) and many
other reasons
– Routine CBC:
•
•
•
•
•
•
Assesses red blood cell count
Hemoglobin levels
Hematocrit levels (RBC per volume)
White blood cell count
Platelet deficiency
Serum cholesterol
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SCENARIO- BLOOD TESTS
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• Urinalysis
– Used to assess specific gravity, pH,
presence of ketones, hemoglobin, proteins,
nitrates, red & white blood cells, bacteria,
electrolytes, hormones and drug levels
– Urinalysis using dip and read test strips
provide fast accurate results for a number
of things including, specific gravity, WBC’s,
nitrate, pH, protein, glucose, ketones,
bilirubin and blood.
• Large area on strip is impregnated with
reagents which change color when dipped in
urine that are then compared to color
comparison charts. © 2011 McGraw-Hill Higher Education. All rights reserved.
Ergonomic Risk Assessment
(ERA)
• If working in a clinic or industrial setting an
athletic trainer may be called upon to
perform this assessment
• Involves evaluation of factors within a job
that increase risk of someone suffering a
workplace-related ergonomic injury
– Assess aspects and movements that could be
modified to reduce risk
• Injury prevention and intervention through
ergonomic control measures and injury
statistics
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