Assessment Protocol
Dr. Michael Gillespie
Doctor of Chiropractic
Anatomic and Biomechanical
Principles
 It is necessary to understand normal anatomy and
healthy biomechanical relationships to accurately
evaluate orthopedic and neurological conditions.
 Understand the relationship between structure and
function.
 Anatomical and biomechanical variants can be present
with a particular patient.
Clinical Assessment Protocol
 Patient History
 Inspection / observation
 Palpation
 Range of Motion
 Orthopedic and Neurologic
Testing
 Diagnostic Imaging
 Functional Testing
Documentation
 Evaluate progress.
 Share information with other practitioners.
 Insurance records.
 Malpractice.
SOAP Notes
 Subjective – Patient History
 Objective – Observation and Testing
 Assessment – Based on compilation of findings
 Plan – Further testing and / or treatment
Patient History
 A thorough patient history can often lead to a proper
diagnosis with no further testing.
 Emphasize the aspect of the patient history with the
greatest clinical significance.
 Acquire all of the patient’s history whether or not
something seems relevant at the time.
Patient History
 Keep the patient focused on the problem.
 Listen carefully.
 Do not lead the patient towards answers.
Closed-Ended History
 Question and Answer Format.
 Written Forms
Open-Ended History
 Dialogue between patient and examiner.
 Identify other problems that are either directly or
indirectly related to the presenting complaint.
 Address the patient’s fears and concerns.
 Develop rapport.
 Keep the patient focused on the presenting problem.
OPQRST Mnemonic
 Onset of complaint
 Provoking or Palliative concerns
 Quality of pain
 Radiation to particular areas
 Site and Severity of complaint
 Time frame complaint
History – Other Factors
 Family History
 Occupational History
 Social History
Observation / Inspection
 General Appearance
 Functional Status
 Body Type
 Postural deviations
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Gait
Muscle guarding
Compensatory movements
Assistant devices
Inspection – three layers
 Skin
 Subcutaneous tissue
 Bony structure
Skin Inspection
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Bruising
Scarring
Trauma or surgery
Changes in color
 Vascular changes of inflammation
 Vascular deficiency – pallor or cyanosis
 Pigmented areas / Hairy areas
 Change in texture
 Open wounds – traumatic or insidious
Detection of Malignant
Melanoma
 Asymmetry
 MM lack symmetry
 Irregular Borders
 MM have notched, indented, scalloped, or indistinct borders
 Color Changes
 MM have uneven coloration, may contain several colors
 Diameter
 MM are typically greater than 6mm (0.25 in)
 Elevation
Subcutaneous Soft Tissue
Inspection
 Evaluate for inflammation and swelling
 Atrophy
 Increase in size
 Edema, articular effusion, muscle hypertrophy
 Nodules, lymph nodes, or cysts
 Compare b/l symmetry, utilize circumferential
measurements
Bony Structure Inspection
 Evaluate bony structure when gait or range of
motion is altered.
 Evaluate the spine
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Scoliosis
Kyphosis
Lordosis
Pelvic tilt
Shoulder height
 Evaluate for congenital and traumatic bone
deformities
Genu Varus
Genu Valgus
Palpation
 Palpate the patient in conjunction with inspection.
 Begin with a light touch.
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Dysesthesia.
Hypoesthesia.
Hyperesthesia.
Anesthesia.
Skin Palpation
 Evaluate skin temperature
 High – inflammation
 Low – vascular insufficiency
 Adhesions
Subcutaneous Soft Tissue
Palpation
 Subcutaneous soft tissue – fat, fascia, tendons,
muscles, ligaments, joint capsules, nerves, blood
vessels.
 Palpate with more pressure than with skin.
 Palpate for tenderness and swelling or edema.
Tenderness Grading Scale
 Grade I
- Patient complains of pain
 Grade II
- Patient complains of pain and winces
 Grade III - Patient winces and withdraws the joint
 Grade IV – Patient will not allow palpation of the joint
Types of Swelling
 Immediately after injury, hard and warm
 Contains blood
 8 to 24 hours after an injury, boggy or spongy
 Contains synovial fluid
 Tough and dry
 Callus
Types of Swelling
 Thickened and leathery
 Chronic swelling
 Soft and fluctuating
 Acute
 Hard
 Bone
 Thick and slow moving
 Pitting edema
Pulse
 Palpate for pulse rate, rhythm, and amplitude
 Normal healthy resting pulse rate for an adult is 60 –
100 bpm
Palpating Bony Structures
 Detection of alignment problems
 Dislocations, luxations, subluxations, fractures
 Identify ligaments and tendons that attach to the bones
 Detect bony enlargements
Range of Motion
 Passive
 Active
 Resisted
Passive Range of Motion
 The examiner moves the body part without the patient’s
help.
 Note normal, increased, or decreased movement.
 Note pain.
 Capsular or ligamentous lesion on side of movement and
/ or muscular lesion on side opposite of movement.
Six Range of Motion Pain
Variations
 1. Normal mobility with no pain.
 No lesion – normal joint.
 2. Normal mobility with pain.
 Minor ligament sprain or capsular lesion.
 3. Hypomobility with no pain.
 Adhesion.
Six Range of Motion Pain
Variations
 4. Hypomobility with pain.
 Acute ligament sprain or capsular lesion. Guarding from
muscle spasm.
 5. Hypermobility with no pain.
 Complete tear with no fibers intact where pain can be
elcited.
 6. Hypermobility with pain.
 Partial tear with some fibers still intact.
Sprain Vs. Strain
 Sprain - A sprain is an injury involving the stretching or
tearing of a ligament (tissue that connects bone to
bone) or a joint capsule, which help provide joint
stability.
 Strain - Strains are injuries that involve the stretching or
tearing of a musculo-tendinous (muscle and tendon)
structure.
End Feel
 Evaluate for end feel after determining the degree of
passive range of motion.
 Passively move the joint to the end of its range of
motion and then apply slight overpressure to the joint.
Active Range of Motion
 Yields information regarding the patient’s general
ability and willingness to use a body part.
 Assessment value is limited.
 Note the degree of motion as well as pain elicited.
 Crepitus should be noted.
 Inclinometers and goniometers are used to
measure range of motion.
Inclinometer
Goniometer
Resisted Range of Motion
 Resisted range of motion assesses musculotendinous
and neurologic structures.
 Musculotendinous injuries tend to be more painful than
they are weak.
 Neurologic injuries tend to be more weak than they are
painful.
Muscle Grading Scale
 5 – Complete range of motion against gravity with
full resistance.
 4 – Complete range of motion against gravity with
some resistance.
 3 – Complete range of motion against gravity.
 2 – Complete range of motion with gravity
eliminated.
 1 – Evidence of slight contractility.
 0 – no evidence of contractility.
Resistant Range of Motion
Reactions
 Strong with no pain – Normal.
 Strong with pain – lesion of muscle or tendon.
 Weak and painless – neurological lesion or complete
rupture of a tendon or muscle.
 Weak and painful – partial tear of muscle or tendon.
Fracture, neoplasm, and acute inflammation are
possibilities.