ASSESSMENT AND EVALUATION Ahmed Alhowimel ASSESSMENT AND EVALUATION Good assessment is dependent upon: Knowledge of functional anatomy History Complete examination EVALUATION Structure governs function Anatomy is the structure Biomechanics/physiology are the function EVALUATION PURPOSE Develop database to establish Patient’s level of function Plan a treatment program and establish outcomes Evaluate results of treatment program Modify treatment program CLINICAL EVALUATION SEQUENCE History Inspection Palpation Functional Testing A/P/ROM Ligamentous Testing Special Tests Neurological Testing HISTORY Most important portion of exam Any special test should confirm what is learned in the history Key questions(identify forces on the body) Acute Injury= What is the mechanism Chronic Injury= Are there changes in treatment routines/equipment/posture HISTORY Mechanism How did injury occur Macrotrauma (single traumatic force) Microtrauma (accumulation of repeated forces) Relevant Sounds or sensations Pop “Giving Way” Location of symptoms Localized Referred(pain from another source) Isolated vs. diffuse Onset and duration of symptoms Immediate pain v. chronic Classification for overuse injuries Stage 1 Pain after activity Stage 2 Pain during/after activity Stage 3 Constant pain Description of symptoms Sharp/dull/achy Intermittent v. constant Weakness Paresthesia (numbness/tingling) Dysfunction/ inability to perform activity Change in symptoms Intensity change with specific motions, postures, treatment, modalities, medications Previous history Previous injury When did previous episode occur Who evaluated and treated injury Diagnosis Course of treatment/rehab/surgery performed Did previous treatment plan decrease symptoms Related history to opposite body part Previous history of injury to uninvolved side General health status congenital abnormality/disease INSPECTION Gait Gross Deformity fracture/discoloration/serious bleeding Swelling (localized v. diffuse) Bilateral Symmetry Discoloration Keloids (surgical scars) Infection Redness/warmth/pus/swelling/red streaks/lymph nodes GIRTH MEASUREMENTS Swelling Identify joint line using bony landmarks Atrophy Make incremental marks (2,4,6 inch) from jt. line Lay tape symmetrically around body Take 3 measurement and record average Repeat and record for uninjured limb PALPATION Detect tissue damage Bones (rule out fracture) Ligaments/tendons Soft tissue Pulses Point tenderness Visualize structure which lie beneath fingers Compare bilaterally Trigger Points Palpated points in muscle which refer pain to another body area Change in tissue density (or feel of tissue) may indicate: Muscle spasm Hemorrhage Edema Scarring Myositis ossificans Crepitus- repeated crackling sensations or sound emanating from the joint or tissue Symmetry Compare muscle tone, bony prominence Increased tissue temperature Indicates active inflammatory process RANGE OF MOTION (ROM) Helps to assess functional status Compare bilaterally Test joints proximal and distal to injured area FUNCTIONAL TESTING AROM Contraindications: immature fracture sites newly repaired Cardinal Planes (test all planes of ROM) Painful ARC compression within range FUNCTIONAL TESTING PROM Quantity of available movement “End feel” reach limit of available ROM Most accurate method is with goniometry measurements NORMAL END FEEL PHYSIOLOGICAL Hard Bone contacting bone elbow extension Soft Soft tissue approximation elbow flexion Firm Capsule stretch(ext of MCP jt) Ligament Stretch (forearm supination) Muscle Stretch (hip flexion with knee extended) ABNORMAL END FEEL PATHOLOGICAL Soft tissue edema synovitis Capsular,muscular, ligamentous shortening osteoarthritis Fracture Bursitis, Joint inflammation Soft Firm Hard Empty FUNCTIONAL TESTING RROM Contraindications for RROM Patient is unable to voluntarily contract injured muscle Patient is unable to perform AROM Underlying fracture site is not healed Involved tissues are not yet healed Manual Resistance Stabilize limb proximally Resistance provided distally on bone to which muscle attaches Watch for compensation GRADING SYSTEM FOR MANUAL MUSCLE TESTING 0/5 Zero No contraction 1/5 Trace Palpable contraction No muscle movement 2/5 Poor Able to move body part through gravity eliminated 3/5 Fair Move against gravity throughout ROM 4/5 Good Moderate resistance 5/5 Normal Maximal resistance CLINICAL SIGNIFICANCE Strength Good Pain None Finding Normal Good Present Minor soft tissue injury Weak Present Major injury Weak None Neurological or Rupture or Chronic LIGAMENTOUS AND CAPSULAR TESTING Ligamentous testing compare bilaterally compare with baseline measures correct positioning (if incorrect positioning may lead to false results) SPECIAL TESTS Specific procedures applied to joint to determine presence of injury Unique to each structure Bilateral comparison NEUROLOGICAL (RADIATING PAIN) Involves Upper/lower quarter screen of: Sensory (dermatome) Motor (myotome) DTR (Deep Tendon Reflex) SENSORY TESTING Bilateral Dermatone Area of skin innervated by a single nerve root Slight stroke over area/pin prick Sharp v. dull Hot v. cold Motor Testing Manuel Muscle Testing POSTURAL ASSESSMENT WHAT IS POSTURE? Defined: “The position of the body at a given point in time.” (Starkey) “A set of muscle contractions that place the body in the necessary location from which a movement is performed.” (Enoka) “The situation or disposition of the several parts of the body with respect to each other for a particular purpose.” (Webster) WHAT IS GOOD POSTURE? posture serves as a reference point. Ideal posture… Distributes gravitational stress for balanced muscle function. Allows joints to move in their mid range to minimize stress on ligaments and articular surfaces. Effective for the individual’s activities of daily living. Allows the individual to avoid injury. POSTURAL DEVELOPMENT Birth Entire spine concave forward (flexed) “Primary curves” Thoracic spine Sacrum Developmental (usually around 3 mos.) Secondary curves Cervical spine Lumbar spine POSTURAL DEVELOPMENT Factors affecting posture Bony contours Laxity of ligamentous structures Fascial & musculotendinous tightness Muscle tonus Pelvic angle Joint position & mobility POSTURAL DEVELOPMENT Causes of poor posture Positional factors Appearance of increased height (social stigma) Muscle imbalances/contractures Pain Respiratory conditions Typically can be managed conservatively through therapeutic ex & education POSTURAL DEVELOPMENT Causes of poor posture Structural factors Congenital anomalies Developmental problems Trauma Disease Not typically easily managed EXAMPLE: TOTAL SPINAL POSTURE Ideal 1. Head sits straight on shoulders nose in-line c/ manubrium, xiphoid, umbilicus Earlobes in-line with acromion process 2. Shoulders and clavicles level are equal 3. normal appearance of Shoulders 4. Arms equidistant from trunk 5. Normal spinal curves 6. 7. 8. 9. 10. 11. 12. 13. Iliac crests, ASIS’s & PSIS’s . ASIS sit lower than PSIS Gluteal folds and knee joints even Patellae point forward No Genu conditions noted Heads of fibula and all malleoli level Achilles tendons & heels appear to be straight Evident arches GOOD SPINAL POSTURE WHAT IS BAD POSTURE? Any position that deviates from “good posture” Static Standing Sitting Sleeping Dynamic Running Throwing, etc. Correct posture “Position in which minimum stress is placed on each joint.” Faulty posture Any position that increases stress on joints COMMON SPINAL DEFORMITIES LordosisLordosis Excessive anterior curvature of the spine Exaggeration of normal curves in the cervical & lumbar spines COMMON SPINAL DEFORMITIES Lordosis causes: Postural deformity Lax muscles (esp. abs) Heavy abdomen Hip flexion contracture Spondylolisthesis Congential problems Fashion (high heels) COMMON SPINAL DEFORMITIES Swayback deformity : Increased pelvic inclination (40) Typically includes kyphosis COMMON SPINAL DEFORMITIES Kyphosis Excessive posterior curvature of the spine Round back Humpback/gibbus Flat back Dowager’s Hump COMMON SPINAL DEFORMITIES Scoliosis Nonstructural “Functional” May be related to leg length discrepancy Structural Lacks normal flexibility Asymmetric movements COMMONLY SEEN POSTURAL DEVIATIONS Shoulder/Scapula Winging Scapula Head and C-Spine HIPS History Inspection Palpation Special (Functional) Tests RELEVANT HISTORY Identify factors that influence posture Overuse Neurological Problems Pain Lack of awareness Ms weakness/ Imbalance Hypermobile Jts Hypomobile Jts Flexibility Bony Abnormality Leg Length Disc. INSPECTION Use of a plumb line Anatomical reference 3 views Lateral (sagittal plane movements) Anterior (frontal/ transverse plane movements) Posterior (frontal/ transverse plane movements) OBSERVATION Body type Ectomorph Mesomorph Endomorph LATERAL VIEW Look for: @ ankle? @ knee? @ hip? @ shoulder? @ neck? @ head? Anterior view Anterior view Head straight on shoulders Shoulders level Clavicles/AC joints Sternum & ribs Waist angles & arm positions Carrying angles Iliac crests ASIS Patellae Knees Fibular heads Malleoli level Arches Foot rotation Bowing of bones Diastematomyelia (hairy patches) Pigmented lesions Café au lait spots POSTERIOR VIEW Look for: @ heel? @ pelvis? @ lumbar spine? @ scapulae? @ neck? @ head? PALPATION In assessment position (i.e., standing), palpate: Laterally ASIS vs. PSIS Anteriorly Patellae Iliac Crests ASIS heights Lateral Malleolar heights Fibular Head heights Shoulder heights Posteriorly PSIS positions Spinal alignment Scapular positions FUNCTIONAL TESTS Assess muscular length ROM Resting muscle length OTHER TECHNOLOGY Video Analysis 3D Motion Analysis Sway Measurement Tools Force Plate Biodex Stability System NeuroCom