TIS                         

EVALUATING PATIENTS WITH MUSCULOSKELETAL PROBLEMS

THE ROLE OF THE THERAPIST

The Therapist as Clinical Decision-maker

When a patient comes to a therapist with a problem, that patient is expecting the therapist to help alleviate or resolve the problem. To do so, therapists must:

• Understand and clarify the origin and the extent of the patient’s problem;
• Assess the impact of the problem on the various aspects of the person's life;
• Establish a baseline of the patient’s functional ability by accurately measuring and recording significant data;
• Establish patient-centered treatment strategies.

Understand and Clarify the Origin and the Extent of the Problem

Does the therapist know the origin of the problem? Determine the onset, including the mechanism of injury, acquire knowledge of circumstances surrounding the injury (or injuries), the behavior of the problem, the physician's intervention, including surgical procedures, etc. Isolate and determine as much as possible the cause of the problem, and whether other structures are involved.

Assess the Impact of the Problem on the Person's Life

• functional deficits: activities of daily living, work, and leisure;
• acute versus chronic: resolve, alleviate, or adapt.

Establish a baseline of the patient’s functional ability by accurately measuring and recording significant data. This also allows the therapist measures against which to judge progress and assess effectiveness of the treatment.

Establish Patient-centered Treatment Strategies to restore premorbid function as much as possible: incorporating the therapist's knowledge of anatomy, physiology, and interventions into treatments focusing on the patient’s desired outcome(s). The therapist assists with and guides the person's healing process.

THE MUSCULOSKELETAL EVALUATION

To make sound clinical decisions regarding their patients, therapists must follow a structured approach. Part I of the Hypothesis Oriented Algorithm for Clinicians (HOAC) proposed by Ecthernach and Rothstein (1989) provides such a structure for the evaluation of a person with a musculoskeletal problem:

Part I

1. Collect initial data (chart review, history, interview patient/family/others)



2. Generate a problem statement.
   
   
   Establish goals with the patient (measurable and functional with time frames).


3. Perform physical examination (collect data on origin and extent of problem and impact on patient’s life).



4. Generate a working hypothesis about the problem(s).
   
   Correlate and interpret findings of the P.E. to determine a P.T Diagnosis or Occupational Challenge
   
   Refer to other practitioner (if therapist cannot generate a hypothesis)


5. Plan reevaluation methodology (schedule dates for reevaluations)
   
   
6. Plan treatment strategy based on hypothesis (overall treatment approach)
   
   Obtain consultation, if needed.


7. Plan tactics to implement strategy (specifics of treatment plan)



8. Implement tactics (perform treatment)

Collecting Data: The Chart Review:

• Physician's H & P, including the physician's diagnosis*
• Physician's orders
• Medications
• X Ray findings
• Surgery Report**
• Lab findings
• EKG, Respiratory, Nurse's Notes, etc.

* The physician's findings will provide valuable information regarding the diagnosis, past history, and current status of all major systems. Remember that the physician's diagnosis will be somewhat different from your own.

** Knowledge of the surgical intervention is crucial to the evaluation and selection of treatment strategies. Awareness of the anatomy that has been affected by the injury and by the surgery, as well as how the structures heal is central to effective and safe rehabilitation.

Collecting Data: The Patient Interview

The primary goals of acquiring a patient's history are to accurately determine the origin of the person's problem and its impact on the person's life.

Remember to LISTEN to your patient, and let those responses guide your interview. Maitland’s Philosophy of Interviewing Patients (1993):

• Make every effort to be as sure as is possible that you understand what your patient is trying to tell you.
• Be ready to recognize from your patients’ communication any gaps they leave which you the therapist should endeavor to fill by asking appropriate questions.
• Make use of every possible opportunity to use your non-verbal expressions to show your understanding and concern for the patient.

The questions that the therapist asks should be, for the most part, open-ended in that they require more than a yes or no response. This allows patients to describe their circumstances in their own words.

Acquiring information about the patient’s problem:

• What brings you to physical therapy? (if not obvious)

Questions about the patient’s problem follow the LOCIDAA format (Hicks & Kelsey, 1997):

• Location: "Where is it located?" Indicate the primary area of pain.

If the person uses:

• a finger: indicates a small area, no spreading of discomfort, problem probably not severe, relatively superficial, or both.
• the whole hand: diffuse area as primary site : suggests lesion is more severe, more deeply situated, or both
• a moving hand: spreading or radiating of the pain : if along a well-defined pathway : dermatome: probably nerve root problem
• general area, diffuse: most likely referred pain, possibly visceral in origin


• Onset: "How and when did it occur?" (Include a description of the mechanism and position of injury.)
  
  How and when did the problem arise (mechanism of injury and date of onset)?
  • Gradual versus sudden onset
  • Sudden onset.
  • Gradual
  
  
  Position the person was in when the injury was acquired (whether sudden or gradual onset).
  
  Have you started any out-of-the-ordinary activities recently?
  
  
  • Characteristics: "Describe your problem," "How does it feel (pain or other symptoms) and how does it make you feel?" "Does your problem occur at certain times?"
  
  
  
  • Intensity: "How bad is your problem?" (What impact does this problem have on your life? What are you unable to do because of this problem, with respect to all aspects of your life: self-care, home, work, and leisure?) Have the patient rank the problem, using a scale, such as 0 to 10 (give criteria for 0 and for 10, such as 0 = at its best, 10 = at its worst).
  
  
  
  • Duration: "If certain activities cause you pain, how long does it last after you stop the activity ?" "Is it constant, or intermittent?"
  
  
  
  • Aggravating factors: "What makes the problem worse?" "What do you notice this problem to be associate with?" When do you typically feel the pain?
  
  
  
  • Alleviating factors: "What makes the problem better?"

Assess the Impact of the Problem on the Person's Life:

Questions about the person should focus on the activities that the person performs and the environments in which they perform them. The activities should address home, work, and leisure/play and should reflect a typical day for the patient.

• "Tell me about yourself."



• "Tell me about your home life." (What physical activities do they have to perform at home, describe the home environment, is the person married, do they have children. etc.)



• "Tell me about your work." (What physical activities do they have to perform, describe the work environment, etc.)



• "What do you like to do in your spare time?" (Describe the physical activities and their environments related to hobbies, recreation, etc.)



• "Prioritize the activities from each of these areas that you want to return to doing."



• "Describe your ‘typical day’ before your problem and after your problem."

Additional Questions:

• What is it that this problem is keeping you from doing that you want to get back to doing?" This is the patient's Outcome Statement. (Have the patient prioritize those affected activities, from most to least important).



• "Do you have any other problems?"



• "What medications are you currently taking?"



• "Have you had any previous physical therapy?" (If yes, describe; was it successful?)



• "How do you feel right now?"



• "Is there anything else you would like for me to know?"

During the interview and subsequent treatment, therapists continually seek to gather information from their patients. When talking with patients, consider Maitland’s "Keys to Successful Communication" (1993):

Paralleling: the process of following the person’s line of thinking and following-up with related questions.

Keying: pay attention to "key" words that people may use to describe their condition, often without realizing its significance.

THE PHYSICAL EXAMINATION

The goal of the physical examination is compare information from the interview with physical findings, ultimately to identify the origin of a person’s problem and to establish a baseline of the person's functional ability.

The Scanning Examination / Quadrant Screening

Although patients may come to a therapist with what appears to be a joint-specific problem, it is very important that therapists do not develop "tunnel vision." Many patient problems can arise from a central pathology but present themselves with peripheral symptoms. Therapists must view the patient as an entire system, evaluating the patient from a larger, wholistic perspective first, then moving toward a more focused evaluation of what appears to be the problematic area.

The scanning examination should briefly but accurately assess each region of the quadrant.

For the Upper Quadrant / Upper Quarter: the TMJ, cervical spine, scapula, shoulder, elbow, wrist, and hand.

For the Lower Quadrant / Lower Quarter: the lumbar spine, the sacroiliac joint, hip, knee, ankle, and foot.

Beginning therapists should make it a habit to perform the scanning examination on most of the patients that they see. Some exceptions: patients whose surgical status would it inappropriate to perform a scanning evaluation.

Once the therapist has ruled out more central or proximal problems, the therapist can then perform an evaluation more specific to an area. This consists of:

• Observation and Preliminary Palpation
• Range of Motion and Selective Tissue Tension Tests consisting of:
  
  
  • Active ROM
  
  
  
  • Passive ROM for Noncontractile Structures (Joint play, component motions, ligamentous stress tests, and end-feel)
  
  
  
  • Resisted ROM for Contractile Structures
  
  
• Neurological Evaluation
• Mobility consisting of:
  Bed Mobility
  Transfers
  Gait
• Postural Control / Balance
• Special Tests / Differential Diagnostic Tests
• Palpation
• Performance of Functional Activities

Observation and Preliminary Palpation: observe the patient's hygiene, emotional status, body build (slim, obese, cachectic, short stature, etc), vital signs if indicated, deformities, or abnormalities in positioning of body parts. Perform preliminary palpation of the area to evaluate tissue warmth and texture.

Range of Motion and Selective Tissue Tension Tests: consists of specific active, passive, and resisted movement tests that assess the status of each of the component tissues of the physiological joint.

• Noncontractile or inert structures: joint capsule, ligament, bursae, nerves and their sheathes, cartilage, disks, dura mater.



• Contractile structures: muscle and tendon.

Assessing both noncontractile and contractile structures with ACTIVE MOVEMENTS: test the general willingness and ability of the person to move the part as well as overall quality of movement. Pain with active movements suggests an irritated structure is being stretched, being pinched between two structures, or an involved contractile tissue is being used. Note loss of full range of motion, crepitus, pain, movement pattern etc.

Assessing noncontractile structures with PASSIVE MOVEMENTS: tests the range of movement available at the joint, end-feels of the joint, and whether there is pain on movement. Emphasizes assessment of the non-contractile/inert structures at the joint, primarily joint capsule and ligament. A tear in a ligament is a sprain.

Joint Play and Component Motions: small passive motions not under the patient’s control that must be present at the joint to allow full painless voluntary motion. Therapist evaluate these motions when they suspect joint hypomobility and must differentiate between restrictions due to capsular fibrosis versus muscular adhesions.

Ligamentous stress tests: stress the major ligaments of a joint in order to detect loss of ligamentous continuity, which may result in joint hypermobility. The therapist will compare the movement allowed by a ligament with that of the opposite joint, then determine the degree of hypermobility.

End-feel: noted at extremes of painful or restricted movements. End-feel is the quality of the resistance to movement that the examiner feels when coming to the end point of a particular movement. Some end-feels may be normal or pathologic, depending upon the movement they accompany at a particular joint, and the point in the range of movement at which they are felt. Other end-feels are strictly pathologic (Magee, 1997, p.21).

"Normal" End-feels:

• Bony end-feel: an abrupt, hard-feeling stop to movement due to the anatomical structures of the joint limiting motion.
• Soft-tissue approximation end-feel: a soft end-feel where two soft tissue structures contact on another, limiting further motion.
• Tissue stretch end-feel: a rubbery end-feel where a soft tissue limits further motion at a joint.

"Abnormal" End-feels:

• Muscle-spasm end-feel: movement stops fairly abruptly, perhaps with some "rebound" due to muscles contracting reflexively to prevent further movement. Magee (1997) describes an early muscle spasm end-feel as being protective in nature following an injury, and a late muscle spasm end-feel as a result of joint instability.
• Capsular end-feel: this is a firm, "leathery" feeling. Magee (1997) defines this end-feel as soft (indicating synovitis or soft tissue edema) or hard (indicative of capsular fibrosis). Some capsular end-feels are normal.
• MU>Bony end-feel: an abrupt, hard-feeling stop to movement due to a bone fragment in the joint space.
• Empty end-feel: the examiner feels no restriction to movement, the patient stops the movement due to severe pain.
• Springy block end-feel: a pronounced springy rebound at the end point of movement. Typically caused by a mechanical block produced by a loose body or displaced meniscus.

Pain on movement of the joint: pain at the extremes of movement indicates that a painful structure is being stretched or a painful structure is being compressed.

Assessing contractile structures with RESISTIVE MOVEMENTS: these assess the status of musculotendinous tissue. Determines tears or inflammation of a muscle or tendon. A tear in a muscle is a strain.

It is critical that therapists stress the muscle and tendon that they wish to test without stressing non-contractile joint structures. Isolate the specific muscle, and place it in a resting position (usually a midposition). It is important to stabilize the part while stressing/applying resistance.

When performing resisted tests, determine whether the contraction is strong or weak, and whether it is painful or painless. Weakness may be due to a neurologic deficit or actual loss of continuity/tearing of the muscle or tendon; a painful contraction signifies the presence of some pathology involving the muscle or tendon.

Four possible findings on resisted tests:

Strong and painless: no lesion or neurologic deficit involving the tested muscle or tendon.

Strong and painful: a minor lesion of the tested tendon or muscle exists.

Weak and Painful: there may be a partial rupture of the muscle or tendon, or may be the result of painful inhibition of the muscle, as seen with a fracture or neoplasm.

Weak and painless: may be an interruption of the nerve supply to the muscle being tested, correlate with the neurologic test; or there may be a complete rupture of the tendon or muscle (Magee, 1997, p. 23).

Strength Evaluation

Depending on the patient's problem, therapists may choose to evaluate the patient's strength via Manual Muscle Testing (MMT). Indications for performing a MMT to assess muscular strength include:

• Weakness due to disuse/atrophy;
• To determine if postural and/or biomechanical deviations are linked to muscular strength (certain muscles short and strong, others lengthened and weak).

Neurological Evaluation

When assessing neurologic function clinically, if you detect a deficit, you can estimate the approximate site of the pathology by correlating the extent of the deficit with peripheral nerve and segmental distributions.

• Cutaneous Sensory Testing: check along the entire distribution of the dermatomes for changes in sensation to light and deep pressures. Compare bilaterally.
• Strength Testing: check for differences in strength or in quality of contraction. To achieve this, the place the joint in a resting position and apply resistance for five seconds.
• Deep Tendon Reflexes:
  
  Evaluate and compare bilaterally and grade (Magee, 1997, p.36):
  0 - 4 scale:
  
  0/4 = no reflex (lower motor neuron lesion)
  
  1/4 = diminished/sluggish
  
  2/4 = average/normal
  
  3/4 = exaggerated/hyperreflexive
  
  4/4 = pathological/clonus (upper motor lesion)


• Neural Tension Tests: the nervous system attaches to surrounding tissues in such a way that the tissues support the nerves, yet allow for movement of the nerve to occur. Certain pathologies may restrict this movement. Therapists can evaluate neural motion by putting the patient in specific positions (Butler, 1989).
  Mobility
  
  Bed Mobility
  
  Transfers
  
  Ambulation
  
  Coordination of Movement

Postural Control / Balance:

Postural alignment / postural assessment: usually done in the scanning examination. If the patient's problem dictates a more detailed assessment, do it here. Perform a thorough biomechanical examination, looking at static and dynamic alignment.

Balance (Static and Dynamic)

Special Tests / Differential Diagnosis: a number of tests to confirm or rule out problems caused by specific structures have been devised and used by orthopedic physicians and by therapists. These tests apply the concepts of biomechanics with a knowledge of anatomy of the specific structure to implicate or rule out a pathology of a specific structure.

Palpation: should consist of an organized inspection of bony structures, soft tissues, and skin/integument with minimal position changes. Therapists should routinely palpate during many aspects of the physical examination, saving the more pain-provoking palpation until the end of the P.E.


Bony structures: look for bony abnormalities.

Soft tissues: check for edema, wasting or atrophy of muscles, and alterations in the general contours of the region.

Skin and nails: changes in color, changes in texture or moisture, local scars, blemishes, abnormal hair patterns, tattoos, etc.

* Always examine bilaterally, use uninvolved side for comparison.

Performance of Functional Activities

In addition to information provided by the person in regard to limitations as a result of an injury/pathology, the therapist should evaluate and measure the person's ability to perform functional tasks. The tasks evaluated should be those that the person has identified and prioritized. Measure limitations related to the patient’s performance of specific activities that are related to the person’s desired outcome(s).

CORRELATION AND INTERPRETATION OF INFORMATION

The therapist will take the information that the patient has provided in the interview, and correlate it with the findings of the physical examination. Then the therapist determines a physical therapy diagnosis / occupational challenge, sets goals based on the patient’s desired outcome, and devises and implements treatment strategies.

The Occupational Challenge and the Physical Therapy Diagnosis:

Is based on an evaluation that is congruent with our education and licenses, that seeks out history, signs and symptoms using tests we are qualified to use or request (Magistro, Delitto, Guccione, Jette, & Sahrman, 1993).

Names the pathophysiology, primary impairment, functional limitation, and/or disability toward which the OT or PT will direct treatment (Sahrman, 1988).

Therapists determine the pathophysiology or impairment(s) by correlating information from the evaluation (in which they ruled-in or ruled-out certain structures) with knowledge of anatomy, physiology, kinesiology, and pathology. The pathophysiology and/or impairment name the origin and extent of the problem.

The functional limitation and/or disability describe the deficits occurring because of a pathophysiological problem or impairment that effect a person's ability to perform his or her usual activities. Therapists determine functional limitations and disabilities from the history provided by the patient or significant other, as well as by the findings from the physical examination. (Cech & Martin, 1995).

When to Refer the Patient to Another Practitioner

Magee (1997) identifies several "red flag" findings that indicate the need for the therapist to refer the patient to another, more appropriate practitioner:

• Indications of Cancer: persistent pain at night; constant pain anywhere in the body; unexplained weight loss of 10 - 15 pounds or more in 2 weeks or less; loss of appetite; unwarranted fatigue; pain along two or more cervical nerve roots simultaneously; pain along three or more lumbar nerve roots.
• Indications of Cardiovascular problems: shortness of breath; dizziness; pain or a feeling of heaviness in the chest; pulsating pain anywhere in the body; constant and severe pain in the lower leg, calf, or arm; discolored or painful feet.
• Potential GI / GU problems: frequent or severe abdominal pain; frequent heartburn; frequent nausea and vomiting; change in bladder function; unusual menstrual irregularities.
• Possible Neurological problems: changes in hearing; frequent or severe headaches with no history of injury; problems with swallowing or speech; changes in vision; balance problems; fainting spells; sudden weakness.
• Other potential red flags: Fever or night sweats; recent severe emotional disturbances; swelling or redness in any joint with no history of injury; pregnancy.

DOCUMENTATION

Documentation of the initial evaluation should be structured (and follow the systematic approach used in the evaluation), objective (with measurements that can be reproduced), and documented treatment should be such that it can be performed by another therapist.

CONCLUSION

The initial orthopedic evaluation, which consists of a thorough history and physical examination, is but the first step in the treatment process of people with musculoskeletal problems. A reevaluation of the patient’s status should always precede subsequent treatments, addressing many, if not all, of the components addressed in the initial evaluation. Therapists are continuously making clinical decisions based on information they acquire from the evaluation, working to guide the body's healing abilities to help the person regain functional abilities that are important to them.

Table of Typical Findings Associated with Problems of Specific Tissues

Therapists should be alert to patterns of signs and symptoms, as well as key words that the patient may use, which can provide clues to the origin of the patient's problem.




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