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Assessment is actually introduces some important principles of musculoskeletal assessment.

It provides an illustrated guide to many of the important techniques and test that are valuable tools in the arsenal of the chartered physiotherapist. Furthermore it provides some assessment templates for specific joints of the body. The objectives of this assessment are:

To identify the appropriate questions to include in a subjective musculoskeletal assessment. To discuss the use of regional and special question for particular joints. To explain the use of appropriatesubjective and objective markers.

To explain the use of specific and regional tests at particular joints.

To recognise the need for continuos reassessment.

SUBJECTIVE ASSESSMENT
Aims of the subjective assessment is to gather all the relevant information about the site,nature, behaviour and onset of symptoms, and past treatments.Review the patients general health, any investigation, medication and social history.This should lead to a formulation of the next step of physical test. INITIAL QUESTIONING Subjective assessment needs to include the name, adress and telephone number of the patient and the patient hospital number if appropriate. Both the age and the date of birth of the patient should be recorded for correspondance, discharge letters and so on. Physiotherapist obtain sufficient details of the patient,s employment. Identify the patients hobbies or interest. Identify the length of time the patient has been off work or has been unable to participate in physical activities. Evaluate the progression of symptoms. PRESENT CONDITION Area of the symptoms It is useful to record the area of the pain by using body chart because this affords a quick visual reference. The patient may complain of more than one symptoms. The symptoms may be recorded to individually as P1 and P2 and so on. Area of anesthesia nad paraesthesia may be recorded differently on the pain chart. Severity of the symptoms Measured on a visual analogue scale or on a numerical scale of 0-10 to quantify the pain 0 stands for no pain at all and 10 is perceived by the patient as the worst pain imaginable.

Duration of the symptoms Establish whether the pain and symptoms are intermittent or constant. Is the pain present all the time or does it come depending on activities of time a day.

AGGRAVATING AND EASING FACTORS Positional factors Aggravating and easing movement may provide the physiotherapist with a clue as to the structure that is causing pain.

The aggravating and easing factors can be recorded on the pain chart.

It is also necessary to record the lenth of time that engaging in aggravating activities produces an increase in symptoms or alternatinely takes to settle down. This indicates the irritability of the patients condition. Time factors Useful to record the behaviour of signs and symptoms over a 24-hours period.-the diurnal pattern. Be careful not to confuse time of day with the performance of particular activities that the patient may undertake at the time. Certain pathologies tend to be more painful at characteristic times of day. Prolonged morning stiffness and pain, which improves only minimally with movement, suggest an inflammatory process.

DETERMINING THE SIN FACTORS


Once the severity of the symptoms and the aggravating and easing factors

have been noted, it is then possible to determine the SIN factors of the condition It is use to guide the length and firmness of the objective assessment and subsequent treatment.

Severity This can be quantified by the visual analogue scale, numerical scale or other valid pain questionnaire. It can be recorded as high (7-10), moderate (4-6) or low (1-3) Irritability The person has to perform the activity to increase the pain, and conversely how long it takes before the pain settles to its farmer intensity. Can be measured as high ( aggravating factors cause the pain to increase very quicklyand pain takes long time to settle down ), moderate ( aggravating factor takes longer to to increase the symptoms ) or low ( aggravating factor can be performed for a long time before exacerbating the patients symptoms and stop the activity the symptoms subside rapidly ).

Nature Hypothesise the nature of the condition following the subjective history.

HISTORY OF THE PRESENT CONDITION Insidious onset- the patients symptoms appear without any obvious cause. Traumatic onset can the onset of symptoms be related to a particular injury. Progression of the condition- are the patients symptoms getting better or worse? Chronicity or age of the condition- how long has the patient experienced the symptoms? Previous treatment- has the patient received any treatment for this condition in the past, and if so was effective? Investigation X-rays, MRI scans, CAT scans and bone scans. Blood test Past Medical History

Determine whether or not the patient is sufferingor has suffered any major operations or illness. Medication Analgesics (painkiller) such as paracetamol and cocodamol Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen Skeletal muscle relaxants such as diazepam and baclofen.

OBJECTIVE ASSESSMENT
Objective assessment aims to seek abnormalities of function, using active, passive, resisted, neurological and special test of all the tissues involved.This may be guided by the history. Objective examination is concerned with performing and recording objective sign. It aims to: Reproduce all or parts of the patients symptoms

Deterdetermine the pattern,quality, range, resistance and pain response for each movement.

Identify factors that have prediposed or arisen from the disorder Obtain sign on which to reassess the sffectiveness of treatment, by producing reassessment arterisks or marker. GENERAL OBSERVATIONS Observe the persons gait and general demeanour on entering the department. Local Observation

Note any swelling at the joints. Measured with a tape measure around the joint or limb circumferences. Note any asymmetry of musculature,deformity,and malignment of the joints. Posture Observe any asymmetry of posture in standing, walking, and sitting. Palpation Palpate tenderness, heat, swelling, and muscle spasm.

ASSESSMENT OF MOVEMENT Active movement Movement performed by the patients voluntary muscular effort. Passive movements Movement performed by an external source, such as the physiotherapist or pulley system. Physiological passive movements- performed actively by patient. Accessory movements- cannot performed actively by patient. Resisted movements These are performed againts the resistant of the physiotherapy or weights by the patients own effort.

SPECIAL TEST
ANTERIOR LIGAMENTS- Fabers test Aim: to examine the tightness of sacroiiliac ligaments. Tecnique: tphysiotherapist push the leg downward just proximal to the knee joint whilst stabilising the opposite hip with the other hand. Positive: if pain at the sacroilliac part. Negative: if pain at the groin area may be due to hip joint problems.

STRAIGHT LEG RAISE (SLR) Aim: to examine the sciatic nerve problem. Technique: physiotherapist lifts the patients leg whilst maintaining extension of the knee. Positive: if patient feel pain below 70 degree flexion of hip. Negative: if patient feel pain which range normally 80-90 degree.

PRONE KNEE BEND (femoral nerve stretch) Aim: examine the femoral nerve tightness Technique: physiotherapist flexes the persons knee and then extends the hip Positive: Pain at the back or distribution of femoral nerve Negative: if pain at the anterior part may due to quadriceps tightness.

SLUMP TEST Aim: to examine the stretch of the dura matter. Technique: patient sits with thighs fully supported with hands clasped behind the the back. The patient is instructed to slump the shoulders towards the groin. Physiotherapist apply gentle overpressure to this trunk flexion. The patient add the cervical flexion, which is maintained by the therapist. The patient then performed unilateral active knee extensionand active ankle dorsiflexion. Physiotherapist should not force the movement. The non-affected side should be assessed first. Positive: The patient is instructed to extend the head.If the pain or symptoms reduce it show the dura matter is tethered.

VERTEBRAL ARTERY TESTING Aim: to determine between vestibular and VBI symptoms. Technique: Physiotherapist fixes the patients head and the patient keeps the feet static and facing forwards.The patient then rotates his or her body to the right and to the left whilst maintaining the head in static position.

Positive: symptoms such as dizziness or light headedness (vetebral artery problem) Technique: The patient stands and rotate the cervical spine to the right and left. Positive: if patient feel pain problem with vestibular.

IMPINGEMENT TEST Aim: to found supraspinatis Technique: 90 degree of abduction bilaterally,full available medial rotation,and 30 degree of horizontal flexion. Physiotherapist resists abduction of the shoulder. Positive: if patient feel pain the supraspinatus tendon is injured.

THOMAS TEST Aim: determines the presence of fixed flexion deformity at the hip. Technique: Patient supine,the hip is fully passively flexed, and the lumbar lordosis is obliterated.

Positive: if the opposite hip rises off the bed this indicates a fixed flexion deformity of that hip.

MODIFIED OBERS TEST (iliotibial band ) Aim: to examine the tightness of illiotibial band Technique: Patient in side lying and the uppermost hip fully laterally rotated,the knee joint in unlocked extension, the uppermost leg should drop (adduct ) to the plinth. Positive: the leg not being able to adduct to the plinth. Negative: the uppermost leg should drop (adduct ) to the plinth.

PIRIFORMIS TEST Aim: to examine the tightness in piriformis muscles. Technique: Patient supine, or side-lying, with hip at 90 degree flexion, adduct maximally to resistance and externally rotate.

Positive: Pain in the buttocks or distribution of the sciatic nerve.

HAMSTRINGS Aim: find hamstring tightness Technique: Patient sitting, spine in neutral, the hip at 90 degree,the person should be able to extend the knee to within 10 degree of full extension. Positive: lumbar goes flat.

TRENDELENBERG TEST Aim: to test the hip abductors functioning

Technique: Patients stand on the unaffected leg and flexes the other knee to a rightangle.The pelvis should remain level or tilts up slightly on the non weight bearing side.The patient then stands on the affected leg and flexes the knee of the other leg. Positive: pelvis drop on the NWB side this signifies a positive Trendelenberg test.

VALGUS STRESS TEST ( medial collateral ligament of the knee ) Aim: to examine the medial collateral ligament injury Technique: physiotherapist apply a valgus force to the knee joint (the femur is pushed medially and the leg pulled laterally) whilst the joint is held in extension Positive: excessive opening up on the medial side of the joint.

VARUS STRESS TEST (lateral collateral ligament of the knee) Aim: to examine lateral collateral ligament injury

Technique: patient supine, physiotherapist applies varus force to the knee joint Positive: excessive opening up on the lateral side of the joint.

ANTERIOR DRAW TEST (anterior cruciate ligament) Aim: to examine anterior cruciate ligament injury Technique: patient crook lying, physiotherapist sits on the patients foot to stabilise the leg and grasps around the proximal tibial tuberosity and pulls the tibia forwards. Positive: excessive translation of the tibial anteriorly

POSTERIOR DRAW TEST (posterior cruciate ligament) Aim: to examine posterior cruciate ligament injury

Technique: patient crook lying, physiotherapist sits on the patients foot to stabilise the leg and grasps around the anterior aspect of the proximal tibia, and pushes the tibia backwards Positive: excessive translation of the tibia posteriorly.

McMurrays medial and lateral meniscus tests: Aim: to examine the minisci problem Technique:The physiotherapist palpates the medial aspect of the joint line,and passively flexes and than laterally rotates the tibia. Positive:Pain is elicited or a snap or click of the joint will occur if the meniscus is torn.

Apleys compression/distraction test(for differentiation between meniscus and ligament): Aim: to examine the minisci problem

Technique:The patient is prone with the knee flexed at right-angles.The physiotherapist medially and laterally rotates the tibia whilst applying a distraction force through the knee joint.The test is repeated by applying a compressive force through the knee joint. Positive:If patient pain when compression,it is meniscus injury,if patient pain when distraction,it is ligamentous injury.

THOMPSONS SQUEEZE TEST Aim: test the integrity of the gastrocnemius/soleus Achilles tendon complex Technique: With the patient prone, the physiotherapist squeeze the calf firmly just distal to its maximum circumference.If the tendon is intact, the foot will plantarflex. Positive: if the tendon or muscle is ruptured and the ankle will not plantarflex.

DROP ARM TEST Aim: to find the rotator cuff tear

Technique: patient in standing.Abduct the shoulder passively and leave it. Positive: Patient cannot maintain position abducted shoulder and drop it.

ERGASONs TEST Aim: assess for pathology in long head of biceps tendon in its sheath. Technique: patient elbow is flexed and forearm pronated fully. Patients hold their arm at wrist. Patient actively supinates againts resistance Positive: pain located to bicipital groove area suggests pathology in the long head of biceps in its sheath.

LACHMANNS TEST ( ANTERIOR DRAWLTRANSLATION )

Aim: for examining the anterior cruciate ligament (ACL) in the knee for patients where there is a suspicion of a torn ACL. Technique:The patient supine and the patients arm at around 30 degrees of abduction,45 degree of lateral rotation and slight flexion .Physiotherapist grasps the humeral head with one hand and the medial hand is used to stabilise the shoulder girdle.The lateral hand applies the anterior draw test of the knee. Positive: Laxity of the joints or excessive movement compared with the other side is positive sign.

FORMULATIONS PROBLEM LIST

GOALS Short term goals - the problems need short treatments and most problematic (pain relief) Long term goals- problems need long duration treatment (severe stiffness of joint)

TREATMENT PLAN Ultrasound for biceps Demonstrate HOME PROGRAME Do and donts Exercise that patient can do himself without supervision

CONCLUSION