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 TESTINGAROM

Contraindications:

immature fracture sites

newly repaired

Cardinal Planes (test all planes of ROM)

Painful ARC

compression within range

FUNCTIONAL TESTINGPROM

Quantity of available movement

“End feel” reach limit of available ROM

Most accurate method is with goniometry measurements

NORMAL END FEELPHYSIOLOGICALHard 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 FEELPATHOLOGICAL

SoftSoft tissue edema

synovitis

FirmCapsular,muscular, ligamentous shortening

Hardosteoarthritis

Fracture

EmptyBursitis, Joint inflammation

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 Pain Finding Good None Normal

Good Present Minor soft tissue

injury

Weak Present Major injury

Weak None Neurological or Rupture or

Chronic

LIGAMENTOUS AND CAPSULAR TESTINGLigamentous 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 TESTINGBilateralDermatone Area of skin innervated by a single nerve root

Slight stroke over area/pin prickSharp v. dullHot v. cold

Motor TestingManuel 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 postureBony contoursLaxity of ligamentous structuresFascial & musculotendinous tightnessMuscle tonusPelvic angleJoint 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

1.1. Head sits straight on Head sits straight on shoulders shoulders nose in-line c/ nose in-line c/

manubrium, manubrium, xiphoid, umbilicusxiphoid, umbilicus

Earlobes in-line Earlobes in-line with acromion with acromion processprocess

2.2. Shoulders and Shoulders and clavicles level are clavicles level are equalequal

3.3. normal appearance of normal appearance of ShouldersShoulders

4.4. Arms equidistant from Arms equidistant from trunktrunk

5.5. Normal spinal curvesNormal spinal curves

6.6. Iliac crests, ASIS’s & Iliac crests, ASIS’s & PSIS’s .PSIS’s .

7.7. ASIS sit lower than PSISASIS sit lower than PSIS8.8. Gluteal folds and knee Gluteal folds and knee

joints evenjoints even9.9. Patellae point forwardPatellae point forward10.10. No Genu conditions No Genu conditions

notednoted11.11. Heads of fibula and all Heads of fibula and all

malleoli levelmalleoli level12.12. Achilles tendons & Achilles tendons &

heels appear to be heels appear to be straightstraight

13.13. Evident archesEvident 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 LordosisLordosisExcessive 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

KyphosisExcessive posterior curvature of the spineRound backHumpback/gibbusFlat backDowager’s Hump

COMMON SPINAL DEFORMITIES

ScoliosisNonstructural“Functional”May be related to leg length discrepancy

StructuralLacks normal flexibilityAsymmetric movements

COMMONLY SEEN POSTURAL DEVIATIONS

Shoulder/ScapulaWinging Scapula

Head and C-Spine

HIPS

History

Inspection

Palpation

Special (Functional) Tests

RELEVANT HISTORY Identify factors that

influence posture

OveruseNeurological Problems

PainLack of awareness

Ms weakness/ Imbalance

Hypermobile JtsHypomobile JtsFlexibilityBony AbnormalityLeg Length Disc.

INSPECTION Use of a plumb line

Anatomical reference3 views

Lateral (sagittal plane movements)

Anterior (frontal/ transverse plane movements)

Posterior (frontal/ transverse plane movements)

OBSERVATION Body typeEctomorphMesomorphEndomorph

LATERAL VIEW

Look for:@ ankle?@ knee?@ hip?@ shoulder?@ neck?@ head?

Anterior view Head straight on shouldersHead straight on shoulders Shoulders levelShoulders level Clavicles/AC jointsClavicles/AC joints Sternum & ribsSternum & ribs Waist angles & arm Waist angles & arm positionspositions

Carrying anglesCarrying angles Iliac crestsIliac crests ASISASIS PatellaePatellae KneesKnees Fibular headsFibular heads

Malleoli levelMalleoli levelArchesArchesFoot rotationFoot rotationBowing of bonesBowing of bonesDiastematomyelia (hairy Diastematomyelia (hairy

patches)patches)Pigmented lesionsPigmented lesions

Café au lait spotsCafé au lait spots

Anterior view

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

PosteriorlyPSIS positionsSpinal alignmentScapular positions

FUNCTIONAL TESTS

Assess muscular length ROM Resting muscle length

OTHER TECHNOLOGY

Video Analysis

3D Motion Analysis

Sway Measurement Tools

Force PlateBiodex Stability SystemNeuroCom