UE Physical Therapy Evaluation

what does the patient history do?

it should tell us 80-90% of what is wrong with the patient to help determine what examination is needed

what are the steps of clinical reasoning?

1. patient history

2. initial clinical hypothesis

3. screening examination

4. focused examination

what does the history/subjective examination tell us?

Severity: rate pain 0-10 (describing ten as the worst imaginable pain); how the pain affects their daily life/how limiting it is

Irritability: how quickly it comes on and how long it takes to ease

Nature of symptoms: annoyance, impairment, or disability; what you think may be going on; what tissue is the issue

Stability of disorder: getting worst, better, or staying the same

Stage of disorder: acute (goal is pain management), subacute, chronic (goal is general exercise)

Pain mechanism: nociceptive (MSK issue), neurogenic (nerve issue), nociplastic (pain that doesnt fit a clearcut pattern)

what is ECHOWS?

a framework used to assess the effectiveness of physical therapy student patient interviews

what are the components of ECHOWS?

E: establish rapport/therapeutic alliance

C: chief complaint

H: health history

O: obtain psychosocial persepective— how it is affecting their daily life

W: wrap up the interview asking “what other questions do you have for me or is there something I didnt ask that you would want me to know”

S: interviewing skills

what skills are evaluated during the S part of ECHOWS?

• attending to patient comfort

• avoiding jargon

• maintaining interview flow

• checking for patient understanding

• documenting without disrupting interaction

what is our goal when doing the upper quarter screen and considering differential diagnosis?

not to diagnose the condition but to decide whether it is safe and appropriate to continue with a physical therapy examination

what are the possible mechanisms of viscerogenic pain?

• convergence of visceral and somatic afferents in the spinal cord

• visceral-somatic cross sensitization

• shared neural pathways and spinal segment overlap

discuss hoffmans test

purpose: to screen for a possible upper motor neuron involvement related to cervical spinal cord pathology

procedure: flick the distal phalanx of the middle finger while holding it into extension

positive test: reflexive thumb flexion and or index finger flexion

how can we interpret a positive hoffmans sign?

• it may suggest cervical spinal cord compression, cervical myelopathy, or upper motor neuron involvement

• however, it should not be used as a stand alone diagnostic test, rather being interpreted within the full neuro screen

• consider additional findings such as hyperreflexia, clonus, gait distrubance, balance changes, or bilateral symptoms

when should a positive hoffmans raise concerns?

• progressive neuro symptoms

• bilateral hand symptoms

• loss of dexterity

• gait changes

• bowel/bladder changes

• consider medical referral for possible cervical myelopathy

what is the question we shoudl ask ourselves every visit?

does this person belong in my clinic?

when a patient presents with upper quarter symptoms, our first responsibility is _______ not just examination. therefore, what should be our steps to dtermine what to do?

clinical decision making

1. listen to the patient

2. screen for red flags

3. screen for the neurological system

4. decide the next steps: treat if MSK, expand screening if unsure, refer out if red flags

what is the referral pattern and possible signs and symptoms of the respiratory system?

• cough, sputum, blood and sputum

• chest pain

• pain with deep breathing

• body sweats, itching

• cyanosis or clubbing of fingernails

• history of smoking, pulmonary disorder

• sinus/facial pain

• loss of smell, nasal discharge, nose bleeds

• difficulty breathing, wheezing, shortness of breath, snoring

• foul odor

what is the referral pattern and possible signs and symptoms of the ears, nose, throat, and mouth?

ears

• change in hearing

• ringing in ears

• ear pain/discharge

• vertigo

• masses/lumps

nose

• sinus/facial pain

• nosebleed or nasal discharge

• itching

• post-nasal drip

• difficulty breathing

• loss of smell or foul odor

throat/mouth

• change in voice/hoaseness

• sore throat or pain when swallowing

• jaw pain

• sores/ulcers

• difficulty swallowing

• masses/lumps

• tooth pain

• gum bleeding

what is the referral pattern and possible signs and symptoms of the MSK system?

referal pattern will be localized pain to the area of interest

signs and symptoms

·      Reproducible pain or symptoms

·      Tenderness to palpation

·      Swelling or tightness

·      Positive special tests

·      Visible deformities or gait abnormalities

·      History of MOI

·      Pain described as aching, soreness, tightness, dull (no concerning descriptors like boring or deep pain)

·      Limitations in ROM and MMT

·      Pain that is relieved with rest and worse with activity

what is the referral pattern and possible signs and symptoms of the lymphatic system?

• abnormal bruising

• weight changes or fatigue

• growths, lumps, bumps

• limb edema

• abdominal or left shoulder pain

• changes in skin color or nails

• heart palpitations

• history of cancer or blood transfusions

what is the referral pattern and possible signs and symptoms of the GI system?

• difficulty or painful swallowing

• indigestion/heartburn

• excessive burping or passing of gas

• change in appetite or food intolerance

• nausea/vomiting

• abdominal pain/distention

• change in skin color

• skin changes like rash or itching

• change in urine color

• consitpation or diarrhea

• change in bowel habits

• change in stool color

• rectal bleeding or pain with defecation

• history of GI disorders

what is the referral pattern and possible signs and symptoms of the genitourinary and reproductive systems?

• Genitourinary

  • Painful or burning with urination (dysuria)

  • Change in urinary frequency (decreased, excessive, urination at night)

  • Change in urinary control (incontinence, urgency, difficulty initiating)

  • Change in urinary flow or force

  • Blood in urine (hematuria)

  • Change in urine color

  • Suprapubic pain

  • Flank pain

  • History of genitourinary disorders (urinary tract infections, kidney infections/stones etc)

• Reproductive

  • Male

    • Discharge or sores on penis

    • Testicular/scrotal pain, swelling or masses

    • Painful intercourse/ejaculation

    • History of sexually-transmitted infection

  • Female

    • Vaginal discharge, sores, masses

    • Breast pain, swelling, warmth or redness

    • Nipple pain or discharge

    • Painful intercourse

    • Menstruation (frequency, length of cycle, dysmenorrhea)

    • History of pregnancy and delivery

    • Menopause (peri/postmenopausal vaginal bleeding)

    • History of sexually-transmitted infection

what is the referral pattern and possible signs and symptoms of the neurologic system?

• Changes in mood, attention, or speech

• Changes in orientation, insight, or judgement

• Memory changes

• Headache

• Lightheaded or dizziness or fainting

• Vertigo

• Changes in vision or hearing

• History of head or spine trauma

• Numbness, tingling, or weakness

• Paralysis

• Fall or change in balance

• Tremors

• Intentional movements

• Seizures or loss of consciousness

• Change in bowel or control of bladder

• Change in muscle tone or loss of muscle

• History of; neurological disease, recent surgery, or cancer

what are possible signs and symptoms of possible psychiatric problems?

• Client feels sad, depressed or anxious much of the time

• Alcohol or drug use/abuse

• Changes in memory, confusion, etc

• Nervousness, tension, irritability or sudden changes in mood

• Changes in personal habits (appetite, bathing, self-care, etc.)

• Suicidal ideations or intent to harm self or others

• Stress levels

• Sleep disturbance

• History of mental health illness or treatments

what is the referral pattern and possible signs and symptoms of the immune system?

• Food allergies

• Seasonal allergies

• Swollen lymph nodes

• Anaphylaxis or allergic reactions

• Frequent infections

• Changes in skin or nails

• Fever, chills, night sweats, weight changes, fatigue or malaise

• Joint or muscle pain, swelling, stiffness, weakness

• Recent travel

• History of HIV/AIDs

• History of cancer

• History of known rheumatological or autoimmune disorder

what are possible signs and symptoms of possible eye problems?

eye pain

red eyes

dry/teary eyes

itching eyes

eye discharge

blurred vision

double vision

loss of vision

what are possible signs and symptoms of possible integumentary problems?

skin

• rashes, lumps, sores, lesions, wounds

• itching, sweating, dryness, or changes in color

• easily bruised

• changes in color or size of moles

• history of known skin disease

hair

• decrease or increase in hair growth or quality

• history of thyroid disease

nails

• change in nail beds

what is the referral pattern and possible signs and symptoms of the cardiovascular system?

• chest pain/heaviness/discomfort

• palpitations or irregular heartbeat

• fatigue

• lightheadedness, dizziness, or fainting

• severe sudden headache

• difficulty talking or swallowing

• double vision

• pulsating or throbbing pain

• shortness of breath

• high or low blood pressure

• limb pain, swelling, or discoloration

• limb pain during activity

• wound/ulcers in legs or slow to heal

• history of CV disease

what bones make up the shoulder girdle?

scapula, humerus, and clavical

what joints make up the shoulder girdle?

scapulothoracic, GHJ, acromioclavicular, sternoclavicular

where do we have the most passive support at the shoulder?

anteriorly and superiorly

where is the only place the shoulder girdle attaches to the rest of the body?

sternoclavicular joint— so it is very stable and cable of withstandings lots of force

what is the significance of the open packed position of the shoulder?

it allows for more movment of hte joint which can be helpful when trying to facilitate movement of ajoint without stressing the end range of tissues when one may be more irritable, making grade 1 and 2 mobilization more applicable. however, it needs more muscular support to stabalize

what is the significance of the closed packed position of the shoulder?

it creates more stability of the joint and brings tissues to end range which can be helpful when trying to stress stiff tisssues that are limiting motion, making grade 3 and 4 mobilizations more applicable. requires more passive stability support

what is the open and closed packed positions of the GHJ?

open: about 40 degress of abduction and 30 degrees of flexion witht he weight of the arm supported

closed: full abduction and ER

what is the open and closed pack position of the sternoclavicular joint?

open: standard anatomical position

closed: maximal posterior rotation (with the shoulder fully flexed)

what is the open and closed pack position of hte acromioclavicular joint?

open: standard anatomical position

closed: greater than 90 degrees of shoulder abduction

what makes up the arthrokinematics of the GHJ?

inert tissue (bones, capsules, and ligaments) + contractile tissue

what are the osteokinematics of the shoulder?

flexion: 0-180

abduction: 0-180

extension: 0-60

IR: 0-70

ER: 0-90

horizontal abduction: 0-45

horizontal adduction: 0-135

what allows for full flexion and abduction motion of the shoulder?

scapulohumeral rythm— the first 120 degrees comes from the GHJ while the remaining 60 degrees is achieved through scapular and clavicular upward rotation

what should the sum of shoulder IR and ER equal?

160 degrees

because of the acriomoclavicular joint, the scapula and clavicle move together how?

1. muscles move the scapula

2. the scapula pulls the clavicle along for the ride via the AC joint

3. the clavicle moves on the fixed sternum at the SC joint

what is happening at the clavicle during scapular upward rotation, elevation, and posterior tilt?

upward rotation (the distal end of the clavicle moves superiorly)

what is happening at the clavicle during scapular downward rotation, depression, and anterior tilt?

downward rotation (the distal end of the clavicle moves inferiorly)

what is happening at the clavicle during scapular protraction (abduction) and internal rotation (winging)?

protraction (distal end of the clavicle moves anteriorly)

what is occuring at the clavicle during scapular retraction (adduction) and ER?

retraction (distal end of the clavicle moves posteriorly)

our scapulohumeral musles serve to stabalize and move the GHJ. what are these muscles?

supraspinatus, infraspinatus, teres minor, and subscapularis

our scapulohumeral movers serve to produce strong movement at the GHJ. what are these muscles?

deltoid, teres major, biceps brachii, triceps brachii, coracobrachialis

our axioscapular muscles serve to stabalize and move the scapulothoracic joint. what are these muscles?

pec minor, serratus anterior, trapezius, levator scapulae, rhomboid major, rhomboid minor

our axiohumeral muscles are powerful movers of the shoulder girdle. what are these muscles?

pectoralis major and latissimus dorsi

what muscles are important in stabalizing our shoulder girdle against gravity?

rotator cuff

when do we care about static position of the shoulder girdle?

1.The patient’s functional limitation is related to a static position.

2.The patient’s pain changes when the static position is changed.

3.The patient’s static positions impacts tissue healing.

4.The patient cares about it.

what is the ideal position of the scapula?

• positioned between T2-T7

• medial border is parallel to the spine

• medial border is around 3 inches from the spine

• rests against the thorax

• no tilting or winging

what is the ideal position of the clavicle?

AC joint should be higher than the SC joint

what is the ideal position of the humerus?

• humeral head is no more than 1/3 anterior of the acromion

• olecranon faces posteriorly

• humeral shaft is parallel with the trunk