Written exam

What is the purpose of a subjective examination?

Obtain sufficient information about a persons symptoms, goals and medical history to be able to plan efficient, effective and safe physical examination and treatment

What are questions you might ask in a subjective examination?

• what are they seeking help for from you?

• what are their goals?

• can you help them?

What are the main components of a subjective assessment?

• patient information

• body chart

• behaviour of symptoms

• history of presenting complaints

• special/ screening questions

• social history

• family history

• interests

• patient perspective

• previous experiences with physiotherapy

• flags

Patient information

age, gender, occupation

Body chart

• Where are the main areas of symptoms (if more than 1 area, marks P1, P2, P3. Tick areas that are pain free)

• Other symptoms related to the main area of symptoms (p&n, numbness, referred pain. Note presence or absence of it)

• Severity and superficial or deep 

• Constant/intermittent/variable 

• Nature of symptoms (sharp/dull/throbbing/pulling)

• Other areas of body with symptoms 

• Relationship of all symptom areas 

Behaviour of symptoms

• aggravating factors

• easing factors

• 24-hour pattern

• irritability

• status

Special/screening questions

• General health (GHx)

• Loss of weight (LOW) and/or history of cancer (Hx Ca)

• Night pain 

• Major illness/injuries/surgeries 

• Current medications 

• Corticosteroid use 

• Anticoagulants 

• Body mass index 

• Physical activity (PA) levels 

• Imaging (X-ray, CT, MRI, bone scan)

• Blood tests  

Flags

• Orange - mental health factors 

• Yellow - psychological factors 

• Blue - social factors 

• Black - litigation and threats to financial security 

When does manual handling occur?

When any person, animal or object is:

• lifted or lowered

• pushed or pulled

• carried

• moved

• held

• restrained

What is hazardous manual handling?

• repetitive or sustained application of force, awkward posture or movement

• Application of high force

• exposure to sustained vibration

• Manual handling of live persons or animals

• manual handling of loads which are unstable, unbalance or difficult to grasp or hold

What is the aim of manual handling techniques?

Protect ourselves from injury and protect person/object you are handling from injury/damage

How to minimise risk of manual handling?

• identify the hazard

• assess the risk

• use hierarchy of control strategies

• monitor and review the control measures

What is masssage?

Is a mechanical stimulation of tissues by means of rhythmically applied pressure and stretching

Why is massage used?

• increase flexibility, coordination, venous return and blood flow

• to reduce muscle spasm

• to promote relaxation

• to decrease neuromuscular excitability and pain

• to stimulate circulation

• to facilitate healing and restore joint mobility

• to remove lactic acid and oedema

When is massage indicated?

• increase range of motion

• stretch scar tissue/ ahdesions

• alleviate muscle cramps

• decrease pain

• remove edema

• increase blood flow

When is massage contraindicated?

• acute contusions

• acute inflammatory conditions

• severe varicose veins

• open wounds/ abscesses

• failed or incomplete fracture healing

• thrombophlebitis and embolisms

What are the massage techniques?

• Stroking

• effleurage

• petrissage

• kneading

• tapotement

• friction

• trigger point

What are the components of an objective assessment?

• Observation

• Palpation

• Functional movements

• Active range of movement

• Passive range of movement

• Muscular system

• Nervous system

• Special tests

• Clearing tests

What are functional movements?

Asking patient to do activities that reproduce the pain or symptoms e.g. walking, running, jumping or hopping

Active range of motion (AROM)

assessing the patients ability to actively move limb themselves

Passive range of motion (PROM)

movement produced by the therapist while the patient remains relaxed

Isotonic

Muscle changes length during contraction. Movement occurs.

Isometric

Muscle contracts without movement. Position held against resistance.

What are the clinical indication of cold therapy?

• Acute injuries

• Post surgery

• pain

• Pain due to muscle spasm

• spasticity

• Change muscle responsiveness

• Inflammation

What are the contraindications of cold therapy?

• Cardiovascular diseases

• High blood pressure

• Cold hyposensitivity 

What are the benefits of cold therapy?

• Reduce inflammation

• Accelerate muscle recovery 

• Ease the soreness of the muscle 

What are the risk factors of cold therpay?

Rapid increase in heart rate and blood pressure 

What are the contraindication of heat therapy?

• Sensation issues 

• Cardiovascular conditions 

• Open wounds 

What are the benefits of heat therapy?

• Relieve pain 

• Reduce pain tension 

• Improve muscle flexibility 

What are the risks of heat therapy?

Burns

What is clinical reasoning?

Is the process of deciding which factors are relevant to a patients presenting problem, then deciding what to do about them

Why is clinical reasoning important?

• each person we assess/treat is unique

• clinical guidelines and results can only provide general guidelines to strategies of assessment and treatment

• clinicians must then use their own clinical reasoning skills to determine how best to proceed with each patient

What are the 3 models of clinical reasoning?

• WHO ICF

• Intervention Process Model

• Collaborative reasoning model (hypothesis categories)

Hypothesis categories

1. Activity & participation capability & restriction

2. Patients’ perspectives on their experiences & social influences (psychosocial status

3. Pain type

4. Sources of symptoms

5. Pathology

6. Impairments in body function or structure

7. Contributing factors to the development & maintenance of the problem

8. Pre-cautions & contraindications to physical examination and treatment

9. Management/treatment selection and progression

10. Prognosis

Pain types

• nociceptive

• neuropathic

• nociplastic

Nociceptive pain

pain that is associated with actual or threatened damage to non-neural tissue and involves the activation of peripheral nociceptors e.g. inflammatory and mechanical pattern, clear aggravating and easing factors

Neuropathic pain

pain associated with a lesion or disease of the somatosensory nervous system e.g. sharp, burning sensation, pins and needles and numbness

Nociplastic pain

Nociplastic pain is pain that continues even when there is no clear tissue damage and no obvious nerve injury.

What is a problem list?

It is a list of problems that may require treatment, management or re-assessment

What does a problem list help with?

It helps to plan and guide your patients management plan and prognosis

How to develop a problem list?

Subjective examination findings: activity restrictions, participation restriction

Physical examination findings: physical impairments

How to make goals SMART?

• Specific: Well defined, clear, and unambiguous

• Measurable: specific criteria that measure progress towards the accomplishment of the goal

• Achievable: Attainable and not impossible to achieve

• Realistic: Within reach, realistic, and relevant to your life

• Timely: With a clearly defined timeline, including a target date

• SMART goals need to be written in one sentence

What are outcome measures?

An outcome measure is a measure or tool, to assess a person’s current or future health status and demonstrate the effectiveness of an intervention or treatment

What are the stages of healing?

• Days 0-5: inflammatory period

  • Days 0-2: vascular phase (new capillaries, re-innervation)

  • Days 3-5: Cellular phase (lymphocytes, macrophages)

• Days 6-21: proliferation period

  • Fibroblasts start to form new collagen

  • Takes 21 days to reach full repair of collagen

• 22 days onwards: organisation period and maturation phase

What are the stages of tissue healing?

• homeostasis and inflammation - days 2-3

• proliferation (fibroblastic) - days 3-5 lasts 2-4/52

• remodelling (maturation) - days 21 to 12 months

Factors that affect healing

• severity of injury

• vasculation of tissue and circulation

• age

• drugs

• surgical repair

• infection

• nutrition

• immobilisation

• general health

• treatment

Factors affecting how we prescribe exercises

• How severe was the injury/surgery?

• Stage of healing

• What are the current pain levels?

• Patient goals e.g. return to sport/ work

• What factors do you want to work on? E.g. neuromuscular/motor control, range of motion, strength, endurance, power, muscle length, combination of these factors

• Muscles involved e.g. fast twitch/phasic or slow twitch/tonic

• What is the function of the muscle within the body?

• Baseline activity levels

What is irritability?

the measure of how easily a patient's symptoms are aggravated, the intensity of those symptoms, and how long they take to subside

What is a hazard?

any agent, condition, or situation with the potential to cause harm, damage, or adverse health effects to humans, property, or the environment

What is a risk?

risk is the likelihood and severity of the hazard actually occurring

Types of hip pain

1. hip oesteoarthritis

2. extra articular hip tendinopathies

3. hip related pain (non-OA)

What is hip osteoarthritis (OA)?

Osteoarthritis (OA) is a clinical syndrome characterised by joint pain, varying degrees of functional limitation, and reduced quality of life. It develops as a response to joint injury, which may result from repeated microtrauma over time or a significant single insult. Physiologically, OA involves the progressive loss of articular cartilage, remodelling of the underlying bone, and varying levels of joint inflammation.

What is the subjective assessment for hip OA?

• Groin pain with mechanical and inflammatory behaviours (pain on loading, pain and morning stiffness)

• Problems putting shoes and socks on

• Loss of mobility of hip joint (bony changes, capsular irritation and thickening, muscle tightness, especially IR +/- F ROM)

NICE Guidelines Diagnostic Criteria

• can diagnosis a person with OA with imaging/ investigation if:

• Age > 45 years

• has activity related joint pain

• has either no morning joint stiffness or morning stiffness that lasts no longer than 30 mins

Altman diagnostic criteria

• can diagnose a person with OA if:

• hip pain and hip internal rotation < 15 deg and hip flexion < 115deg

• hip internal rotation > 15 deg and pain on hip internal rotation and morning stiffness that lasts < 60 mins and age > 50 years

Hip OA objective examination

• functional movements (activity): sit to stand, stairs, gait - walking, stairs

• 30 sec sit to stand

• timed up and go

• 6 minute walk test

• observation of gait

• PROM and AROM

• muscle tightness

• muscle atrophy/weakness in quads and glutes

Hip OA diagnostic takeaways

• morning stiffness 30-60 mins

• trouble putting shoes and socks on in the morning

• deep hip pain that is activity related

• impairments - restricted hip internal rotation +/- restricted hip flexion

Hip OA conservative management

• treatment and management is guided by goals ad finding on assessment

• education (exercise benefits, encourage behaviour change)

• local muscle strengthening (increase muscle strength all around hip, glutes, quads and back)

• heat/cold therapy for pain relief

• manual handling and stretching (increase or maintain joint ROM)

• gait aids

• refer to GP for pain relief or if pain doesn’t improve with physiotherapy for surgical options

Types of surgical management

• Hip resurfacing

• Partial hip replacement

• Total hip replacement

Lateral hip pain - Greater Trochanteric Pain Syndrome

Greater trochanteric pain syndrome (GTPS) is a common condition causing chronic, persistent pain on the outer (lateral) side of the hip and thigh. It occurs when the tendons and bursa that wrap over the hip bone's bony prominence (the greater trochanter) become irritated, overloaded, or damaged.

Risk factors of lateral hip pain

• female

• over the age of 40

• lower back pain

• high weight/BMI

Lateral hip pain subjective examination

• pain on outside of the hip

• Aggravating activities - lying on side at night, walking, climbing up/down stairs, walking up stairs and hill, sitting

• 24 hour pattern - disturbs sleep

• History - gradual onset or a change in training load or physical activity

• imagining - thickening/thinning/tears of gluteus medius/gluteus minimus tendons

Lateral hip pain objective examination

• observation - gait (may have trendelenburg sign)

• palpation (pain on palpation greater trochanter and common gluteal tendon)

• functional tests - single leg stance, single leg squats, step up, hop

• special test: resisted hip abduction, resisted hip ER de-rotation, FABER, obers, single leg stance (all will have pain provocation)

• education: reduce compression at greater trochanter, avoid - standing with weight on one leg, sitting with legs crossed, sleeping on side with top leg/hip forward in a flexed and adducted position. Sleep on back with pillow under knees. Strengthen gluteus medius/minimus - sit to stand, ½ squat, bridging, stepping

Lateral hip pain treatment

• need to slowly progress exercise

• manual therapy - soft tissue work at muscle belly (don’t irritate the tendon)

• mechanical - single point stick in same hand as painful hip

• Refer to GP for pain relief

• don’t stretch gluteus medius as it causes compression at greater trochanter

What is motion in arthrokinematics?

• motion - motion of a joint is the result of movement of one joint surface in relation to another

• Movements that occur at joint surfaces = slides (glides), rolls and spins

What is a slide movement is arthrokinematics?

sliding of one joint surface over another - translatory movement

What is a spin movement is arthrokinematics?

All points of a joint on the moving joint rotate on a fixed axis of motion - rotary motion

What is a roll movement in arthrokinematics?

a forward and backward rolling motion similar to that of a bottom of a rocking chair - rotary motion

What are the planes of movement

• sagittal (divides the body into left and right - flexion and extension)

• frontal (divided the body into anterior and posterior - abduction and adduction)

• transverse (divides the body into upper and lower sections - rotation)

What is end feel?

sensation that is transmitted to the examiners hands at the extreme end of PROM and that indicated the structure that is limiting joint movement

What is normal end feel?

when there is full PROM and normal anatomy limits/stops the movement

What is abnormal end feel?

occurs when there is an increased or decreased PROM (outside the normal range), or when there is normal PROÂ, but the structures other then the normal anatomy limit the movement

Soft end feel

When 2 surfaces come together and there is a soft spongy feel e.g. elbow flexion

Firm end feel

firm or spongy sensation that has a little give when muscle is stretched or firm stop to movement when capsule or ligaments are stretched e.g. ankle DF

Hard end feel

Abrupt hard stop to movement when bone contacts bone e.g. elbow extension

How to measure ROM

• Axis of the goniometer is placed at either the axis of movement of the joint or a landmark that can represent the axis of movement

• Stationary arm is placed parallel to the longitudinal axis of the fixed proximal joint or segment, or points to the distal bony prominence

• Moveable arm is placed parallel to the longitudinal axis of the distal joint or segment, or points to the distal bony prominence

Hip ROM

What is palpation?

Is a method of feeling with the fingers or hands during a physical examination to evaluate the structures beneath

Prior to palpation what do you need to do?

• ensure the client is comfortable

• the therapists body positioning

• expose the area that we need to assess

When palpating you need to be …

• deliberate, purposeful and systematic

• consider irritability/pain

• use pads of fingers

• compare to other side

• palpate superficial to deep

During palpation the following should be noted …

• temperature chnages of the area

• localised increased skin mosture

• presence of oedema/effusion

• mobility and feel of superfical tissues

• muscle spasm, guarding, knots, tenderness

Common hip and groin conditions

• Femoroacetabular impingement syndrome (FAI)

• Acetabular dysplasia and/or hip instability

• other conditions: labral tears, chondral lesions, ligamentum teres tears

Acetabular dysplasia

Misalignment between the femoral head and acetabulum secondary to changes in shape/size/orientation. Instability and overload of the acetabular rim

FAI syndrome

Is a motion related clinical disorder of the hip with a triad of symptom, clinical sings and imaging findings. It represents symptomatic premature contact between the proximal femur and the acetabulum

FAI subjective examination

• motion or position related pain in hip or groin

• pain may be felt in back, buttock or thigh

• patient may describe clicking, catching, locking, stiffness, restricted ROM, giving way

• Deep groin pain worse in FADIR functional positions

• often presents with generalised groin pain

• may complain of chronic back/gluteal pain

• kicking sports, martial arts

FAI objective examination findings

• pain on hip impingement test (FADIR)

• limited ROM - restricted internal rotation in hip flexion

• imaging - x-ray confirmation of cam/pincer morphology

FAI objective examination

• functional movements: DL squat - reduced squat depth, single leg balance - poor balance

• AROM and PROM - IR may be restricted or imbalance between affected and non affected hip

• Muscle strength - reduced strength in hip adduction, abduction, flexion, internal rotation, external rotation

• imbalance between affected and non-affected hips

• Special tests - pain on anterior impingement test (FADIR), IR at 90 deg hip F less than 20 deg = FAI, pain and reproducible clunk/catch on hip quadrant test

FAI standardised outcome measures

• patient reported outcome measures

• hip and groin out come score (HAGOS)

• international hip outcome tool (iHOT)

FAI treatment/managment

• strengthen around the hips

• manual therapy to soft tissues

• stretching

Risk factors of groin pain

• previous injury

• pain and reduced strength on adductor squeeze test prior to onset of symptoms

• reduced hip internal rotation/bent knee fallout

Groin pain subjective examination

• pain in the groin area

• aggravating factors include kicking and change of direction, pain during and after exercise, tight/stiff during or after activity

• 24 hour pattern - pain/stiffness in morning, especially after training/playing

• History: loss of acceleration, max speed, distance with kick. Previous groin injury. Increase in training load

Groin pain objective examination

• functional movements: single leg stance, single leg squat, kicking motion

• AROM/PROM: Hip IR and ER ROM at 90deg hip F and in neutral

• muscle strength: squeeze test and pain rating at 60deg hip F

• Isometric strength around hip in all directions - will have weakness and asymmetries between abduction and adduction and between affected and unaffected leg

• special tests: FADIR and FABER

• Palpation

Groin pain standardised outcome measures

• hip and groin outcome score (HAGOS)

• hip outcome score (HOS)

• international hip outcome score (iHOT)

Groin pain diagnosis

• pain in affected region that worsens on exercise

• pain on palpation, resistance testing and stretching

• pain resistance testing should be felt in the affected area structures and reproduce the patients familiar/recognisable pain

Adductor related groin pain

adductor tenderness on palpation and pain on resisted adduction testing

Illiopsoas related groin pain

• iliopsoas tenderness

• pain on resisted hip flexion

• pain in stretching the hip flexors

Inguinal related groin pain

• pain at location of the inguinal canal

• tenderness of the inguinal canal

• no palpable inguinal hernia

• pain on reisted testing of the abdominal muscles

Pubic related groin pain

• local tenderness on palpation of the pubic symphysis and immediately adjacent bone

• no particular resistance test will provoke pubic-related groin pain

Hip related groin pain

• FAI syndrome can refer to the groin

• common cause of groin pain

Groin pain treatment/management

• education

• Physiotherapy specific: address stability, increase ROM - manual therapy and stretching, address strength deficits

• address overtraining