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Physical Therapy Examination Procedures

PHYSICAL THERAPY EXAMINATION PROCEDURES 1

Dr. Olfat Ibrahim

OBJECTIVES

  • Upon conclusion of this lecture, students will be able to:

    • Understand the scope of physical therapy examination and assessment.

    • Identify joints of the upper and lower extremities, including their degrees of freedom and the planes and axes associated with each movement.

    • Differentiate between normal and abnormal end feel.

    • Employ measurement tools of range of motion (ROM).

GOALS OF PHYSICAL THERAPY EXAMINATIONS

  • The goals of physical therapy examinations are as follows:

    • Determine Presence or Absence of Impairments: Identify impairments involving muscle, bone, and associated structures.

    • Identify Specific Tissues Causing Impairment: Pinpoint the exact tissues responsible for the impairment.

    • Formulate Therapeutic Goals, Outcomes, and Interventions: Generate tailored therapeutic strategies for patient recovery.

    • Determine Need for Orthotic and Adaptive Equipment: Assess what equipment is necessary to enhance functional ability in daily activities.

    • Assess Effectiveness of Rehabilitation, Medical, or Surgical Management: Evaluate how well the current management strategies are supporting recovery.

    • Motivate the Patient: Foster an encouraging environment that promotes patient engagement in their recovery.

EXAMINATION PROCEDURES

  • Various methods are employed during physical therapy examinations:

    • Patient History and Interview: Gathering background and current health information.

    • Vital Signs Assessment: Monitoring essential health indicators.

    • Mental Status Evaluation: Assessing cognitive function and emotional well-being.

    • Observations/Inspection: Visual assessment of the patient’s condition.

    • Palpation: Physical examination through touch to identify abnormalities.

    • Anthropometric Characteristics: Evaluation of extremity circumference and length measurements.

    • Range of Motion (ROM) Measurement: Techniques include:

    • Active Range of Motion (AROM) Test: Patient performs movements actively.

    • Passive Range of Motion (PROM) Test: Therapist assists in movement, assessing joint integrity.

MUSCULOSKELETAL JOINTS

  • Definition:

    • A joint is an articulation, where two or more bones or parts of bones meet in the skeleton.

  • Types of Joints:

    • Immovable Joints: Fixed joints providing no movement.

    • Slightly Movable Joints: Limited mobility depending on structure.

    • Freely Movable Joints: Permit various types of movements.

TERMINOLOGY OF MOVEMENTS

  • Understanding key terms related to joint movement is crucial:

    • Flexion: A decrease in the angle between two bones.

    • Extension: An increase in the angle between two bones.

    • Abduction: Movement away from the midline of the body.

    • Adduction: Movement towards the midline of the body.

    • Rotation: Movement of a bone around its axis, which can be inward (medial) or outward (lateral).

    • Circumduction: The lower end of the bone moves in a circular manner.

    • Lateral Flexion: Bending sideways.

    • Plantar Flexion: Pointing the foot downwards.

    • Dorsiflexion: Bending the foot upwards towards the tibia.

    • Pronation: Facing the palm of the hand downwards.

    • Supination: Facing the palm of the hand upwards.

JOINT MOVEMENTS

  • Various joints and their possible movements include:

    • Shoulder: Flexion, extension, adduction, abduction, circumduction, internal and external rotation.

    • Elbow: Flexion and extension.

    • Radio-ulna: Pronation and supination.

    • Wrist: Flexion, extension, adduction, abduction, circumduction.

    • Spine: Flexion, extension, lateral extension, internal and external rotation.

    • Hip: Flexion, extension, adduction, abduction, internal and external rotation, circumduction.

    • Knee: Flexion and extension, rotation.

    • Ankle: Dorsiflexion and plantarflexion.

DEGREES OF FREEDOM

  • Types of joint movement degrees:

    • Uniaxial: One degree of freedom, movements occur in only one plane (e.g., ankle joint permits only flexion and extension).

    • Biaxial: Two degrees of freedom in two planes (e.g., knee joint provides flexion and extension of the leg on the thigh, and medial/lateral rotation).

    • Multiaxial: Three degrees of freedom, movement around horizontal, transverse, and sagittal planes (e.g., hip and shoulder joints).

ANATOMICAL PLANES AND AXES

  • Planes: Imagined flat surfaces describing sections of the body. There are three main anatomical planes:

    • Sagittal Plane: Divides the body into left and right portions; flexion and extension typically occur here.

    • Frontal Plane: Divides the body into front (anterior) and back (posterior) portions; abduction and adduction movements occur here.

    • Horizontal Plane: Divides the body into superior and inferior portions; rotational movements occur here.

  • Axes: Lines around which movements take place, with three basic types:

    • Sagittal Axis: At right angles to the sagittal plane.

    • Frontal Axis: At right angles to the frontal plane.

    • Horizontal Axis: At right angles to the horizontal plane.

MOVEMENT IN RELATION TO PLANES AND AXES

  • Flexion & Extension: Occur in the sagittal plane around the frontal axis.

  • Abduction & Adduction: Occur in the frontal plane around the sagittal axis.

  • Rotation: Occur in the horizontal plane around longitudinal axes.

FACTORS AFFECTING RANGE OF MOTION (ROM)

  • Internal Influences:

    • Joint type.

    • Bony structures that limit movement.

    • Elasticity of muscle tissue, tendons, ligaments, and skin around the joint.

    • Muscle ability to relax and contract to achieve maximum movement.

  • External Influences:

    • Temperature (warmer temperatures enhance flexibility).

    • Time of day (flexibility tends to be higher in the afternoon).

    • Age (younger individuals are generally more flexible).

    • Gender (females are typically more flexible than males).

    • Clothing or equipment restrictions.

    • Types of motion (active vs. passive).

ACTIVE RANGE OF MOTION (AROM) VERSUS PASSIVE RANGE OF MOTION (PROM)

  • PROM: Performed by the therapist, provides information about joint integrity rather than muscular integrity.

  • AROM: Conducted by the patient themselves, provides insight into muscular function as opposed to joint function.

  • Pain during AROM: Indicates issues related to muscle contraction or stretching of contractile and/or non-contractile tissues.

  • Pain during PROM: Indicates problems within the joint itself.

  • PROM is generally slightly greater than AROM due to involuntary movements at the end of the range, assisting in joint protection against external forces.

END FEEL

  • Definition: End feel refers to the sensation felt by a therapist at the extreme end of passive ROM, indicating structures that limit joint movement, which could be normal (physiological) or abnormal (pathological).

    • Normal End Feel (Physiological): Movement is halted at full ROM by intact joint anatomy.

    • Abnormal End Feel (Pathological): ROM is altered or halted by structures other than normal anatomy, indicating dysfunction.

NORMAL END FEEL EXAMPLES

  • Hard (Bony):

    • Abrupt stop with bone contacting bone.

    • E.g., elbow and knee extension.

    • Typically painless.

  • Soft (Soft Tissue Apposition):

    • Soft compression of tissue (muscle).

    • E.g., knee and elbow flexion.

  • Firm (Soft Tissue Stretch):

    • Springy sensation with slight give, depending on tissue thickness (Achilles tendon more robust than wrist).

    • E.g., dorsiflexion with an extended knee (gastrocnemius).

  • Firm (Capsular Stretch):

    • Hard arrest with some give indicating stretching of the joint capsule or ligament.

    • E.g., passive external rotation of the shoulder.

ABNORMAL (PATHOLOGIC) END FEELS

  • Hard (Bony):

    • Abrupt stop from bone-on-bone contact or grating sensation from rough articular surfaces.

    • Indicative of conditions such as loose bodies, degenerative disease, dislocations, or fractures.

  • Soft:

    • Boggy feeling indicating the presence of synovitis or edema.

  • Firm (Leathery/Capsular Stretch):

    • A hard arrest with some give, often indicating muscular, capsular, or ligamentous shortening.

  • Springy Block:

    • A rebound sensation felt or observed, typically indicating internal derangement (e.g., torn meniscus).

  • Empty:

    • Absence of sensation before the end of passive ROM caused by pain, indicating conditions like abscess or acute inflammation.

  • Spasm (Protective):

    • Sudden hard stop that often accompanies pain, indicative of acute arthritis or severe active lesions to prevent further injury.

GONIOMETRY / RANGE OF MOTION (ROM) MEASUREMENT

  • Definition: Goniometry is the technique of measuring human joint angles. The term derives from Greek words:

    • "gonia" meaning angle, and "metron" meaning measure.

  • ROM Assessment Tools:

    1. Universal Goniometer:

    • Instrument to measure joint ROM, displaying the angle available at the joint.

    1. Inclinometer: Tool used as needed.

    2. Tape Measurement: Often for the spine.

    3. Ruler and Calipers: Useful for the temporomandibular joint (TMJ).

    4. Radiographs and Photographs: Additional visual methods of assessment.

GONIOMETER DETAILS

  • A goniometer consists of:

    • Moving Arm: Represents the part of the limb undergoing movement.

    • Stationary Arm: Aligned with the inactive part of the joint.

    • Fulcrum: Sits over the joint being measured, scaled 0 to 180 degrees for alignment during measurement.

INCLINOMETER

  • Construction: Composed of a circular, fluid-filled disk with a bubble or needle that indicates degrees on a protractor scale.

  • Functionality: Majority are calibrated to gravity, ensuring consistent starting and reference points.

  • Usage: Can be handheld against the patient during various movements or mounted on a frame (e.g., CROM device for cervical ROM, BROM for back ROM).

VALIDITY OF ROM MEASUREMENT

  • Validity Defined: A measurement concept addressing whether the measurement system accurately measures its intended focus—joint range of motion in the context of goniometry.

  • Challenges: Validity often decreases in goniometric measurements, typically due to poor stabilization.

RELIABILITY OF ROM MEASUREMENT

  • Reliability Defined: Refers to the consistency and repeatability of successive measurements.

    1. Intratester Reliability: Same tester measuring on different occasions should have an error < 5 degrees.

    2. Intertester Reliability: Differing testers likely present a greater measurement error (> 5 degrees).

  • Maximizing Reliability: Maintain consistency using the same:

    1. Goniometer

    2. Positioning

    3. Procedure

    4. Examiner

ANATOMICAL DIRECTIONAL TERMS

  • Anterior: The front, or in front of.

  • Posterior: The back, or behind (towards the rear).

  • Distal: Away from, furthest from the origin.

  • Proximal: Near, closest to the origin.

  • Superior: Above, over.

  • Inferior: Below, under.

  • Lateral: Away from the mid-line (towards the sides).

  • Medial: Towards the mid-line (away from the sides).

THANK YOU

  • Appreciation to students for their attention to the lecture.