NME 2025 no VR

Principles of Neuromusculoskeletal Examination

  • Institution: Brunel University London

  • Course Codes: PH1605, PH5675

  • Instructor: Christina Scorringe

  • Focus: Musculoskeletal Examination techniques

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Introduction

  • Aim: To outline the structure and content of musculoskeletal examination.

  • Learning Outcomes:

    • Identify essential components of subjective/objective examination.

    • Understand clinical relevance of each examination section.

    • Reflect on holistic examination approaches.

Subjective Examination

  • Components:

    • The Interview: Establish communication and rapport to determine assessment needs.

    • Gather details on problem severity, irritability, and nature to form a hypothesis for a safe objective exam.

Objectives of Subjective Examination

  • Goals:

    • Obtain patient information regarding:

      • What is the problem?

      • Why did it occur?

      • Impact on life and recovery factors.

Communication Skills

  • Importance of body language, tone of voice, and a motivational attitude.

  • Skills:

    • Ask questions and actively listen.

Interview Techniques

  • Types:

    • Structured: Physiotherapist leads the interview.

    • Unstructured: Patient-led.

  • Creating a balanced dialogue is essential to avoid an interrogation style.

Suggested Order of Inquiry

  • Who: Personal information including occupation and hobbies.

  • What: Identify the main problem.

  • Where: Symptoms’ location, depth, and relationship.

  • When/How: History including current and past medical context.

Behavior of Symptoms

  • Key Characteristics:

    • Constant, intermittent, or occasional.

    • Factors affecting symptoms, including specific times of day.

    • Example:

      • P1: Deep ache 8/10 after walking 20 mins, eases on rest.

      • P2: Sharp twinges 6/10 after sudden movements, eases with rest.

24-Hour Pattern Assessment

  • Investigate night pain, including factors affecting sleep, and daily variability in symptoms.

Assessing Severity and Irritability

  • Severity: Degree of function and pain intensity (use VAS scale).

  • Irritability: Correlate provocation level with symptom relief time.

History of Present Condition (HPC)

  • Consider onset time, mechanism of injury, swelling, and treatment outcomes, as well as recurrence of symptoms.

Past Medical History

  • Record significant operations, illnesses, joint disease history, and previous imaging results.

Drug History

  • Note all current medications, including potential side effects or contraindications.

Family and Social History

  • Understand hereditary diseases impact and assess lifestyle factors including occupational risks and leisure activities.

Special Questions

  • Identify issues such as paraesthesia, anaesthesia, and unexplained weight loss.

Red Flag Questions

  • Assess for serious conditions like CNS involvement or malignancy through careful questioning.

Yellow Flag Elements

  • Address psychosocial factors related to health beliefs affecting outcomes, including attitudes towards pain and behaviours.

  • Explore concerns relating to expectations from physiotherapy.

Formulating Hypotheses

  • Assess symptoms’ sources, stages of illness, and prognosis based on findings.

Objective Examination

  • Aims:

    • Confirm or refute hypotheses and establish baseline data.

    • Identify goals for management based on examination findings.

Planning the Objective Examination

  • Assess symptoms’ causes:

    • Joints, soft tissue, and nerve involvement in the symptomatic area.

Objective Examination Techniques

  • Utilize techniques such as observation, functional demonstration, muscle testing, and special tests.

Observation Techniques

  • Look for functional deficits and any physical abnormalities during the assessment.

Muscle Testing

  • Assess muscle strength through isometric testing and range of motion evaluations.

Special Tests and Palpation

  • Conduct tests to differentiate structures contributing to symptoms and palpate for tenderness or swelling.

Summary of Assessment

  • By conclusion, clarify the source and underlying pathophysiology of observed symptoms, and confirm initial hypotheses.

Triage Process

  • Evaluate the presence of red flags to determine further management options and clinical plans based on severity and irritability levels.

Essential Reading

  • Petty NJ (2013) Neuromusculoskeletal Examination and Assessment – A Handbook for Therapists. 4th Edition, Churchill Livingstone.