Tests & Measures – Comprehensive Study Notes (DPT 6150, Week 3)

Examination Framework & Sequencing

• Eight broad elements repeated in course slides; memorize the order because it structures every evaluation:

  1. Patient interview & outcome measures (subjective)
  2. Observation
     –
     “big picture” & ongoing
  3. Triage / screening to rule out non
     –
     musculoskeletal (MSK) or emergent MSK sources
  4. Motion tests (AROM, PROM, accessory)
  5. Muscle performance testing
  6. Special tests
  7. Palpation
  8. Physical
     ‐
     performance measures

• First-order decision that immediately follows the interview & screening:

  • Treat?
  • Treat & Refer?
  • Refer?

History & Hypothesis Generation

• Data collection
  →
  working differential Dx that continually evolves

  • Classify as Neuro-Musculo-Skeletal (NMS), Non-NMS, or mixed

• History dictates which tests you plan and the depth of the exam

• Plan of care stems from the hypothesis list; refined only after T&M data are added

Planning the Tests & Measures (T&M)

• Hypothesis-based, systematic clinical-reasoning model

• Take time to interpret the interview before you touch the patient

• The history determines:

  • Which regions to focus on today

  • Which regions merely need to be screened

  • What can wait until a future session

Goals of T&M

• Confirm or refine the primary hypothesis
• Identify contributing factors to Dx design
• Reproduce the patient’s concordant symptoms
• Establish baselines / outcome metrics for reassessment

Universal Testing Principles

1. Always examine the uninvolved side first

2. Record & monitor resting symptoms before and between tests

3. For every movement or test document:

   • Quality • Quantity • Symptom response

4. Standardize positions & verbal commands

Observation (General Appearance)

• Ongoing from the waiting room onward
• Check facial expression, use of assistive devices, willingness to move, typical vs atypical movement patterns
• Ask “What are your symptoms now?” at rest and after positional changes

Systematic Postural Scan

• View anterior, posterior, right, left

• Adequate draping/exposure is mandatory

• Look for symmetry, bony contours, trunk & extremity position, soft
  ‐
  tissue changes (atrophy, edema), skin changes (erythema, hair loss, shiny skin, scars)

Triage & Screening (Rule-Out Stage)

• May be completed solely from the subjective if red flags emerge

• Components:

  • Review labs & imaging

  • Vital signs, mental status, cranial nerves, upper motor neuron tests

  • Upper/Lower Quarter neuro screen

  • Highly sensitive special tests

• Examples:

  • Acute Coronary Syndrome cluster (chest pain, SOB, dizziness; SN = 0.98)

  • Closed-fist percussion test for spinal fracture SN = 0.88,

  -LR = 0.20,

  SP = 0.93,

  +LR = 11.6

Non-PT Diagnostic Tests (possible referral needs)

• Radiographic: X-ray, MRI, CT, bone scan
• Lab: UA, CBC, Rheumatoid Factor
• Electrodiagnostic: EMG, NCV

Likelihood Ratios & Diagnostic Accuracy Refresher

• Negative LR formula: -LR = \frac{1-SN}{SP}

• Interpretation of -LR

  •

Region Selection & Screening Order

• After deciding the patient belongs in PT, pick:

  • Region(s) for detailed exam today

  • Regions to screen today • Regions to examine later

• Standard regional rule-outs:

• Cervical spine for most UE complaints & TMJ( Must Rule out )
• Lumbar spine for most LE complaints
• Upper thoracic for UE; lower thoracic for LE

Neuro Screens For Radiculopethy

• Purpose: detect radiculopathy, myelopathy, sensory deficits early
  ⇒
  place them BEFORE painful joint testing
• LQ screen learned in lab: dermatomes, myotomes, reflexes, pathologic reflexes

Neurodynamic Tests (r/o neural component)

• Lower Quarter, Straight-Leg Raise, Slump
• Upper Quarter: ULTT 1 (Median), ULTT 2a (Median), ULTT 2b (Radial), ULTT 3 (Ulnar)

Static Posture Analysis

• Deformity guides hypotheses (joint restriction, muscle length/strength imbalance, neuro deficit, habitual pattern, structural)
• May be protective or completely normal for that individual

Functional Movement / Asterisk Signs

• Ask pt to demonstrate a painful or limited task (looking up, squat, reach)
• Observe both local & regional compensations
• Mark the movement as an “asterisk” to quickly reassess after intervention
• Standardize starting position; always re-check resting symptoms before/after

Gait & Balance Quick Screen

• Note deviations, assistive devices, hypothesize cause
• Balance positions: double-limb, single-limb, tandem

Motion Tests – Active Range of Motion (AROM)

Osteokinematic(Bone) movement performed voluntarily

• Goals: reproduce concordant Sx, identify motion pattern restrictions/excess, obtain baseline ROM, infer contractile involvement if painful

• Evaluate:

  • Quality (smooth? compensated?)

  • Quantity (goniometric measure)

  • Symptom response (onset, point in range, pain arc)

• If full & pain-free
  ⇒
  apply graded overpressure; still no symptoms
  ⇒
  add repeated, sustained, or combined motions

Causes of AROM Deficits

• Pain (swelling, effusion, fear-avoidance)
• Hypermobilityonditioning, neuro impairment)
• Altered motor control (timing, recruitment issues)
• Hypomobility (joint, muscle, neural)
• Hypermobility / instability

Hypermobility Assessment – Beighton Score

• \text{Positive if} \;\ge 4/9

  • Elbow hyperextension >10^{\circ} (2 pts)

  • Thumb to forearm (2 pts)

  • Little finger passive ext >90^{\circ} (2 pts)

  • Knee hyperextension >10^{\circ} (2 pts)

  • Palms-to-floor with straight knees (1 pt)

Standard AROM Procedure

1. Explain & demo
2. Uninvolved side first
3. Record resting Sx
4. Perform movement; immediately ask: “Does this change your symptoms?”
5. Document Quality–Quantity–Sx response overpreasure: how does it feel at the very end. if AROM is full preform it at the end.

Passive ROM (PROM)

• Done when AROM < normative or painful; evaluates effect of passive movement on both contractile & non-contractile tissues

• Tissue irritability insight via pain
  –
  resistance sequence:

  • Pain before resistance ⇒
  high irritability (acute)
  –
  no stretching

  • Pain with resistance
  ⇒
  moderate irritability (subacute)

  • Resistance before pain
  ⇒
  low irritability (chronic)

• Assess capsular pattern loss (traditional shoulder pattern: ER>ABD>IR) but remember evidence is weak

End-Feel Categories

• Normal: Capsular (firm/leathery), Bony (hard), Soft tissue approximation, Muscular/elastic
• Abnormal: Early capsular, bony block, muscle guarding, boggy, springy rebound, empty (pain stops motion)

PROM Procedure Highlights

• Patient fully relaxed, joint in loose-packed start
• Uninvolved first
• Monitor Sx & pain/resistance relationship throughout; apply overpressure at end range if still painless

Passive Accessory Movements (PAM)

• Arthrokinematic “glides” necessary for full physiologic motion

• Tested only passively by PT; patient cannot self-perform

• Example wrist glides:

  • Flexion
  ⇒
  posterior (dorsal) glide

  • Extension
  ⇒
  anterior (volar) glide

  • Radial dev
  ⇒
  ulnar glide

  • Ulnar dev
  ⇒
  radial glide

• Open-packed (rest) position used for initial assessment

Open-Packed and Closed-Packed Principles

• Open-Packed Position (Loose-Packed Position):
  • The position where the joint capsule is most lax and the joint surfaces have the least congruence.
  • Allows for maximum accessory motion (joint play).
  • This is typically the preferred position for initial assessment and mobilization techniques as it minimizes stress on the joint.
  • Example: For the knee, about 25^{\circ} of flexion.
• Closed-Packed Position:
  • The position where the joint surfaces are maximally congruent, the capsule and ligaments are maximally taut, and the joint is most stable.
  • There is minimal accessory motion available.
  • This position is often associated with high compressive forces and is where the joint is most susceptible to injury under sudden loads.
  • Example: For the knee, full extension with external rotation.

PAM Grading

1. Typical
2. Hypomobile
   –
   treat with joint mobilization
3. Hypermobile
   –
   treat with motor-control exercise / stabilization

Interpretation Matrix

• Typical painless
  ⇒
  normal
• Typical painful
  ⇒
  minor sprain/capsular irritation
• Hypomobile painless
  ⇒
  mobility deficit
• Hypomobile painful
  ⇒
  mobility deficit + irritability/effusion
• Hypermobile painless
  ⇒
  complete rupture or benign laxity
• Hypermobile painful
  ⇒
  ligamentous laxity with inflammation

Muscle Length Testing

• Passively elongate the muscle opposite to its action; key for 2-joint muscles
• Short & strong vs long & weak paradigm: tightness can be cause OR effect of movement dysfunction
• Contributing factors: posture, trauma, immobilization, repetitive activity, poor stabilization, altered neuromotor control

Muscle Performance Testing Spectrum

• Resisted Isometric (static) tests: quick screening when full MMT impossible or painful

  • Joint placed in neutral/rest; “Hold, don’t let me move you” for \approx 5\;\text{s}

  • Positive if pain, weakness, or both
  ⇒
  implicates contractile tissue

• Manual Muscle Testing: standardized course covers details; document deviations

• Additional metrics

  • Strength (force/torque)

  • Endurance (ability to sustain)

  • Power (Force \times Velocity)

  • Motor-control observation during functional tasks

Palpation Checklist

• Mandatory over symptomatic area

1. Skin: mobility, temp, sweating, edema
2. Soft tissue: mobility, tone, texture, tenderness
3. Vascular & lymphatic: pulses, nodes
4. Bony alignment, ligament & tendon insertions

Special Tests to Rule IN (Diagnostic Tests)

• Perform after regional clearing & motion / strength testing so tissues are warmed and irritability judged
• Only valuable when combined with interview & other findings (pre-test probability)
• Must consider reliability, SN, SP, \pm LR before adoption into practice
• High SN + negative
  ⇒
  rules out (SnNout)
• High SP + positive
  ⇒
  rules in (SpPin)

Nomogram Use Example (Lachman)

• Pre-test probability =50\%
• +LR = 9.56 shifts post-test probability markedly
  ↑
• -LR = 0.15 shifts probability
  ↓
  if negative

End-of-Exam Tasks

• Synthesize data
  ⇒
  refine diagnosis & prognosis; if uncertain, revisit history or consult colleague
• Formulate intervention plan & immediate treatment strategy
• Establish STG/LTG consistent with prognosis

Patient Education Essentials

Explaining the Diagnosis

• Relate objective findings to patient’s story in clear, non-threatenin'glanguage
• Avoid fear-inducing terms (“disc is damaged”, “spine is unstable”)

Communicating Prognosis

• Emphasize positives: “Good news—this is very treatable.”
• Outline expected recovery time & overall plan

Describing the Intervention

• Detail modality or exercise choices, frequency, duration, risks/benefits, criteria for progression
• Reassure, explain, educate—patients want to know what YOU can do for THEM