Physical Therapy Assessment

SUBJECTIVE DATA

QUESTION GUIDELINES

Describe the onset of the symptoms or mechanism of injury. Dete De terrmine mine whet whethe herr symp sympto toms ms are are recen ecent, t, recur ecurrren ent, t, or insidious. Determine whether perpetuating circumstances exist. Describe how the symptoms are perceived. Est Establi ablissh the the locat cation ion, type, pe, and natur ture of the pain or symptoms. Determine whether the pain and symptoms fit into a Pattern: Segmental reference zones Nerve root patterns Extra segmental reference patterns (Dural reference, myofascial pain patterns, periphe peripheral ral nerve nerve patter patterns, ns, or circula circulatory tory pain) Describe the behavior of the symptoms through a 24-h 24 -hou ourr pe peri riod od wh whil ile e ca carr rryi yin ng out ty typ pic ica al dai aily ly activities. Iden Identi tiffy whi which motio tions or positi itions cau cause or eas ease the the symptoms. Determine how severe or how functionally limiting the problem is. (Functional limitations in terms of daily living, work, family, social, and recreational activities) Determine how irritable the problem is by how easily easily the sympto symptoms ms are are evo evoked an and d how how long long they last. Describe any previous history of the condition. Find outt if th ou ther ere e ha hass be been en pr prev evio ious us tr trea eatm tmen entt fo forr th the e problem and the results of the treatment. Desc De scri ribe be rel elat ated ed hi hist stor ory, y, su such ch as an any y me medi dica call or su surrgi gica call 1

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intervention. Briefly describe general health, medications, and x-ray or other pertinent studies that have been performed. Identify any medical conditions that may alert you to using special precautions or to contraindications to any testing procedures.

PAIN Pain Descriptions and Related Structures Type o f Pain Cramping, dull, aching

Structure Muscle

Sharp, shooting

Nerve root

Sharp, bright, lightning-like

Nerve

Burning, pressure-like, pressure-like, stinging, aching

Sympathetic nerve

Deep, nagging, dull

Bone

Sharp, severe, intolerable Throbbing, diffuse

Fracture Vasculature

INSPECTION Helps to focus and individualize physical examination

SENSORIUM

Alert Lethargic Obtunded Stupor Coma

awake and attentive to normal stimulation drowsy, may fall asleep if not stimulated difficult to arouse, frequently confused when awake respo responds nds only to strong, strong, noxiou noxiouss stimuli: stimuli: retur returns ns to unconscious state cannot be aroused















Awareness of Time, Time, Person Person,, and Place (oriented x 3) AMBULATOR AMBU LATORY Y STA STATUS TUS

Note patient’s mode of locomotion (wheelcha (wheelchair, ir, ambulatory with or without assistive device, bedridden, bed bound etc. ) SKIN (color, texture, presence of lesions, scars) PRESSURE SORES

Stage 1 Stage 2 dermis) Stage 3 Stage 4

non-blanchable erythema of intact skin abra abrassion, ion, blis bliste ter, r, or shal shallo low w crat crater er (epi (epide derrmis mis & deep crater, necrosis/damage of necrotic tissue extensive destruction, tissue necrosis extending up to muscle and bone

BODY BUILD

Ectomorphic thin, prominence of structures from ectoderm Mesomorphic muscul cular, ar, promine inence of stru tructu ctures fro from mesoderm Endomorphic heavy, fat body built, prominence of structures from endoderm

PALPATION PALPATION GUIDELINES

Note differences in tissue tension, muscle tone & texture Note differences in tissue thickness Identify palpable anomalies Define areas of tenderness Temperature Temperature variations Pulses, tremors, fasciculations Dryness, excessive moisture Abnormal sensation Remember!! Palpate uninvolved part first and painful areas last















Tenderness Tenderness Scale/Grading Scale/Gradi ng

1 2 3 4

complains of pain complains of pain & winces winces & withdraws limb patient won’t allow palpation

EDEMA

Grading of Edema depression

Mild 1+ Moderate 2+

<

¼”

¼”

to

depth ½”

depth

of of

depression Severe 3+ ½” to 1” depth of depression

VITAL SIGNS BLOOD PRESSURE

Adult Blood Pressure

Normal Pre-HTN Stage 1 Stage 2

<120 mmHg / <80 mmHg 120-139 mmHg/80-89 mmHg 140-159 mmHg/90-99 mmHg ≥ 160 mmHg/100 mmHg

Infant Blood Pressure

< 2 y.o. 3-5 y.o.

106-110 mmHg/59-63 mmHg 113-116 mmHg/67-74 mmHg

Factors that may alter the Blood Pressure Elevate Elev ate BP

Lowers BP

Pain Auscultatory gap Sleeplessness gap Recent smoking Distended bowel/bladder

Recent meal Dehydration Auscultatory















PULSE RA RATE TE

Adult Pulse Rate

Normal 60-100 bpm (avg. 70 bpm) Tachycardia >100 bpm Bradycardia < 60 bpm

Infant Pulse rate

Normal

Pulse Grading

4+ 3+ 2+ 1+ 0

70-170 bpm (avg. 120 bpm)

Bounding Increased Brisk, expected Diminished, weaker than expected Absent, unable to palpate

RESPIRATORY RATE

Adult RR

Normal 12-20 cpm Tachypnea > 20 cpm Hyperpnea increase depth and rate

Infant RR

Normal

30-60 cpm

Dyspnea (shortness of breath) to px

scale

+1 mild, noticeable +2 mild mild,, noti notice ceab able le to

observer +3

moderate,

can

continue +4

severe,

can’t

continue TEMPERATURE

Normal Conversion

98.6˚F or 37˚C ˚F= [˚C x 9/5] + 32 ˚C= [˚F-32] x 5/9

Types of Fever

Intermittent normal and

alter alterna nate te b/n pyre pyrexia xia &















Relapsing/Recurrent

alter alterna nate te b/n pyre pyrexia xia &

Sustained/Constant

lapse for > 24 hr consistently elevated temperature

normal

SENSORY ASSES A SSESSMENT SMENT Sensory impairments interfere with acquisition of new motor skills since motor learning is dependent on sensory information and feedback

SENSORY ASSESSMENT PRINCIPLES

Senso Sensory ry asses assessm smen entt is compl complete eted d prior prior to an any y testin testing g that that involves active motor function Init Initia iall scree creeni ning ng for for ment mental al stat status us (ar (arousa ousal, l, atte attent ntio ion, n, orientation, cognition & memory), vision & memory should be done prior to performing sensory tests. Patient should be instructed not to guess if uncertain about the response Demonstrate the test to orient the patient on what to expect and what response is needed Test order: Superficial—Deep—Cortical & Distal to Proximal Apply the stimuli in a random order to avoid giving patient “clues” to the correct response It is good to use a chart or picture to represent the areas with sensory problem so as to easily identify if a certain pattern exists EXAMINATION PROTOCOL

Superficial sensation

Pain avoid

Use sharp end of a pin,

















Let finger slide over the pin Light touch

Use cotton or camel hair

brush Pressure Temperature Response

Deep sensation

Kinesthesia passively

Use thumb enough to indent skin Use test tubes with warm (41-50˚F) and cold (104113˚F) When patient feels stimuli, respond with yes, now or unable to tell Move

the

extremity

in initial, mid or terminal range Response

Proprioception

Response

with very minimal grip to reduce tactile stimulation Describe direction as up or down, in or out while the extremity is in motion. Also patient can imitate the movement in opposite extremity. The extremity extremity is held in a stati st atic c po posit sition ion in in initi itial, al, mid mi d or te terrmi mina nall ra rang nge e with very minimal grip to reduce tactile stimulation Describe direction as up or down, in or out while

















Response Cortical sensation familiar

to rem emov ove e th the e au audi dito tory ry clues. Verbally identify the vibrating stimuli

Stereognosis

The The pa pati tien entt is gi give ven n a

Response

object to be held and manipulated The The pa pati tien entt is as ask ked to identify the object verbally

Tactile Tactile localization Therapist touches different areas in patient skin surface Response Patient points out the area that the therapist touches Two-point Discrimination Applies simultaneous stimuli on the patient’s skin Response Identify if the perception of one or two stimuli Graphesthesia Trace letters, numbers or designs on skin Response Identify what is the traced figure

































MUSCULOSKELETAL ASSESSMENT ASSESSMENT

PATIENT HISTORY HI STORY & INTERVIEW INTE RVIEW

Symptom

Onset Location

sudden, gradual, insidious, traumatic loc lo cali lize zed d, dif iffu fusse, deep, superfi fici cia al, changes, spreads severity, characteristic aggravating factors, relieving factors

Quality Behavior

Illustrations: Numerical Pain Rating Scales Circle the number which best represents the intensity of your pain 0

No Pain

1

2

3

4

5

6

7

8

9

10

Worst

















Occupational, recreational, social history patient’s work and activ activiti ities, es, archi architec tectur tural al barr barrier iers, s, en envir viron onme menta ntall accessibility Illustrations: Rate Patient’s Function What percentage of your work activities are you able to perform? 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Illustrations: Rate Patient’s Function What percentage of your home activities are you able to perform? 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Illustrations: Rate Patient’s Function What percentage of your recreational activities are you able to perform? 0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

RANGE OF MOTION

Things to remember

Normal side is tested first, unless bilateral



















Resisted isometrics are done with the joint in resting position Active ROM

Often Often estimate estimated d except except if more more accurate accurate meas measur urem emen entt is ne need eded ed,, goni goniom omet eter er should be used If can can be perf perfor orme med d by pati patien entt easil asily y with withou outt pain pain or othe otherr symp sympto toms ms,, then then passive testing is usually not necessary

Attention!! Limitations in AROM may indicate affection of either contractile or none contra contracti ctile le tissu tissue e or both both.. The exami examine nerr mu must st perfor perform m furth further er testing to isolate the cause.

Passive ROM

Slightly greater than AROM Tested for amount of motion (goniometric value),

















End Feel

Abnormal End Feels End Feel

Examples

Soft Occurs sooner or later in the Soft tissue edema ROM RO M th than an is us usua ual, l, or in a Synovitis join jointt th that at no norma rmall lly y ha hass a firm or hard end-feel. Feels boggy Firm Occurs sooner or later in the Increa Increased sed mus muscul cular ar ton tonus us ROM RO M th than an is us usua ual, l, or in a Ca Caps psul ular ar,, mu musc scul ular ar,, li ligaga join jointt th that at no norma rmall lly y ha hass a mentous shortening soft or hard end-feel. Hard Occurs sooner or later in the ROM RO M th than an is us usua ual, l, or in a join jointt th that at no norma rmall lly y ha hass a soft or firm end-feel. A bo bony ny gr grat atin ing g or bo bony ny block is felt.

Chondromalacia Osteoarthritis Loose bodies in joint Myositis ossificans Fracture

Empty No re real al en end-f d-feel eel be becau cause se pain prevents reaching reaching end of ROM ROM.. No re resist sistanc ance e is

Acute joint inflammation Bursitis Abscess

















Pattern of Limitation

Capsular Patterns Can be due to 2 situations

a. b.

Joint effusion or synovial inflammation (acute stage) Relative capsular fibrosis (chronic stage)

Attention!!!

















Joint

Pattern

Shoulder

ER>ABD>IR

Elbow

F>E

Forearm

Pronation=Supination

Wrist

F=E

CMC 1 2-5

ABD & EXT Equ Eq ual res estr tric icti tio on direction

UE digit

F>E

Hip

IR, F, ABD

Knee

F>E

Ankle

PF>DF

Subtalar

Varus restricted

Midtarsal

Res estr tric icte ted d DF DF,, medial rotation

Metatarsalphalangeal joint Metatarsalphalangeal 1

E>F

PF,, PF

in

all

ABD, AB D,

















Elbow Forearm Wrist

Thumb CMC

Lateral Flexion Pronation Su ination Extension Flexion Radial Ulnar deviation Abduction Flexion Extension O osition

0-90 0-150 0-80 0-80 0-70 0-80 0-20 0-30

Knee Ankle

Subtalar Great toe

0-70 MTP 0-15 0-20 PI Ti of thumb to or tip tip of of fifth fifth digit digit Le Lesse sserr toe toe MTP

MCP Flexion IP Flexion Digits Second Fifth Flexion MCP H erextensio Abduction PIP DIP

Flexion Flexion Hyperextensio

0-50 0-80

0-90 0-45 0-100 0-90 0-10

PIP DIP

ER/IR Flexion PF DF Inversion Eversion Inv/Evr

0-45 0-135 0-50 0-20 0-35 0-15 0-5

flexion extension flexion

0-45 0-70 0-90

flexion extension flexion flexion

0-40 0-40 0-35 0-30



















RESISTED ISOMETRIC TESTING Joint should be placed in a position midway through the range, to produce minimal tension in inert structures.

RESULTS OF RESISTED ISOMETRIC TESTING

Findings

Possible Pathologies

















MANUAL MUSCLE TESTING

Manual Muscle Muscl e Testing Testing Grades G rades Grades

Criteria

Normal

N

5

10

Good Plus

G+

5–

9

Full available ROM, against gravity, strong manual resistance Full available ROM, against gravity, nearly strong

















Trace

T

1

T No observable motion, palpable muscle contraction, no resistance

Zero

0

0

0

No observable or palpable muscle contraction

CLOSE-OPEN PACKED POSITION

Resting (Loose/open Packed) Position of Joints of Joints Joi nt

Facet (spine) Temporomandibular

Position

Midway between flexion and extension Mouth slightly open (freeway space)

















Metacarpophalangeal Interphalangeal Hip Knee Talocrural (ankle) Subtalar Midtarsal Tarsometatarsal Metatarsophalangeal

Full opposition (thumb) Full extension Full extension, medial rotation* Full extension, lateral rotation of tibia Maximum dorsiflexion Supination Supination Supination Full extension

MOTOR EVALUATION TONE

















Grade Evaluation 0 Absent contraction

Response Characteristics No visible or palpable muscle with reinforcement.

1+

Hyporeflexia

2+

Normal joint

Slight or sluggish muscle contraction with little little or no joint joint moveme movement. nt. Reinforc einforceme ement nt may be required to elicit a reflex response. Slight muscle contraction with slight movement.

3+

Hyperreflexia contraction

Clearly visible, brisk muscle



















1

2

3

4

5

6

















Result-Interpretation 2,3,5,6 Visual loss 5, 6 Vestibular loss

















T ES T 1. Finger

to nose

2. Fi Finger nger to

therapist's finger

PROCEDURE The shoulder is abducted to 90 degrees with the elbow extended. The patient is asked to bring the tip of the index finger to the tip of the nose. Alterations may be made in the initial initial starting starting position position to assess assess perform performance ance from from differen differentt planes of motion.

The patient and therapist sit opposite each other. The therapist's index finger is held in front of the patient. The patient is asked to ch the ti of the inde inde fi th

































the knees while sitting on a Swiss ball.

Impairment Dysdiadochokinesia

Sample Test Finger to nose























































































































































Physical Therapy Assessment

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