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
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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
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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
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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 &
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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,
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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
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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
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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
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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
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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),
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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
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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!!!
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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,
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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
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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
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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
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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)
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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
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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
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1
2
3
4
5
6
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Result-Interpretation 2,3,5,6 Visual loss 5, 6 Vestibular loss
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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
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the knees while sitting on a Swiss ball.
Impairment Dysdiadochokinesia
Sample Test Finger to nose
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