Evaluating Test Results

Transcription

1 Evaluating Test Results Performing AROM, PROM, & MRT tests is not difficult. Interpreting the results from those procedures and what they mean for clinical evaluation is more challenging. We ll use two visual aids to help in this process: The Physical Examination Triangle (PET) and Physical Examination Chart (PEC). Physical Examination Triangle (PET) AROM I I PRO M C C MRT Active motion involves inert and contractile tissues. (Note the I and C listed under AROM) Passive motion engages primarily inert tissues, but not contractile. (Note the I listed above PROM) Manual resistive tests emphasize contractile tissues, but not inert. (Note the C listed above PROM). Use the PET when you are investigating a specific soft-tissue pain complaint with a particular motion. For example, if you are investigating a particular pain that is reproduced when the client performs lateral shoulder rotation: If the client s primary pain is reproduced when performing active and passive lateral flexion and there is no pain with the manual resistive test, we should suspect an inert tissue as the cause of the problem. If client s primary pain is reproduced with active and resisted lateral flexion but is not felt with passive lateral flexion, we should suspect a contractile issue There is a potential exception to this process and the Physical Examination Chart (PEC) helps understand that in more detail. It is described on the next page.

2 Physical Examination Chart (PEC) The Physical Examination Chart (PEC) is used in conjunction with the PET described on the previous page. However, in the PEC, the contractile tissue category is divided into agonists and antagonists. This is where the exception to the PET results mentioned on the previous page is evident. Look at the first and third rows in the chart. They correspond to the two interpretations we determined with the PET. Using our previous example: If the client s primary pain is reproduced when performing active and passive lateral flexion and there is no pain with the manual resistive test, we should suspect an inert tissue as the cause of the problem. If client s primary pain is reproduced with active and resisted lateral flexion but is not felt with passive lateral flexion, we should suspect a contractile issue You will notice there is a yes in the columns where the specific motion (or resisted motion) reproduced the client s pain. AROM PROM MRT Contractile: Agonist YES NO YES Contractile: Antagonist YES* YES* NO Inert YES YES NO Now look at the middle row. You will notice that it is the same as the row for inert tissues except that there is a * by the yes answers. When the specified active or passive motion is performed, the muscle-tendon units that are antagonistic to that motion will be stretched. Consequently, if there is injury to them, there could be pain in the designated active as well as passive motion. However, the pain is usually not felt until near the end of the range when the muscle-tendon unit is stretched. Let s look at our example again to see how this might occur. Assuming the motion being tested is lateral rotation of the shoulder and the client reports pain with that motion (especially near the end). If there is pain near the end range of both active and passive lateral flexion and no pain during the MRT you might also suspect the medial rotator muscles as a possible cause in addition to various inert tissues. Te medial rotators are being stretched in both active and passive lateral rotation. Notice the pattern of contractile:antagonist and inert tissues is the same. The next step is to determine if the problem is from inert tissues or from the antagonist contractile tissues (in this case, the medial rotators). There is a simple solution to this. Simply engage that contractile antagonist muscle group in a MRT where they become the agonist instead. In this example that would mean using a MRT for resisted medial rotation instead of lateral rotation. If the same pain is reproduced, it is likely the medial rotators (contractile tissue). If the pain is not produced, the primary complaint is then most likely narrowed to an inert tissue.

3 Clinical Practice Questions 1. Perform two evaluation procedures that would likely reproduce your client s pain if they have a strain to the teres minor muscle. 2. Demonstrate and describe three different procedures that would help discriminate between a muscle strain and a ligament sprain. 3. Perform a PROM evaluation that would likely exaggerate your client s symptoms if they have Achillles tendinosis. 4. If there is compression of the median nerve near the wrist, perform two evaluation procedures that would likely exaggerate the client s sensory symptoms. 5. What are three factors, including history and/or physical examination, that would help in discriminating frozen shoulder (adhesive capsulitis) from shoulder impingement syndrome. 6. Perform two evaluation procedures that would help you distinguish upper extremity neurological symptoms arising from cervical nerve root pathology from those caused by a peripheral median nerve entrapment in the forearm or wrist. 7. Describe and perform two evaluation procedures that may help discriminate between a lateral ankle sprain and a syndesmosis ankle sprain. 8. Perform two evaluation procedures that you think would help discriminate between pain caused by plantar fasciitis and that caused by tarsal tunnel syndrome. 9. Perform two evaluation procedures that would help in discriminating knee pain from patellar tendinosis from that of iliotibial band friction syndrome. 10. Perform two evaluation procedures, including history and/or physical examination that may be helpful in discriminating between pain caused by piriformis syndrome and that caused by a lumbar disc herniation. 11. What are two factors, including history and/or physical examination, which would help in discriminating a quadratus lumborum muscle strain from spondylolisthesis? 12. Perform two evaluation procedures that may be helpful in discriminating between pain caused by lateral epicondylitis and thoracic outlet syndrome.

4 Case 1 Derek is a 29 year old male who is currently working at a mountaineering shop. One of his favorite hobbies is rock climbing and he tries to do that whenever he has spare time. Derek hurt his back about 3 months ago when he was lifting a small keg of beer at a friend s wedding reception. He said he felt a sharp pain in his back, mostly on the right, at the time and it has been giving him problems ever since. The pain is not constant, but there are certain things that will definitely make it worse. When he drives for long periods the pain seems to get aggravated. If he is very active the pain is likely to flare up, especially if he tries lifting things that are moderately heavy. He said sometimes there is pain in his gluteal and thigh region, but not always. He has tried to do some stretching and yoga and that seems to help a bit, but the problem is still lingering. Forward flexion from a standing position will cause some of the pain to recur near the end range of motion in flexion. He has no significant pain when he moves into the far end of extension from a standing position. There are some areas on the right side of his low back that he can press on and cause some increased pain. 1. What are two different inert (non-contractile) structures that may be the source of Derek s pain? What clues in the history lead you to think these may be involved? 2. What do you think about the facet joints being the source of his pain based on his report of increased pain with forward flexion and decreased pain with extension? Why? 3. How will you attempt to discover if his pain is primarily originating from neurological structures as opposed to muscles or other soft-tissues? 4. Do you think his pain could be originating from any organ system dysfunction such as a gall bladder disorder or kidney stones? Why or why not? 5. Derek reports pain near the end range of motion in forward flexion of his torso. What happens to the following tissues during active forward flexion of the torso from a standing position: Erector spinae muscles Quadratus lumborum muscles Zygapophysial joint capsules Anterior longitudinal ligament Interspinous ligaments Nerve roots that feed the sciatic nerve Iliopsoas muscles 6. If Derek s pain turns out to be primarily neuromuscular distress (hypertonicity, myofascial trigger points, etc.), will you attempt to treat this with massage therapy? If so, why, and how will you go about it? (Discuss what kinds of techniques you will use as well as some of your expectations for how long his treatment should last). If not, why not?

5 Case 2 Katherine is a female in her mid 30s. She is approximately 5 ft. 3 in. tall, is average weight for her height and is in good physical condition due to a regular program of exercise. She regularly attends a gym and runs about 4 miles several times a week. She has no reports of serious accidents, injuries, or illnesses. There have been a few incidents of Achilles tendinosis that have slowed her exercising, however, she has not had this problem recur for about a year and a half. Her primary complaint is of right anterior knee pain that is interfering with her running. This pain has been developing gradually for several weeks and it is limiting her ability to keep up with her exercise regimen. It does not impair her from doing things at work, but she is starting to notice it bothering her a little more when she ascends or descends stairs or squats down. When she starts to run she will usually feel this within the first mile or so when it manifests as an aching pain sensation in the anterior knee region. She reports that she cannot press on any one particularly area and reproduce the pain. She sometimes feels as though the pain is deeper in the knee. Sometimes, along with the pain, her knee feels weak, as though it is going to give way. The symptoms are reduced when she decreases her running regimen. However, she is not eager to cease that exercise program and wants to find out what the problem is. She has tried applications of ice and heat to the area. Both of these sometimes decrease the pain sensations but do nothing to alleviate the underlying condition. She is concerned that this problem may limit her ability to continue with her running schedule, which is very important to her. 1. What are three possible causes of her pain? If possible, name specific conditions such as: hamstring muscle strain, iliotibial band friction syndrome, or anterior cruciate ligament sprain. 2. Do you think her problem could be the result of a systemic disorder (i.e. muscular sclerosis, diabetes, or rheumatoid arthritis)? Why or why not? 3. What are several additional questions that you want to ask her to find out more about her problem? 4. Based on the conditions you listed in #1, how will you go about differentiating between them? Describe some of the specific characteristics of these conditions that would help distinguish them e.g. condition A would cause pain with resisted knee extension, but condition B would not. 5. An important means of identifying problems in various regions is to understand the biomechanical forces acting on those regions in the midst of injury and during evaluation. Describe what happens to the following tissues during these actions: Rectus femoris during passive knee extension Medial meniscus during active knee extension (non-weight-bearing) Iliotibial band during flexion and extension Quadriceps retinaculum during weight-bearing with genu valgum Lateral meniscus during weight-bearing with genu valgum Quadriceps muscle during knee flexion while weight-bearing Biceps femoris tendon during eccentric knee flexion