Week 1

Question 1

What can we do as a physio?

Answer 1

PEMAT
Physical devices
EPA
Manual therapy
Advice and education
Therapeutic exercise

Question 2

aims of patient interview

Answer 2

• To establish rapport with the client, including cultural safety.
  
  • To begin the process of identification of a musculoskeletal disorder as opposed to other causes (red flags)
  • To determine any precautions &/or contraindications to assessment or treatment
  • To determine any relevant psycho-social factors for the patient (yellow flags)
  • Determine and document a clear and accurate representation of the client’s consultation today
• to create goals

Question 3

types of yarning

Answer 3

social yarn
managemrnt yarn
diagnostic yarn

Question 4

patient interview - main problem

Answer 4

• Establish why the client has come to see you or why they have been referred
  ○ “What brings you here today?” (90 second rule)

Question 5

red and yellow flags

Answer 5

Red flag:
○ Symptoms, signs and patterns suggestive of serious pathology
Yellow flag
○ Psychological and social predictors of chronicity

Question 6

patient interview - body chart

Answer 6

• Indicate area of body involved (and possible structures)
  
  • Clear other areas using a tick

Question 7

aggravating factors

Answer 7

• “What aggravates the pain?”
  
  • “Is there an activity or movement that brings on the pain or makes it worse?”
  • “How long can you do the activity before pain starts or increases?”
  • “Does the pain stop or can you continue?”
  • “How long before the pain eases?”
    Example record: Aggr. Going up 12 stairs, Pk immed (5/10), stops immediately after

Question 8

AM-PM (day) - patient interview

Answer 8

• “Does the pain change during the day?”
  
  • “Is the pain worse on waking or does it worsen during the day?”

Question 9

Irritability - patient interview

Answer 9

• Severity (VAS)
  
  • Duration to onset
  • Duration to ease
  • Consider type of activity that aggravates e.g. pain immed with waling vs pain immed with running
  • Classify as mild, moderate or severe

Question 10

Current history (CHx) - patient interview

Answer 10

• “When did the pain/sympton start?”
  
  • Duration of symptoms may indicate stage of pathology e.g.
    acute or chronic/overuse injury, stage of healing
    Mechanism of injury (MOI)
  • “How did the injury happen?”
    Predisposing factors
  • Ask patient if they have changed any factors recently
    Progress
  • “Is the pain better, worse or unchanged?”
    This information can help you decide if the condition
    Treatment to date
  • “Have you had any treatment?” “Was the treatment effective?”

Question 11

Previous history (PHx)

Answer 11

• “Is this the first episode/time you’ve had this injury/symptom?”
  
  • “When was the first time?”
  • “Is it occurring more frequently and/or more severely?”
  • “Have you recovered completely after each episode?”

Question 12

Medical and social history - patient interview

Answer 12

Explain to the patient why you need to know this
- Determine contraindications and precautions to Rx and examination
- Diagnosis

Question 13

Observation (Obs)

Answer 13

• Starts from as soon as they/you enter room, or even prior
  
  • Observe total body posture
  • Gross changes in skin, muscle contours, body alignment

Question 14

observations at the local area

Answer 14

• Then in detail at local area
  ○ Deformity
  ○ Swelling
  ○ Skin colour
  ○ Muscle wasting
  ○ Muscle spasm
  ○ Muscle imbalance
  ○ Traumatic or surgical scars

Question 15

Active movements (AROM) purpose

Answer 15

To find movement impairments with signs (pain, resistance, spasm, etc) that are comparable with the patient’s symptoms & disability (“their pain”).

Question 16

Passive movements (PROM) purpose

Answer 16

To differentiate between contractile and non-contractile sources of symptoms
- E.g. joint versus muscle/tendon
- Q: the movement is painful when performed actively, but not when performed passively - interpretation?

Question 17

Passive Physiological movement (PPM)

Answer 17

Movements that a person can carry out actively
e.g. ankle dorsiflexion

Question 18

Passive Accessory movement (PAM)

Answer 18

Movements that a person cannot perform independently but are
necessary for joint movement
- Roll, spin, slide/glide
- Distraction, compression
e.g. anteroposterior glide of talus during ankle dorsiflexion

Question 19

Quantitative tests

Answer 19

Strength testing
- Manual muscle test (through range)
- Handheld dynamometry
Isotonic/Isokinetic testing

Question 20

Qualitative tests

Answer 20

• Functional muscle testing
  
  • Resisted isometric contractions
    Recruitment /activation patterns

Question 21

Resisted/Static Manual Muscle Testing (MMT)

Answer 21

• Assess whether muscle/tendon is a source of pain
  
  • Provides a quick screen of general strength
  • Standardised test procedure
  • Note if there is pain and where (“what are you feeling and where are you feeling it”, “is that YOUR PAIN that you came to me about”?)

Question 22

Recruitment/activation pattern

Answer 22

• Hip extension should be initiated by gluteus maximus, then hamstrings (hamstrings often dominant in hip / lower limb dysfunction)
  
  • Knee extension should recruit VL & VMO simultaneously (often VMO delay in dysfunction of the knee)

Question 23

Adjacent joints or regions

Answer 23

• May refer pain/symptoms to the area of primary problem
  
  • May have altered function that is a predisposing factor to presenting problem (e.g. ↓ calf strength = ↑ risk Achilles Tendinopathy

Question 24

Special orthopaedic tests

Answer 24

• Depends on the area examined and its unique anatomy and function
  ○ Ligament stress tests (e.g. valgus stress test for MCL)
  ○ Dynamic instability tests (e.g hop)
  ○ Meniscal (e.g. McMurrays)

Question 25

Neurological assessment

Answer 25

- Neurological examination ○ Tests nerve conduction and function - Neurodynamic tests - Tests sensitivity to movement

Question 26

observation and initial palpation - knee and patella

Answer 26

Position of the limb - evidence of deformity such as genu varus or valgus Swelling – size of effusion, location, intra vs extra capsular * Bruising * Scars - Position of patella in the transverse plane – centrally, medially or laterally positioned. * Squinting of patellae * Patella height (patella alta or baja) * Fat pad hypertrophy at base of patella * Quadriceps (VL vs VM), VMO bulk q-angle - normal is approx 17 degrees in females and 14 degrees in males

Question 27

General - observation and palpation

Answer 27

* Symmetry of weight bearing / ability to weight bear. * Lower limb positioning e.g. if OA hip may stand with hip in ER and slight flexion. * Swelling, bruising, scars * Leg length

Question 28

Feet - observation and palpation

Answer 28

* Observe resting fore, mid and rear foot positions. * Hallux valgus or bunions * Abducted or adducted relative to midline and rest of leg. * First toe – hallux valgus (adducted first toe) deformity. * Location of calluses * Often useful to look at wear patterns on shoes for insidious onset problems.

Question 29

Mid foot - observation and palpation

Answer 29

* Malleolar height (R vs L) * Medial longitudinal arch – intact, high (pes cavus), flattened (pes planus)

Question 30

Ankle - observation and palpation

Answer 30

* Swelling in lower leg or ankle – joint versus soft tissue * Location of bruising if present

Question 31

Femur and Tibia - observation and palpation

Answer 31

* Tibial inclination, any impression of tibial IR or ER * Lower tibial varus or valgus * Tibial torsion * Femoral torsion * Muscle bulk (esp. calf)

Question 32

pelvis - observation and palpation

Answer 32

* Iliac crest heights R vs L * Symmetry of height of ASIS

Question 33

spine and trunk - observation and palpation

Answer 33

- Symmetry of shoulders * Abdominal tone (lower abdominal wall, external oblique, rectus abdominis)

Question 34

Standard Procedure for all Functional Movements

Answer 34

- informed consent - test unaffected side - before movement ask about symptoms instruct the patient - perform moveemnt - record

Question 35

Examples of functional movements/tasks for the lower limb:

Answer 35

* Walking: assess gait speed (1.2m/s for community ambulation, Langlois et al, 1997; normative values dependent on age and gender, Bohannon & Andrews, 2011) * 10MWT * TUG * Walking on toes and heels, medial and lateral foot borders * Heel raise (bilateral +/- unilateral) * Standing on one leg (+/- higher level proprioceptive challenges) * Single Leg Squat * Standing hip flexion * Squat o 1⁄4 Squat, 1⁄2 Squat etc. * Steps/stairs * Sit to stand. * Sitting – cross legs, figure 4 * Jumping (Landing Error Scoring System) * Hopping * Jog or running * Foot loading (from non-weight bearing to weight bearing) * Picking something up off the floor, putting on a sock (lumbar/pelvis/hip) * Activities described by the patient in patient interview. * Dorsiflexion in WB/Lunge Test (Knee-to-wall test)

Question 36

DF in WB/Lunge Test/Knee to Wall Test

Answer 36

* Patient standing with foot perpendicular to wall with middle of calcaneus & 2nd toe on a line perpendicular to wall. * Lunge forward with knee until anterior knee just touches wall with the heel and foot in remaining in position above. * Ensure heel does not lift. * Use tape measure to record - 10cm is normal

Question 37

Assessment of active and passive physiological movement and clearning tests - hip

Answer 37

hip joint quadrant or F/Add test

Question 38

Assessment of active and passive physiological movement and clearning tests - knee

Answer 38

- Flexion (allowing hip flexion), with abduction/adduction - extension, with abduction/adduction