Professional Documents
Culture Documents
Yueh-Ling Hsieh
Department of Physical Therapy
China Medical University
Required fundamentals
• Anatomy and surface anatomy
• Kinesiology and Biomechanics
• Basic assessment and special orthopedic tests
• Clinical reasoning
• Treatment selection
• Manual therapy
• Modality
• Movement (therapeutic exercise)
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Correct PT findings (diagnosis)
• functional anatomy
• an accurate patient history
• diligent observation
• a thorough examination
Differential diagnosis (DD) process
• use of clinical signs and symptoms
• Physical examination
• a knowledge of pathology and mechanisms of injury
• provocative and palpation (motion) tests
• laboratory and diagnostic imaging techniques
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James Cyriax
(October 27, 1904 – June 17, 1985)
• “Diagnosis is only a matter of applying one’s anatomy.
• developed a series of simple objective clinical exams that
would effectively diagnose soft tissue musculoskeletal
lesions.
• His collected results, after many years of trial and error,
coalesced into a set of systematic simple clinical exams
for each joint and a treatment system for the soft tissue
lesions around each joint.
James Cyriax
主動被動都會痛
• Cyriax‘s Rule states 韌帶 關節囊 軟骨出問題
• pain with both active range of motion and passive
range of motion in the same direction points to inert
tissue dysfunction (ligament, capsular, cartilage).
• Pain with active range of motion in one direction and
pain with passive range of motion in the opposite
direction signal contractile tissue dysfunction.
主動會痛 被動反向會痛
會收縮的組織受傷contractile
肌腱肌肉
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檢查
– Systematic examination utilizing tests and measures 轉介與否
– History, subjective, physical examinations
– Evaluation of the outcomes obtained from the examination
評估 – Interpretation of the meaning and the “overall picture”
Based on the assessment outcomes and the evaluation process, determine
診斷 the most likely provisional and secondary diagnosis
– Based on the diagnosis, determine the likely prognosis in order to formulate a
預後 treatment plan, discharge plan and follow up plan
– Based on the plan of care, design the “Procedural Intervention”
– Must also include coordination, communication, documentation, instruction,
consultation and referral
Re‐Examination
– Examination of treatment outcome and modify if necessary
© 2014 by American Physical Therapy Association
Sequential methods of PT assessment
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History taking and observation
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Patient history_ listening and query
• A complete medical and injury history should be taken and written to
ensure reliability.
• Speaking at a level and using terms the patient will understand
• Taking the time to listen
• Being empathic, interested, caring, and professional
• Subjective assessment
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Patient history
– More important to be able to identify the presence of any Red flags or
Yellow flags
the examiner should listen for any potential red flag signs and symptoms
Refer for medical management when necessary
– To confirm that this is a Musculoskeletal PT “treatable” condition
• A scanning examination to determine if the symptoms are related to the spine or
extremities
indicate the problem is not a musculoskeletal one or a more serious problem that should
Red Flag be referred to the appropriate health care professional.
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Yellow Flag
denote problems that may be more
severe or may involve more than one area:
1. requiring a more extensive examination
2. may relate to cautions and contraindications
to treatment
3. may indicate overlying psychosocial issues
that may affect treatment
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Patient’s age and sex
• Legg‐Perthes disease(osteonecrosis or avascular necrosis in child) or Scheuermann
disease (juvenile kyphosis), are seen in adolescents or teenagers.
• Degenerative conditions, such as osteoarthritis and osteoporosis, are more likely to be
seen in an older population.
• Shoulder impingement:
• Younger (15‐35 yo):muscle weakness, primarily in the muscles controlling in
scapulae
• Older people (40+ years) :degenerative changes in the shoulder complex.
• Cancer:
• Male: prostate, bladder
• Female: breast, cervical
Patient’s occupation
• What does the patient do at work?
• What is the working environment like?
• What are the demands and postures assumed?
• Laborer: occupational injury
• a sedentary worker: overstress their muscles or joints on weekends
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Reasons for PT helps
• History of the present illness or chief complaint
• describe in their own words what is bothering them and the
extent to which it bothers them.
•
• It is important for the clinician to determine what the
patient wants to be able to do functionally and what the
patient is unable to do functionally.
解決功能性問題
Trauma (macrotrauma)
Repetitive activity (microtrauma)
• what was the mechanism of injury? (macrotrauma)
e.g. Motor vehicle accident: Roles? Part of the car was hit? Speed?
determine the direction and magnitude of the injuring force and how the
force was applied.
determine which structures were injured and how severely by knowing
the force and mechanism of injury.
• any predisposing factors? (microtrauma)
• Determine whether there were any predisposing, unusual, or new factors
• sustained postures or repetitive activities, general health, or familial or genetic
problems
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The onset of patient’s problems
• slow or sudden?
• as an insidious, mild ache and then progress to continuous pain?
• a specific episode in which the body part was injured?
• Inciting trauma has occurred? location of the problem
• Does the pain get worse as the day progresses?
• Was the sudden onset caused by trauma, or was it sudden with locking
because of muscle spasm (spasm lock) or pain?
• Is there anything that relieves the symptoms?
Symptoms bothering the patient
• Does the patient point to a specific structure or a more general area?
Ask the patient to point to the area with symptoms.
consider the yellow flag
• the dominant or nondominant side been injured?
the dominant side may lead to greater functional limitations.
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Yellow Flag
denote problems that may be more
severe or may involve more than one area:
1. requiring a more extensive examination
2. may relate to cautions and contraindications
to treatment
3. may indicate overlying psychosocial issues
that may affect treatment
Pain dimensions or other symptoms
• Severe: is unable to move in a certain direction or hold a particular posture
• Irritable: the symptoms or pain become progressively worse with movement or
the longer a position is held
• Acute pain: severe, continuous, disabling, irritable, anxiety
• Chronic pain: aggravating, depression
• Peripheral sensitization: primary hyperalgesia (affecting PNS)
• Central sensitization: secondary hyperalgesia (involving CNS)
• Referred pain: felt deeply and radiates segmentally without crossing the
midline.
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• Pain also may shift as the lesion shifts.
• Lesion worsens: the area of pain
enlarges or becomes more distal
• Lesion improves: becomes smaller
or more localized
• Pain occurs only at the end of the ROM, in
part of the range, or throughout the ROM?
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Movements or activities that cause pain
不能在問診時叫病人做
• the examiner should not ask the patient to do the movements
or activities; this will take place during the examination.
• With cessation of the activity, does the pain stay the same, or how long
does it take for the pain to return to its previous level?
• Are there any other factors that aggravate or help to relieve the pain?
• Do these activities alter the intensity of the pain?
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Duration of the problem existed
• What are the duration and frequency of the symptoms?
Acute: present for 7 to 10 days
Subacute: present for 10 days to 7 weeks
Chronic: present for longer than 7 weeks
Acute on chronic cases: the injured tissues usually have been
reinjured.
Do not confuse with inflammatory phases!
Pain condition
• occurred before? 以前發生
• Where was the site of the original condition, and has there been any
radiation (spread) of the symptoms?
• how long did the recovery take? Did any treatment relieve symptoms?
• Does the current problem appear to be the same as the previous problem,
or is it different? If it is different, how is it different?
• McGill‐Melzack pain questionnaire and its short form
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10‐2 六
PPI
McGill‐Melzack pain questionnaire _short form
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Pain duration and frequency
• Constant, periodic, episodic (occurring with certain activities), or
occasional
Constant pain suggests chemical irritation, tumors, or possibly
visceral lesions
Periodic or occasional pain: is more likely to be mechanical and
related to movement and stress.
Episodic pain: is related to specific activities.
Pain associated with certain condition or
postures or visceral function
• Pain on activity that decreases with rest usually indicates a mechanical problem
interfering with movement, such as adhesions.
• Morning pain with stiffness that improves with activity usually indicates chronic
inflammation and edema, which decrease with motion.
• Pain or aching as the day progresses usually indicates increased congestion in a
joint.
• Pain at rest and pain that is worse at the beginning of activity than at the end
implies acute inflammation.
• Pain that is not affected by rest or activity usually indicates bone pain or could
be related to organic or systemic disorders, such as cancer or diseases of the
viscera.
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Pain associated with certain condition or
postures or visceral function
• Chronic pain is often associated with multiple factors, such as fatigue or
certain postures or activities.
• pain occurs at night, the posture of patient lies in bed: supine, sidelying, or
prone?
• Intractable pain at night may indicate serious pathology (e.g., a tumor).
• Visceral pain: Movement seldom affects, unless the movement compresses
or stretches the structure.
Pain associated with certain condition or
postures or visceral function
• Peripheral nerve entrapment (e.g., carpal tunnel syndrome) and thoracic
outlet syndromes tend to be worse at night.
跛行
• Pain and cramping with prolonged walking may indicate lumbar spinal
stenosis (neurogenic intermittent claudication) or vascular problems
(circulatory or vascular intermittent claudication).
• Intervertebral disc pain is aggravated by sitting and bending forward. 坐立難安
• Facet joint pain is often relieved by sitting and bending forward and is
aggravated by extension and rotation. 前彎較不痛
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Pain associated with certain condition or
postures or visceral function
• Foam pillows often cause more problems for persons with cervical
disorders because these pillows have more “bounce” to them than do
feather or buckwheat pillows.
• Too many pillows, pillows improperly positioned, or too soft a mattress
may also cause problems.
Quality of pain
• Nerve pain tends to be sharp (lancinating), bright, and burning and also tends to
run in the distribution of specific nerves. 在這裡輸入文字
• the sensory distribution of nerve roots (dermatomes) and peripheral nerves as the
different distributions may tell where the pathology or problem is if the nerve is involved.
• Bone pain tends to be deep, boring, and localized.
• Vascular pain tends to be diffuse, aching, and poorly localized and may be
referred to other areas of the body.
• Muscle pain is usually hard to localize, is dull and aching, is often aggravated by
injury, and may be referred to other areas
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Quality of pain
• Muscle is injured, when the muscle contracts or is stretched, the pain will
increase.
• Inert tissue, such as ligaments, joint capsules, and bursa, tend to exhibit pain
similar to muscle pain; however, pain in inert tissue is increased when the
structures are stretched or pinched.
• Neuropathic pain
鈍痛
灼熱
深
尖銳
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Pain involved nervous systems
• problem is in bone: very little radiation of pain.
• pressure is applied to a nerve root, radicular pain (radiating pain) results
from pressure on the dura mater, which is the outermost covering of the
spinal cord.
• pressure on the nerve trunk, no pain occurs, but there is paresthesia, or an
abnormal sensation, such as a “pins and needles” feeling or tingling.
• Autonomic pain is more likely to be a burning type of pain.
感覺異常 神經根 主幹壓迫
• Referred pain
Joint locking, unlocking, twinges,
instability, or giving way
• Locking and Pseudolocking (not in a certain postion)
• Spasm locking may mean that the joint cannot be put through a
full ROM because of muscle spasm or because the movement was
too fast
• Giving way is often caused by reflex inhibition or weakness of the
muscles, and so the patient feels that the limb will buckle if
weight is placed on it or the pain will be too great.
caused by anticipated pain or instability.
• Laxity (nonpathology) and hypermobility (pathology)
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Joint instability
• Instability can cover a wide range of pathological hypermobility
• Translational instability :a loss of control of arthrokinematic
joint movements (e.g., spin, slide, roll, translation) when the
patient attempts to stabilize (statically or dynamically)
• Anatomical instability (clinical or gross instability, or
pathological hypermobility) : subluxation or dislocation
Joint instability
Functional instability: implies an inability to control either
arthrokinematic or osteokinematic movement in the available ROM either
consciously or unconsciously during functional movement.
be evident during high‐speed or loaded movements.
Voluntary instability: initiated by muscle contraction
Involuntary instability: the result of positioning.
Circle concept of instability: states that injury to structures on one side of
a joint leading to instability can, at the same time, cause injury to structures
on the other side or other parts of the joint.
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Bilateral spinal cord symptoms, fainting, or
drop attacks
Severe neurological problems: should be emergency conditions
potentially requiring surgery.
• bowel/bladder incontinence
Cervical myelopathy, cauda equina syndrome
• “saddle” anesthesia: abnormal sensation in the
perianal region, buttocks, and superior aspect of
the posterior thighs)
cauda equina syndrome
Bilateral spinal cord symptoms, fainting, or
drop attacks
• Severe neurological problems: should be emergency
conditions potentially requiring surgery.
• “Vertigo” (severe) and “dizziness” : a swaying, spinning sensation
accompanied by feelings of unsteadiness and loss of balance.
• Drop attacks occur when the patient suddenly falls without warning or
provocation but remains conscious.
brain involvement
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Skin color
• circulatory problems (ischemia): white, brittle skin; loss of
hair; and abnormal nails on the foot or hand.
Raynaud’s disease
Raynaud’s disease
• Reflex sympathetic dystrophy (RSD) :Complex regional
pain syndrome (CRPS), an autonomic nerve response to
trauma
Usually starting in a limb, it manifests as extreme pain,
swelling, limited range of motion, and changes to the skin
and bones.
Reflex sympathetic dystrophy (RSD)
Psychological stress
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Physical disease or illness behaviors
Family or developmental history
• Tumors
• Arthritis
• Heart disease
• Diabetes
• Allergies
• Congenital anomalies
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Observation
• the “looking” or inspection phase.
• Its purpose is to gain information on visible defects, functional deficits, and
abnormalities of alignment.
• note the patient’s way of moving as well as the general posture, manner, attitude,
willingness to cooperate, and any signs of overt pain behavior.
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Pain behaviors
(observation)
Observation
• body alignment: asymmetric? 對稱
• obvious deformity
• Structural deformities : torticollis, fractures, scoliosis, and kyphosis.
• Functional deformities: the result of assumed postures and disappear when posture is
changed.
a scoliosis due to a short leg seen in an upright posture disappears on forward flexion.
A pes planus (flatfoot) on weight bearing may disappear on non‐weight‐bearing.
• Dynamic deformities: caused by muscle action and are present when muscles contract or
joints move.
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Observation
• Body and soft‐tissue (e.g., muscle, skin, fat) contours:
normal and symmetric? Is there any obvious muscle
wasting?
• Limb positions equal and symmetric: compare limb size,
shape, position, any atrophy, color, and temperature with
nonaffected side. 跟好邊比較
• pelvic position: keep, hold and control the neutral pelvic
position during movement?
• the color and texture of the skin: ecchymosis (bleeding),
cyanosis, or a bluish (ischemia), Redness (blood flow
increase or inflammation), scars (keloid?)
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ecchymosis (bleeding)
跟上面的肌肉比
calf muscle pseudohypertrophy
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Observation
病人無意中做出來的
• Audible crepitus, snapping (tendon moving), or abnormal sound in the
joints
• Inflammation sign: heat, swelling, or redness
• Patient’s attitude: psychological state
attitude toward their own problems and toward you?
– Don’t be “judgmental”
– Apprehensive, restless, resentful, depressed?
– Facial expressions?
– Willingness to participate in the treatment?
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Summary
• On completion of the observation phase of the assessment, the examiner should
return to the original preliminary working diagnosis made at the end of the history
to see if any alteration in the diagnosis should be made with the additional
information found in this phase.
• History taking combined with observation in the same time
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