Principles of Neuromusculoskeletal Examination

• Subjective examination: 

  The interview  

  Communication 

  Rapport 

  Establishing what needs to be assessed 

  AIMS – to obtain info from patients 

  Determine – severity, irritability, nature  

  Make a hypothesis 

  Plan a safe objective exam to prove/disprove hypothesis  

   
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  What is the problem?  

  Why is there a problem?  

  How did it come about?  

  What impact is the problem having?  

  What factors may influence recovery? 

   
• Objective examination: 

  Testing of structures  

  Based on subjective examination findings 

  May take longer, to be done after an initial subjective examination 
• Communication: 

  Body language 

  Tone of voice 

  Motivational attitude – build a therapeutic alliance 

  Questioning style is very important 

  Listen to patient 
• Interview technique: 

  Structured - physiotherapist leads  

  Unstructured - patient leads 
• Behaviour of symptoms: 

  • Constant/ intermittent/ occasional  
  • Aggravating/easing factors- time taken  
  • Morning: On waking, On rising  
  • Afternoon  
  • Nocturnal 
• Severity – The degree to which symptoms affect function/ pain intensity  

  Could use VAS to score out of 10 

  
  

  Irritability – the degree to which the symptoms increase with provocation and how quickly they ease 

  How long to aggravate/ease 

  This helps plan our assessment 
• What to ask

  The History of Present Condition (HPC)

  Past medical history

  Drug history

  Family history

  Social history

  Occupation

  Leisure

  Home responsibilities
• Red flag Questions: 

  • Caution/contraindications  
  • CNS involvement  
  • Malignancy  
  • Serious systemic illness  
  • Active inflammatory joint disease  
  • Drug history/abuse 

   

  Cauda equina compression: 

  • Causes – includes disc extrusion, stenosis, tumour, etc  
  • Potential surgical emergency  
  • Very limited capacity for natural recovery  
  • Symptoms-saddle anaesthesia, bladder/bowel dysfunction, bilateral sciatica 
• Yellow Flag Issues: 

  • External Locus of Control 
  • Fear Avoidance behaviour 
  • Low mood and withdrawal from social interaction 
  • Expectation of passive solution 

   

  A – Attitude about pain  

  B – Behaviours  

  C – Compensation Issues  

  D – Diagnosis & Treatment 

  E – Emotions  

  F – Family  

  W – Work 
• Formulation of hypothesis: 

  • Structures involved in production of symptoms.  
  • Stage of the disease/healing process  
  • Prognosis  
  • Severity, irritability of the problem 
• Objective examination- aims: 

  • Confirm/disprove hypothesis  
  • Establish baseline data for re-assessment & evaluation  
  • Contraindications/precautions  
  • Make clinical diagnosis  
  • Identify problems & goals for management 
• Planning the objective examination: 

  • Must/should/could examine as cause of symptoms  
  • Joints in the symptomatic area  
  • Soft tissue in the symptomatic area  
  • Joints, soft tissue, nerve that refers into symptomatic area  
  • Structures that could be affected – e.g. neural integrity 
• SIN factors- the relevance: 

  • Effect of pain on patient 
  • The kind of examination required  
  • Testing to onset of pain  
  • Testing into pain  
  • Testing to limit of available range 
• The objective examination: 

  •  Observation  
  • Functional demo   
  • Active movements  
  • Passive movements  
  • Accessory movements   
  • Muscle tests  
  • Palpation  
  • Special tests 
• Observation: 

  Formal and informal  

  Functional deficits 

  Abnormalities  

  Asymmetries 

  Gait 

   

  Look for:  

  Muscle wasting  

  Swelling   

  Scars   

  Skin changes  

  Bony alignment  

  Positional deformities 

   

  Functional Demonstration or Quick Test: 

  Ask patient to perform their aggravating movement  

  Detection of abnormal/ antalgic movement patterns 

  Objective markers 
• Active/passive physiological movements: 

  • Look to reproduce symptoms  
  • Consider structures stretched/compressed  
  • Willingness to move  
  • Pain at rest and SIN 

   

  • Range of movement 
  • Pain  
  • Behaviour   
  • Limiting factor  
  • Quality of movement   
  • End-feel -normal/abnormal 

   

  • Over-pressure  
  • Combined movements   
  • Sustained  
  • Rapid movements  
  • Move under compression 

   

   
• Passive ROM: 

  If active ROM was restricted test passively  

  Look for difference in ROM  

  Assess end feel  

  Assess for quality/crepitus etc 

   
• Muscle testing: 

  • Groups before individual muscles  
  • Isometric testing   
  • ? Reproduction of pain  
  • Through range testing – more functional  
  • Grading of strength   
  • Weakness or inhibition  
  • Length and strength 

   
• Neural Provocation (dynamic) tests: 

  Ability of nervous system to be subjected to tensile loading  

  Tests nerves, connective tissues, associated blood vessels  

  Test / retest after treatment 

   
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  Positive findings:  

  Reproduction of symptoms  

  Change of symptoms with distant movement  

  Different response from “normal”  
• Summary of assessment – analysis 

  By the end of the examination you should:  

  • Have a clear idea of the SOURCE of symptoms  
  • Have a good understanding of the pathophysiology  
  • Have a clear idea of CAUSE of those symptoms