Chapter 4. Patient/Client Management

At the completion of this chapter, the reader will be able to:

1. Understand the principles and considerations of a comprehensive examination.

2. List the components involved in the continuum of care.

3. Take a complete history.

4. Explain the importance of the systems review.

5. List the components of the tests and measures portion of the examination.

6. Understand the value of a complete observation of the patient and the information that can be gleaned from such an assessment.

7. Describe the differences between a traditional examination and a postsurgical examination.

8. Explain the differences between the examination and the evaluation.

9. Explain how to determine whether a technique is clinically useful.

10. Outline the components of clinical documentation.

Patient/client management comprises five elements:1

1. Examination of the patient

2. Evaluation of the data and the identification of problems

3. Determination of the diagnosis

4. Determination of the prognosis and the plan of care (POC)

5. Implementation of the POC (intervention)

The examination process involves a complex relationship between the clinician and the patient. The aims of the examination process are to provide an efficient and effective exchange and to develop a rapport between the clinician and the patient. The success of this interaction involves a myriad of factors. Successful clinicians are those who demonstrate effective communication, sound clinical reasoning, critical judgment, creative decision making, and competence.

The primary responsibility of a clinician is to make decisions in the best interest of the patient. Although the approach to the examination should vary with each patient, and from condition to condition, there are several fundamental components to the examination process. The principles outlined in this chapter, and integrated throughout this text, are based on the views of a number of experts,2–12 as well as principles I have learned, and used, over the years.

All clinicians should commit to be lifelong students of their profession and should strive toward a process of continual self-education. Part of this process involves the utilization of the expertise of more experienced clinicians. This necessitates that the early years of practice are spent in an environment in which the novice is surrounded by a staff of varying levels of clinical and life experiences, both of which can serve as valuable resources. The clinician can also improve by investing time in reading relevant material, attending continuing education courses, completing home study courses, watching videos specializing in techniques, and observing exceptional clinicians. Exceptional clinicians are those who demonstrate excellent technical skills, combined with excellent people skills.

Finally, one must also never forget that the patient can serve as the most valuable resource. Each interaction with a patient is an opportunity to increase knowledge, skill, and understanding. Integral to this relationship is patient confidentiality. Patient confidentiality must always be strictly adhered to. Except when discussing the patient's condition with other clinicians with the object of teaching or learning, the clinician should not discuss the patient's condition with anyone without the patient's permission.

Much about becoming a clinician relates to an ability to communicate with the patient, the patient's family, and the other members of the health-care team. The nonverbal cues are especially important, because they often are performed subconsciously. Special attention needs to be paid to cultural diversity and to nonverbal communication such as voice volume, postures, gestures, and eye contact. The appearance of the clinician is also important, if a professional image is to be projected.

Communication between the clinician and the patient begins when the clinician first meets the patient and continues throughout any future sessions. Communication involves interacting with the patient using terms he or she can understand, and being sensitive to cultural diversity as appropriate. The introduction to the patient should be handled in a professional yet empathetic tone. Listening with empathy involves understanding the ideas being communicated and the emotion behind the ideas. In essence, empathy is seeing another person's viewpoint, so that a deep and true understanding of what the person is experiencing can be obtained.

At the end of the first visit and at subsequent visits, the clinician should ask if there are any questions. Each session should have closure, which may include a handshake, if appropriate.

Examination Considerations

An examination refers to the gathering of information from the chart, other caregivers, the patient, the patient's family, caretakers, and friends in order to identify and define the patient's problem(s) and to design an intervention plan.14 In contrast, an evaluation is the level of judgment necessary to make sense of the findings in order to identify a relationship between the symptoms reported and the signs of disturbed function.14

The examination is an ongoing process that begins with the patient referral or initial entry and continues throughout the course of rehabilitation. During the examination phase, the clinician hypothesizes the clinical problem then chooses and implements measures to test the hypotheses. The examination must be performed with a scientific rigor that follows a predictable and strictly ordered thought process. The purpose of the examination is to obtain information that identifies and measures a change from normal. This is determined using information related by the patient, in conjunction with clinical signs and findings. The examination should not be viewed as an algorithm. Rather, it is a framework that has specific points that can be applied to various situations. The strength of an examination relies on the accuracy of the findings of the testing procedures. Diagnostic tests are divided into two main categories:15

1. Tests that result in a discrete outcome—they permit interpretations from the test as present/absent, disease/not disease, mild/moderate/severe.

2. Tests that result in a continuous outcome—they provide data on an interval or a scale of measurement such as degrees of range of motion.

For the clinician to formulate an appropriate interpretation and an accurate final diagnosis, the tests chosen must be useful. Reliability, validity, and significance are essential in determining the usefulness of a test (see Evaluation):

• Reliability. A test is considered reliable if it produces precise, accurate, and reproducible information.16
• Validity. Test validity is defined as the degree to which a test measures what it purports to be measuring, and how well it correctly classifies individuals with or without a particular disease.17–19
• Significance. The term significance is used in statistics to describe the probability of something happening. A study generally will give a value of p for any conclusions they draw (see Evaluation).

The Examination

Examination tools can be divided into two categories:20

• Performance-based or self-report measures. Performance-based measures involve the clinician's performance of the test or observation of the patient's performance. Examples include assessment of joint mobility, muscle strength, or balance. Self-report measures involve the patient rating his or her performance during activities such as walking, stair climbing, or sporting activity based on the ability to perform a task, difficulty with the task, help needed for the task, and pain during performance of the task. For example, the Fear Avoidance Beliefs Questionnaire (FABQ),21 which was originally designed to help measure how much fear and avoidance impacted a patient with low back pain thereby helping to identify those patients for whom psychosocial interventions may be beneficial (Table 4-1). However, the scale can be modified to apply to patients with other types of chronic pain as only two items mention the word “back”. The scoring for the FABQ is outlined in Table 4-2.
• Generic or disease-specific measures. A number of generic or disease-specific measures currently exist that examine the performance of functional activities. Disease-specific measures are questionnaires that concentrate on a region of primary interest that is generally relevant to the patient and clinician.22 As a result of this focus on a regional disease state, the likelihood of increased responsiveness is higher. Some examples of the primary focus of these instruments include populations (rheumatoid arthritis), symptoms (back pain), and function (activities of daily living).22 The disadvantage of a disease-specific outcome is that general information is lost, and therefore, it is generally recommended that when evaluating patient outcomes, both a disease-specific and generic outcome measure should be used.22

Patient discomfort should always be kept to a minimum. It is important that examination procedures only be performed to the point at which symptoms are provoked or begin to increase, if they are not present at rest.

The examination consists of three components of equal importance: (1) patient history, (2) systems review, and (3) tests and measures.14 These three components are closely related, in that they often occur concurrently. One further element, observation, occurs throughout.

History

The history taking, specific to each joint, is detailed in each of the chapters. The history usually precedes the systems review and the tests and measures components of the examination, but it may also occur concurrently. Whenever it occurs, it should always be used in conjunction with the findings from the system review and the tests and measures rather than performed in a vacuum. One of the purposes of the history (Table 4-3) is to focus the examination, especially if the clinician has a good understanding of the underlying anatomy and biomechanics. There has been a recent trend to put less emphasis on the history and use the results from imaging studies to determine a clinical diagnosis, which is ironic given the fact that much of these diagnostic tests would be unnecessary if more attention was paid to the clinical examination.24 Indeed, multiple studies have demonstrated the incidence of MRI abnormalities in the spine,25 the shoulder,26 the knee,27 and other areas in normal subjects. Obviously, an improper diagnosis leads to an inappropriate treatment.

Ideally, the interview of a patient should be conducted in a quiet, well-lit room that offers a measure of privacy. To encourage good communication, the clinician and the patient should be at a similar eye level, facing each other, with a comfortable space between them (approximately 3 feet). The clinician must record the history in a systematic fashion so that every question has a purpose and no subject areas are neglected. Formal questioning using a questionnaire (Table 4-4) helps to ensure that all of the important questions are asked. Knowing the importance of each question is based on the didactic background of the clinician, as is the ability to convert the patient's responses into a working hypothesis. For example, if the patient reports that lumbar flexion relieves their low-back pain, but that lumbar extension aggravates it, the clinician needs to know which structures are stressed in lumbar extension, but unstressed in lumbar flexion.

The method of questioning should be altered from patient to patient, as the level of understanding and answering abilities varies between each individual. In general, the interview should flow as an active conversation, not a question-and-answer session. A transfer of accurate information must occur between the patient and the clinician. A successful learning process requires the clinician to have patience, focus, and self-criticism.6

Open-ended questions or statements, such as “Tell me why you are here,” are used initially to encourage the patient to provide narrative information, help determine the patient's chief complaint, and to decrease the opportunity for bias on the part of the clinician.29 More specific questions, such as “How did this pain begin?” are asked as the examination proceeds (Table 4-5). The specific questions help to focus the examination and deter irrelevant information. The clinician should provide the patient with encouraging responses, such as a nod of the head, when the information is relevant and when needed to steer the patient into supplying necessary information. Neutral questions should be used whenever possible. These questions are structured in such a way so as to avoid leading the patient into giving a particular response. Leading questions, such as “Does it hurt more when you walk?” should be avoided. A more neutral question would be, “What activities make your symptoms worse?”

In addition to the details listed in Table 4-5, the history can help the clinician to:

• develop a working relationship with the patient and establish lines of communication with the patient. To help establish a rapport with the patient, the clinician should discuss the information provided on the medical history form with the patient, at either the initial or the subsequent visits.
• determine the chief complaint, its mechanism of injury, its severity, and its impact on the patient's function. It is worth remembering that a patient's chief complaint can sometimes differ from the chief concern, but both should be addressed.
• ascertain the specific location and the nature of the symptoms.
• determine the irritability of the symptoms.
• establish a baseline of measurements.
• ascertain which medications the patient is currently taking and whether they are prescribed or over the counter (see Chap. 9).
• elicit information about the past history of the current condition.
• determine the goals and the expectations of the patient from the physical therapy intervention. It is important that the clinician and the patient discuss and determine mutually agreed-upon anticipated goals and expected outcomes. The discussion can help the clinician determine whether the patient has realistic expectations or will need further patient education concerning his or her condition and typical recovery time frames.

• elicit reports of potentially life-threatening symptoms, or red flags, that require an immediate medical referral (see Chap. 5).

The components of the patient history described in this section are based on the Guide to Physical Therapist Practice.14

Age

Certain conditions are related to age, ethnicity, gender, morphology, and family history. For example,

• degenerative and overuse syndromes are more frequent in the over 40 age group.
• cervical spondylosis is often seen in persons 25 years of age or older, and it is present in 60% of those older than 45 years and 85% of those older than 65 years of age.30–32
• the onset of ankylosing spondylitis often occurs between the ages of 15 and 35 years.33
• both osteoporosis and osteoarthritis are more often associated with the older population.
• diseases such as Legg–Perthes disease or Scheuermann's are seen in adolescents or teenagers.
• prostate cancer has a higher incidence in men older than 50 years.34
• among African-Americans in the United States, 1 in 600 has sickle cell anemia.35
• Caucasians experience higher osteoporotic fracture rates than either Asians or African-Americans.36
• some diseases, such as hypertension and renal disease, are more prevalent in African-American populations than among Caucasians.37,38
  • basal cell carcinoma and melanoma are more common among Caucasians.
  • the male-to-female ratio of bladder cancer is 2:1 to 4:1, and the disease is twice as common in male Caucasians as in African-American men in the United States.39,40
  • breast cancer is the most frequently diagnosed cancer and the second leading cause of cancer-related deaths among women in the United States.41
  • melanoma is the leading cause of cancer death in women aged 25–36 years.42
  • anterior knee pain caused by patellofemoral syndrome is most common in young teenage girls and young men in their 20s.43
  • obesity has been linked to many diseases such as diabetes, cardiovascular disease, and degenerative joint disease.
  • many diseases can be linked to family history, including diabetes, cardiovascular disease, and Charcot Marie Tooth disease.

History of Current Condition

This portion of the history taking can prove to be the most challenging as it involves the gathering of both positive and negative findings, followed by the dissemination of the information into a working hypothesis. An understanding of the patient's history of the current condition can often help determine the prognosis and guide the intervention.

The clinician should determine the circumstances and manner in which the symptoms began and the progression of those symptoms.6 The mode of onset, or the mechanism of injury, can be either traumatic (macrotraumatic) or atraumatic (microtraumatic) and can give clues as to the extent and nature of the damage caused.

If the injury is traumatic, the clinician should determine the specific mechanism, in terms of both the direction and the force, and relate the mechanism to the presenting symptoms. If the injury is recent, an inflammatory source of pain is likely. A sudden onset of pain, associated with trauma, could indicate the presence of an acute injury such as a soft tissue tear or even a fracture, whereas immediate pain and locking are most likely to result from an intra-articular block. Joint locking and twinges of pain may indicate a loose body moving within the joint. Reports of a joint “giving way” usually indicate joint instability or a reflex inhibition or weakness of muscles. An injury that is not recent but which the symptoms have persisted could indicate a biomechanical dysfunction. Oftentimes a particular motion or posture may continue to aggravate the condition.

If the onset is gradual or insidious, the clinician must determine if there are any predisposing factors, such as changes in the patient's daily routines or exercise programs. Symptoms of pain or limitations of movement, with no apparent reason, are usually a result of inflammation, early degeneration, repetitive activity (microtrauma), or sustained positioning and postures.44 However, such symptoms may also be associated with something more serious, such as a vascular insufficiency, a tumor, or an infection.

If pain is present, the clinician's major focus should be to seek the cause and methods to control it. Pain may be constant, variable, or intermittent. Variable pain is pain that is perpetual, but that varies in intensity. Variable pain usually indicates the involvement of both a chemical and a mechanical source. The mechanical cause of constant pain is less understood but is thought to be the result of the deformation of collagen, which compresses or stretches the nociceptive-free nerve endings, with the excessive forces being perceived as pain.45 Thus, specific movements or positions should influence pain of a mechanical nature.

Chemical, or inflammatory, pain is more constant and is less affected by movements or positions than mechanical pain. Intermittent pain is unlikely to be caused by a chemical irritant. Usually, this type of pain is caused by prolonged postures, a loose intra-articular body, or an impingement of a musculoskeletal structure.

Unfortunately, the source of the pain is not always easy to identify, because most patients present with both mechanical and chemical pain.

Finally, the clinician should determine if a specific intervention has been used in the past for the same condition and, if so, the clinician should ask about the effectiveness of that intervention.

Location

The clinician should determine the location of the symptoms because this can indicate which areas need to be included in the physical examination. Information about how the location of the symptoms has changed since the onset can indicate whether a condition is worsening or improving. In general, as a condition worsens, the pain distribution becomes more widespread and distal (peripheralized). As the condition improves, the symptoms tend to become more localized (centralized). A body chart may be used to record the location of symptoms (see Fig. 4-1).

It must be remembered that the location of symptoms for many musculoskeletal conditions is quite separate from the source, especially in those peripheral joints that are more proximal, such as the shoulder and the hip. For example, a cervical radiculopathy can produce symptoms throughout the upper extremity. The term referred pain is used to describe symptoms that have their origin at a site other than where the patient feels the pain. For example, pain due to osteoarthritis of the hip is often felt in the anterior groin and thigh along with the sclerotomes or the dermatomes for L2 and L3. The concept of referred pain is often difficult for patients to understand. An explanation of referred pain enables the patient to better understand and answer questions about symptoms they might otherwise have felt irrelevant. The major sources of referred pain are neurogenic, vasculogenic, viscerogenic, and spondylogenic (see Chap. 3). If the extremity appears to be the source of the symptoms, the clinician should attempt to reproduce the symptoms by loading the peripheral tissues. If this proves unsuccessful, a full investigation of the spinal structures must ensue.

Behavior of Symptoms

The presence of pain should not always be viewed negatively by the clinician. After all, its presence helps to determine the location of the injury, and its behavior aids the clinician in determining the stage of healing and the impact it has on the patient's function. For example, whether the pain is worsening, improving, or unchanging provides information on the effectiveness of an intervention. In addition, a gradual increase in the intensity of the symptoms over time may indicate to the clinician that the condition is worsening or that the condition is nonmusculoskeletal in nature (Table 4-6).6,46

Maitland7 introduced the concept of the degree of irritability. An irritable structure has the following characteristics:

• A progressive increase in the severity of the pain with movement or a specific posture. An ability to reproduce constant pain with a specific motion or posture indicates an irritable structure.
• Symptoms increased with minimal activity. An irritable structure is one that requires very little to increase the symptoms.
• Increased latent response of symptoms. Symptoms that do not resolve within a few minutes following a movement or posture indicate an irritable structure.

According to McKenzie and May,44 the intervention for the patient whose symptoms have a low degree of irritability and which are gradually resolving should focus only on education initially. However, if the improvement ceases, a mechanical intervention may then be necessary.44

The frequency and duration of the patient's symptoms can help the clinician to classify the injury according to its stage of healing: acute (inflammatory), sub-acute (migratory and proliferative), and chronic (remodeling) (Table 4-7)(see Chap. 2).

• Acute conditions: present for 7 to 10 days.
• Subacute conditions: present for 10 days to several weeks.
• Chronic conditions: present for more than several weeks.

In the case of a musculoskeletal injury that has been present without any formal intervention for a few months, there is a good possibility that adaptive shortening of the healing collagenous tissue has occurred, which may result in a failure to heal, and the persistence of symptoms.44 The persistence of symptoms usually indicates a poorer prognosis, as it may indicate the presence of a chronic pain syndrome. Chronic pain syndromes have the potential to complicate the intervention process (see Chap. 5).44

If the frequency and duration of the patient's symptoms are reported to be increasing, it is likely the condition is worsening. Conversely, a decrease in the frequency and duration of the symptoms generally indicate that the condition is improving.

One of the simplest methods to quantify the intensity of pain is to use a 10-point visual analog scale (VAS). The VAS is a numerically continuous scale that requires the pain level be identified by making a mark on a 100-mm line, or by circling the appropriate number in a 1–10 series (Table 4-8).47 The patient is asked to rate his or her present pain compared with the worst pain ever experienced, with 0 representing no pain, 1 representing minimally perceived pain, and 10 representing pain that requires immediate attention.48

If the behavior of the symptoms includes locking or giving way, the clinician must elicit further details about the causes of the hypomobility, the hypermobility, or the instability (see Chap. 2).

Aggravating and Easing Factors

Of particular importance are the patient's chief complaint and the relationship of that complaint to specific aggravating activities or postures. Questions must be asked to determine whether the pain is sufficient to prevent sleep or to wake the patient at night and the effect that activities of daily living, work, sex, and so forth, have on the pain.

Musculoskeletal conditions are typically aggravated with movement and alleviated with rest. If no activities or postures are reported to aggravate the symptoms, the clinician needs to probe for more information. For example, if a patient complains of back pain, the clinician needs to determine the effect that walking, bending, sleeping position, prolonged standing, and sitting have on the symptoms. Sitting or standing upright increases the lumbar lordosis and can aggravate symptoms in a patient with an anterior instability of the lumbar spine, spondylolisthesis, stenosis, or a lumbar zygapophyseal joint irritation. Sitting in a slouched posture typically aggravates symptoms of a lumbar disk protrusion or a sacroiliac joint dysfunction. Nonmechanical events that provoke the symptoms could indicate a nonmusculoskeletal source for the pain46:

• Eating. Pain that increases with eating may suggest gastrointestinal (GI) involvement.
• Stress. An increase in overall muscle tension prevents muscles from resting.
• Cyclical Pain. Cyclical pain can often be related to systemic events (e.g., menstrual pain).

If aggravating movements or positions have been reported, they should be tested at the end of the tests and measures portion of the examination to avoid any overflow of symptoms, which could confuse the clinician.

Nature of the Symptoms

It is important to remember that pain perception is highly subjective and is determined by a number of factors. The clinician must determine whether pain is the only symptom, or whether there are other symptoms that accompany the pain, such as bowel and bladder changes, tingling (paresthesia), radicular pain or numbness, weakness, and increased sweating.

• Bowel or bladder dysfunction. This finding usually indicates a compromise (compression) of the cauda equina.
• Paresthesia. Peripheral neuropathies can manifest as abnormal, frequently unpleasant sensations, which are variously described by the patient as numbness, pins and needles, and tingling.49 When these sensations occur spontaneously without an external sensory stimulus, they are called paresthesias (Table 4-9).49 Patients with paresthesias typically demonstrate a reduction in the perception of cutaneous and proprioceptive sensations. The seriousness of the paresthesia depends on its distribution. Although complaints of paresthesia can be the result of a relatively benign impingement of a peripheral nerve (see Chap. 3), the reasons for its presence can vary in severity and seriousness.
• Radicular pain. This type of pain is produced by nerve root irritation and is typically described as sharp or shooting. Numbness that has a dermatomal pattern indicates spinal nerve root compression. Radiating pain refers to an increase in pain intensity and distribution. Radiating pain typically travels distally from the site of the injury.
• Weakness. Any weakness should be investigated by the clinician to determine whether it is the result of spinal nerve root compression, peripheral nerve lesion, disuse, inhibition resulting from pain or swelling, injury to the contractile or inert tissues (muscle, tendon, bursa, etc.), or a more serious pathology such as a fracture (see section “Muscle Performance: Strength, Power, and Endurance” in the later discussion of tests and measures).
• Increased sweating. This finding can have a myriad of causes, ranging from increased body temperature, as a result of exertion, fever, apprehension, and compromise, to the autonomic system. Night sweats are of particular concern, because they often indicate the presence of a systemic problem.50

Quality of Symptoms

The quality of the symptoms depends on the type of receptor being stimulated (see Chap. 3).

• Stimulation of the cutaneous A-δ nociceptors leads to pricking pain.51
• Stimulation of the cutaneous C nociceptors results in burning or dull pain.52
• Activation of the nociceptors in muscle by electrical stimulation produces aching pain.53
• Electrical stimulation of visceral nerves at low intensities results in vague sensations of fullness and nausea, but higher intensities cause a sensation of pain.54

Motivational-affective circuits may also mimic pain states, most notably in patients with anxiety, neurotic depression, or hysteria.55 The mnemonic MADISON outlines the behavioral indicators that suggest motivational-affective pain56,57:

1. Multiple complaints, including complaints about unrelated body parts.

2. Authenticity claims in an attempt to convince the clinician that the symptoms exist.

3. Denial of the negative effect the pain is having on function.

4. Interpersonal variability, manifested by different complaints to different clinicians or support staff.

5. Singularity of symptoms, wherein the patient requests special consideration because of his or her type and level of pain.

6. Only you, whereby the clinician is placed at a special level of expertise.

7. Nothing works.

A description of pain is commonly sought from the patient. Because pain is variable in its intensity and quality, describing pain is often difficult for the patient. The McGill Pain Questionnaire (MPQ)58 was the first systematic attempt to use verbal descriptors to assess the quality of the patient's symptoms, and has been the most widely used instrument in pain research and practice (Table 4-10). The MPQ is a self-report inventory of 78 pain descriptors distributed across 20 subcategories (with six additional descriptors in the present pain index). The subcategories are further grouped into three broad categories, termed sensory, affective, and evaluative, respectively, in addition to a miscellaneous category. The implication is that each word reflects a particular sensory quality of pain.

The patient is asked to indicate on a body diagram the location of the pain and to rate his or her symptoms based on the 20 categories of verbal descriptors of pain.59 The 20 categories are ranked according to severity.60 The patient is then asked to describe how the pain changes with time (continuous, rhythmic, or brief) and how strong the pain is (mild, discomforting, distressing, horrible, or excruciating).

The most commonly reported measure from the MPQ instrument, the pain-rating index total, provides an estimate of overall pain intensity. This measure, obtained by summing all the descriptors selected from the 20 subclasses, has a possible range of 0–78. Separate scores for each class may be obtained by summing the values associated with the words selected from subclasses that comprise that dimension. Scores for each of these dimensions vary in range from 0 to 42 for the sensory class, 0 to 14 for the affective class, and 0 to 5 for the evaluative class.

The strength of the MPQ is its ability to distinguish patients with a sensory pain experience from those who have an affective pain experience. The MPQ has been found to be sensitive to intervention effects61 and to have a high test–retest reliability58 and good construct validity.62

Symptom magnification, an exaggerated subjective response to symptoms in the absence of adequate objective findings, is an increasingly common occurrence in the clinic. The patients who display this type of behavior are a difficult population to deal with. The causes of symptom magnification can be categorized into two main patient types:

1. Patients with a psychosomatic overlay and those whose symptoms have a psychogenic cause.

2. Patients who are involved in litigation.

The concept of malingering is discussed in Chapter 5.

Imaging Studies

It is important for the clinician to determine whether the patient has undergone any imaging studies and, if so, the results of those studies. The role that imaging studies play in the examination and evaluation processes is outlined in Chapter 7. It is important to remember that, in general, imaging tests have a high sensitivity (few false negatives) but low specificity (high false-positive rate), so are thus used in the clinical decision-making process to test a hypothesis but should not be used in isolation.

Based on the history, there may be times when the extent of the remainder of the examination may have to be limited. The decision to limit the examination is based on the presence of any subjective features that indicate the need for caution. These features include63

• an irritable or severe disorder;
• worsening symptoms;
• subjective evidence of potential involvement of vital structures, such as the vertebrobasilar system, the spinal cord or the central nervous system (CNS), or the spinal nerve roots;
• symptoms that do not behave in a predictable manner.

Observation

Observational information forms the basis of the early clinical impression. It is, in essence, the beginning of the clinical search for patient consistency and reliability. Observation of the patient begins when the patient enters the clinic. As the clinician greets the patient and takes him or her to the treatment room, an initial observation is made. This early observation can provide the clinician with information that includes, but is not limited to, how the patient holds the extremity, whether an antalgic gait is present, and how much discomfort appears to be present. Much can be learned from thorough observation64:

• How does the patient arise from a seated position to greet the clinician, easily or in a guarded manner?
• Does the patient look directly into the eyes of the clinician or look away? Is there a nervousness or fear present?
• Is there an exaggerated pain response, as demonstrated by facial expression and/or voiced complaints?
• Does the patient sit to the side with the majority of weight on one buttock while the opposite leg is extended, a position associated with a lumbar spinal nerve root syndrome?65–67
• In the case of an adult, is a spouse, or significant other, in attendance and does such a presence seem appropriate? If the presence appears inappropriate, some form of abuse occurring at home should be suspected.
• In the case of a child, is there any unexplained or excessive bruising, and does the parent or guardian appear to be answering for the child? These findings could indicate some form of abuse occurring at home.
• Does the patient require assistance in ambulation, transferring, or changing of clothing?
• Does the patient answer his or her own questions or have an overly attentive assistant (i.e., spouse, parent, friend, or relative)? An overly attentive assistant could indicate some form of abuse occurring at home.
• Do the observation findings match the findings from the history?

Throughout the history, systems review, and tests and measures, collective observations form the basis for diagnostic deductions. Some of the observations made may be very subtle. For example, hoarseness of the voice could suggest laryngeal cancer, whereas a weakened, thickened, and lowered voice may indicate hypothyroidism.68 Warm, moist hands felt during a handshake may indicate hyperthyroidism.68 Cold, moist hands may indicate an anxious patient. Patients react differently to injury. Some patients may exaggerate the symptoms through facial expressions and gestures, whereas others remain stoic. Patients may appear calm and pleasant, defensive, angry, apprehensive, or depressed. Anxious patients, or patients in severe pain, often appear restless. Clinicians must learn to adopt their approaches to these different reactions. For example, an anxious or apprehensive patient may require more reassurance than a calm and pleasant patient.

Much of the observation involves assessment of posture (see Chap. 6). Postural deviations negatively affecting the location of the center of gravity in relation to the base of support may result in a patient complaining of pain and/or dysfunction when in sustained positions. Changes in the contours of the body shape or posture can be so specific that it often is possible to isolate the single muscle involved, the movements affected, and the related joint dysfunction from observation alone.69 For example, a change in a soft tissue contour as compared to the other side could indicate muscle atrophy. These deviations and changes prompt further musculoskeletal examination to determine the cause and potential management strategies. If there are any obvious deformities, the clinician must determine whether they are structural or functional:

• Structural: those deformities present at rest. For example, torticollis, and kyphosis.
• Functional: deformities that are the result of assumed postures and which disappear when the posture is changed. For example, a functional scoliosis due to a leg length discrepancy that disappears when the patient bends forward.

The patient's position of comfort can provide the clinician with valuable information. For example, patients with lateral recess spinal stenosis of the lumbar spine, congestive heart failure, or pulmonary disease often prefer the sitting position, whereas patients with pericarditis often sit and lean forward.68 Patients with a posterior–lateral lumbar disk herniation often prefer to stand or lie rather than sit.

The more formal observation, which is included in each of the relevant chapters, includes, but is not limited to, an analysis of the presence of any asymmetry, scars, crepitus, color changes, and swelling.

Systems Review

The information from the history and the systems review serves as a guide for the clinician in determining which structures and systems require further investigation. The systems review is the part of the examination that identifies possible health problems that require consultation with, or referral to, another health-care provider (Table 4-11).14 The systems review consists of a limited examination of the anatomic and physiologic status of all systems (i.e., musculoskeletal, neurological, cardiovascular, pulmonary, integumentary, GI, urinary system, and genitoreproductive).14 The systems review includes the following components14:

• For the cardiovascular/pulmonary system, the assessment of heart rate, respiratory rate, blood pressure, and edema. There are four so-called vital signs that are standard in most medical settings: temperature, heart rate, blood pressure, and respiratory rate. Pain is considered by many to be a fifth vital sign.70–79 The clinician should monitor at least heart rate and blood pressure in any person with a history of cardiovascular disease or pulmonary disease, or those at risk for heart disease.80
• Temperature. Body temperature is one indication of the metabolic state of an individual; measurements provide information concerning basal metabolic state, possible presence or absence of infection, and metabolic response to exercise.81 “Normal” body temperature of the adult is 98.4°F (37°C). However, a temperature in the range of 96.5–99.4°F (35.8–37.4°C) is not at all uncommon. Fever or pyrexia is a temperature exceeding 100°F (37.7°C).82 Hyperpyrexia refers to extreme elevation of temperature above 41.1°C (or 106°F).81 Hypothermia refers to an abnormally low temperature (below 35°C or 95°F). The temperature is generally taken by placing the bulb of a thermometer under the patient's tongue for 1–3 minutes, depending on the device. In most individuals, there is a diurnal (occurring everyday) variation in body temperature of 0.5–2°F. The lowest ebb is reached during sleep. Menstruating women have a well-known temperature pattern that reflects the effects of ovulation, with the temperature dropping slightly before menstruation, and then dropping further 24–36 hours prior to ovulation.82 Coincident with ovulation, the temperature rises and remains at a somewhat higher level until just before the next menses. It is also worth noting that in adults older than 75 years of age and in those who are immunocompromised (e.g., transplant recipients, corticosteroid users, persons with chronic renal insufficiency, or anyone taking excessive antipyretic medications), the fever response may be blunted or absent.81
• Heart rate. In most people, the pulse is an accurate measure of heart rate. The heart rate or pulse is taken to obtain information about the resting state of the cardiovascular system and the system's response to activity or exercise and recovery.81 It is also used to assess patency of the specific arteries palpated and the presence of any irregularities in the rhythm.81 When the heart muscle contracts, blood is ejected into the aorta and the aorta stretches. At this point, the wave of distention (pulse wave) is most pronounced, but relatively slow moving (3–5 m/s). As it travels toward the peripheral blood vessels, it gradually diminishes and becomes faster. In the large arterial branches, its velocity is 7–10 m/s; in the small arteries, it is 15–35 m/s. When taking a pulse, the fingers must be placed near the artery and pressed gently against a firm structure, usually a bone. The pulse can be taken at a number of points. The most accessible is usually the radial pulse, at the distal aspect of the radius. Sometimes, the pulse cannot be taken at the wrist and is taken at the elbow (brachial artery), at the neck against the carotid artery (carotid pulse), behind the knee (popliteal artery), or in the foot using the dorsalis pedis or posterior tibial arteries. The pulse rate can also be measured by listening directly to the heart beat, using a stethoscope. One should avoid using the thumb when taking a pulse, as it has its own pulse that can interfere with detecting the patient's pulse. The normal adult heart rate is 70 beats per minute (bpm), with a range of 60–80 bpm. A rate of greater than 100 bpm is referred to as tachycardia. Normal causes of tachycardia include anxiety, stress, pain, caffeine, dehydration, or exercise. A rate of less than 60 bpm is referred to as bradycardia. Athletes may normally have a resting heart rate lower than 60. The normal range of resting heart rate in children is between 80 and 120 bpm. The rate for a newborn is 120 bpm (normal range 70–170 bpm).

• Respiratory rate. The normal chest expansion difference between the resting position and the fully inhaled position is 2–4 cm (females > males). The clinician should compare measurements of both the anterior–posterior diameter and the transverse diameter during rest and at full inhalation. Normal respiratory rate is between 8 and 14 per minute in adults and slightly quicker in children. The following breathing patterns are characteristic of disease82:
  • Cheyne–Stokes respiration, characterized by a periodic, regular, sequentially increasing depth of respiration, occurs with serious cardiopulmonary or cerebral disorders.
  • Biot's respiration, characterized by irregular spasmodic breathing and periods of apnea, is almost always associated with hypoventilation due to CNS disease.
  • Kussmaul's respiration, characterized by deep, slow breathing, indicates acidosis, as the body attempts to blow off carbon dioxide.
  • Apneustic breathing is an abnormal pattern of breathing characterized by a postinspiratory pause. The usual cause of apneustic breathing is a pontine lesion.
  • Paradoxical respiration is an abnormal pattern of breathing, in which the abdominal wall is sucked in during inspiration (it is usually pushed out). Paradoxical respiration is due to paralysis of the diaphragm.
• Blood pressure. Blood pressure is a measure of vascular resistance to blood flow.81 The normal adult blood pressure can vary over a wide range. The assessment of blood pressure provides information about the effectiveness of the heart as a pump and the resistance to blood flow. It is measured in mm Hg and is recorded in two numbers. The systolic pressure is the pressure that is exerted on the brachial artery when the heart is contracting, and the diastolic pressure is the pressure exerted on the artery during the relaxation phase of the cardiac cycle.81 The JNC 7 report released in May 2003 has added a new category of prehypertension and has established more aggressive guidelines for medical intervention of hypertension. The normal values for resting blood pressure in adults are:
  • normal: systolic blood pressure <120 mm Hg and diastolic blood pressure <80 mm Hg;
  • prehypertension: systolic blood pressure 120–139 mm Hg or diastolic blood pressure 80–90 mm Hg;
  • stage 1 hypertension: systolic blood pressure 140–159 mm Hg or diastolic blood pressure 90–99 mm Hg;
  • stage 2 hypertension: systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥100 mm Hg.

The normal values for resting blood pressure in children are:

• systolic: birth to 1 month, 60–90 mm Hg; up to 3 years of age, 75–130 mm Hg; and over 3 years of age, 90–140 mm Hg;
• diastolic: birth to 1 month, 30–60 mm Hg; up to 3 years of age, 45–90 mm Hg; and over 3 years of age, 50–80 mm Hg.

Orthostatic hypotension is defined as a drop in systolic blood pressure when assuming an upright position. Orthostatic hypotension can occur as a side effect of antihypertensive medications (see Chap. 9), and in cases of low blood volume in patients who are postoperative or dehydrated, and in those with dysfunction of the autonomic nervous system, such as that which occurs with a spinal cord injury or postcerebrovascular accident.81 Activities that may increase the chance of orthostatic hypotension, such as application of heat modalities, hydrotherapy, pool therapy, moderate-to-vigorous exercise using the large muscles, sudden changes of position, and stationary standing, should be avoided in susceptible patients.81 The normal systolic range generally increases with age. The pressure should be determined in both the arms. Causes of marked asymmetry in blood pressure of the arms include the following: errors in measurements, marked difference in arm size, thoracic outlet syndromes, embolic occlusion of an artery, dissection of an aorta, external arterial occlusion, coarctation of the aorta, and atheromatous occlusion.82

• Edema. Edema is an observable swelling from fluid accumulation in certain body tissues. Edema most commonly occurs in the feet and legs, where it is also referred to as peripheral edema. Swelling or edema may be localized at the site of the injury or diffused over a larger area. In general, the amount of swelling is related to the severity of the injury. However, in some cases, serious injuries produce very limited swelling, whereas, in others, minor injuries cause significant swelling. Edema occurs as a result of changes in the local circulation and an inability of the lymphatic system to maintain equilibrium. The swelling is the result of the accumulation of excess fluid under the skin, in the interstitial spaces or compartments within the tissues that are outside of the blood vessels. Most of the body's fluids that are found outside of the cells are normally stored in two spaces: the blood vessels (referred to as blood volume) and the interstitial spaces (referred to as interstitial fluid). Generally, the size of lymph nodes is dependent on the size of the drainage area. Usually, the closer the lymph node is to the spinal cord, the greater the size of the lymph node. The neck is the exception to the rule. In various diseases, excess fluid can accumulate in either one or both of the interstitial spaces or blood vessels. An edematous limb indicates poor venous return. Pitting edema is characterized by an indentation of the skin after the pressure has been removed. A report of rapid joint swelling (within 2–4 hours) following a traumatic event may indicate bleeding into the joint. Swelling of a joint that is more gradual, occurring 8–24 hours following the trauma, is likely caused by an inflammatory process or synovial swelling.

The more serious reasons for swelling include fracture, tumor, congestive heart failure, and deep vein thrombosis.

• For the integumentary system, the assessment of skin integrity, skin color, and presence of scar formation. The integumentary system includes the skin, the hair, and the nails. The examination of the integumentary system may reveal manifestations of systemic disorders. The overall color of the skin should be noted. Cyanosis in the nails, the hands, and the feet may be a sign of a central (advanced lung disease, pulmonary edema, congenital heart disease, or low hemoglobin level) or peripheral (pulmonary edema, venous obstruction, or congestive heart failure) dysfunction.81 Palpation of the skin, in general, should include assessment of temperature, texture, moistness, mobility, and turgor.81 Skin temperature is best felt over large areas using the back of the clinician's hand. An assessment should be made as to whether this is localized or generalized warmth81:
  • Localized. May be seen in areas of the underlying inflammation or infection.
  • Generalized. May indicate fever or hyperthyroidism.

Skin texture is described as smooth or rough (coarse). Skin mobility may be decreased in areas of edema or in scleroderma.

• For the musculoskeletal system, the assessment of gross symmetry, gross range of motion, gross strength, weight, and height.
• For the neuromuscular system, a general assessment of gross coordinated movement (e.g., balance, locomotion, transfers, and transitions). In addition, the clinician observes for peripheral and cranial nerve integrity and notes any indication of neurological compromise such as tremors or facial tics.
• For communication ability, affect, cognition, language, and learning style, the clinician notes whether the patient's communication level is age appropriate; whether the patient is oriented to person, place, and time; and whether the emotional and behavioral responses appear to be appropriate to his or her circumstances. It is important to verify that the patient can communicate their needs. The clinician should determine whether the patient has a good understanding of his or her condition, the planned intervention, and the prognosis. The clinician should also determine the learning style that best suits the patient.

The Scanning Examination

Designed by Cyriax,83 the scanning examination is based on sound anatomic and pathologic principles. The Cyriax scanning (screening) examination traditionally follows the history and is often incorporated as part of the systems review, especially if:

• there are symptoms when no history of trauma is present.
• there is no history to explain the signs and symptoms.
• the signs and symptoms are unexplainable.

The purpose of the scanning examination is to help rule out the possibility of symptom referral from other areas, to ensure that all possible causes of the symptoms are examined, and to ensure a correct diagnosis.

The scanning examination is typically applied to patients presenting with neuromusculoskeletal complaints and differs from the five elements of patient/client management from The Guide in that the latter can be used as a system to approach virtually any type of patient, ranging from a pediatric patient with a permanent neurological condition to a patient with a serious injury to the integument, such as a burn patient.84 The other major difference between the two approaches is that the scanning examination is designed to identify a specific pathoanatomical dysfunction, while The Guide works within movement-based diagnostic categories known as practice patterns.84 Thus, the tests used in the scanning examination may produce a medical diagnosis rather than a physical therapy diagnosis.85 The scanning examination should be carried out until the clinician is confident that there is no serious pathology present and is routinely carried out unless there is some good reason for postponing it (e.g., recent trauma, in which case a modified differential diagnostic examination is used).4 Often, the scanning examination does not generate enough signs and symptoms to formulate a working hypothesis or a diagnosis. In this case, further testing with the tests and measures outlined in The Guide are required in order to proceed. The clinician must choose which scanning examination to use, based on the presenting signs and symptoms. The upper quarter scanning examination (Table 4-12) is appropriate for upper thoracic, upper extremity, and cervical problems, whereas the lower quarter scanning examination (Table 4-13) is typically used for thoracic, lower extremity, and lumbosacral problems. The preferred sequence of the scanning examination is outlined in Table 4-14.

The tests of the Cyriax83 upper or lower quarter scanning examination (Table 4-15) can be used to:

• examine the patient's neurologic status. The tests that comprise the scanning examination are designed to detect neurologic weakness, the patient's ability to perceive sensations, and the inhibition of the muscle stretch reflexes and other reflexes by the CNS, which would highlight the presence of a lesion to the central or peripheral nervous systems (see Chap. 3).
• help determine whether the symptoms are being referred.
• confirm or refute the physician's diagnosis.
• help rule out any serious pathology, such as a fracture or a tumor.
• assess the status of the contractile and inert tissues.83
  • Contractile. The term contractile tissue, as defined by Cyriax, is a bit of a misnomer, because the only true contractile tissue in the body is the muscle fiber. However, included under this term are the muscle belly, tendon, tenoperiosteal junction, submuscular/tendinous bursa, and bone (tendo-osseous junction), because all are stressed to some degree with a muscle contraction.
  • Inert. Inert tissue, according to Cyriax, includes the joint capsule, the ligaments, the bursa, the articular surfaces of the joint, the synovium, the dura, the bone, and the fascia.

NB: The tendo-osseous junction and the bursae are placed in each of the subdivisions, owing to their close proximity to contractile tissue and their capacity to be compressed or stretched during movement.

• Generate a working hypothesis.

The thoroughness of the scanning examination is influenced by both patient tolerance and professional judgment. A general guideline is that the examination must continue until the clinician is confident that the patient's symptoms are not the result of a serious condition that demands medical attention.

The tests included in the scanning examination are strength testing, sensation testing (light touch and pinprick), muscle stretch reflexes, and the pathological reflexes (see Chap. 3). The various tests of the scanning examinations specific to the cervical, thoracic, and lumbar spine are described in the relevant chapters.

At the end of each of the scanning examinations, either a medical diagnosis (e.g., disk protrusion, prolapse, or extrusion; acute arthritis; specific tendonitis; muscle belly tear; spondylolisthesis; or stenosis) can be made or the scanning examination is considered negative. A negative scanning examination does not imply that there were no findings; rather, the results of examination were insufficient to generate a diagnosis upon which an intervention could be based. In this case, further examination is required using the various tests and measures pertinent to the body region.

The entire scanning examination should take no more than a few minutes to complete.

If a diagnosis is rendered from the scan, an intervention may be initiated using the guidelines outlined in Table 4-16. The scan or the history, or both, also may have indicated to the clinician that the patient's condition is in the acute stage of healing. Although this is not a diagnosis in the true sense, it can be used for the purpose of the intervention plan.

Although two studies86,87 questioned the validity of some aspects of the selective tissue tension examination, no definitive conclusions were drawn from these studies. The scarcity of research to refute the work of Cyriax would suggest that its principles are sound and that its use should be continued.

Tests and Measures

The tests and the measures (Table 4-17) component of the examination, which serves as an adjunct to the history and the systems review, involves the physical examination of the patient. The tests and the measures now currently used in physical therapy have been largely influenced by the work of a number of clinicians over the years, including Cyriax,83,88–90 Maitland,7,91 Grieve,92 Kaltenborn,5 Butler,12 Sahrmann,11 and McKenzie.93,94

The traditional goals of the physical examination have been to determine the structure involved, reproduce the patient's symptoms, confirm or refute the working hypothesis, and establish an objective data baseline.6,95 More recently, the focus of the examination has shifted to include the identification of impairments, functional limitations, disabilities, or changes in physical function and health status resulting from injury, disease, or other causes. This information is then used through the evaluation process to establish the diagnosis and the prognosis, and to determine the intervention.14

The physical examination must be supported by as much science as possible, so that the decision about which test(s) to use during the examination should be based on the best available research evidence. According to Sackett and colleagues,96evidence-based practice (EBP) involves the integration of best research evidence with clinical expertise and patient values. A good test must differentiate the target disorder from other disorders, with which it might otherwise be confused.97 The gathering of evidence must occur in a systematic, reproducible, and unbiased manner to select and interpret diagnostic tests and to assess potential interventions.98 The EBP process generally occurs in five steps99:

• Formulating a clinical question including details about the patient type or problem, the intervention being considered, a comparison intervention, and the outcome measure to be used.
• Searching for the best evidence, which can include a literature search on Ovid, EMBASE, PubMed, PEDro, or other medical search engine database, using the keywords from the clinical question.
• Critical appraisal of the evidence. In general, there are two types of clinical studies—those that analyze primary data and those that analyze secondary data.22 Studies that collect and analyze primary data include case reports and series and case-controls, cross-sectional, cohort (both prospective and retrospective), and randomized controlled trials.22 Analysis of second-rate data occurs in systematic reviews or meta-analysis for the purpose of pooling or synthesizing data to answer a question that is perhaps not practical or answerable within an individual study.22 Another way to broadly categorize studies is experimental, where an intervention is introduced to subjects, or observational, in which no active treatment is introduced to subjects.22
• Applying the evidence to the patient.
• Evaluation of the outcome.

The choice of which tests to use should be based on pretest probabilities, which are used to assess the diagnostic possibility of a disorder. The results from these tests are then combined with value judgments to arrive at the correct diagnosis. Unfortunately, many tests and procedures used in physical therapy practice are not, as yet, evidence based. This is particularly true with the so-called special tests (see “Special Tests”). Indeed, many of the purportedly effective special tests listed in many orthopaedic texts exhibit such poor diagnostic accuracy that only 50% of patients who have a positive test result are found to have the condition that the test is supposed to detect.98,100 Without EBP, clinicians fail to provide the consumer with scientific evidence regarding clinically effective and cost-effective practice. Throughout this text, wherever possible, the sources of evidence will be identified for each of the examination and intervention techniques described. However, in an ever-changing profession, it is ultimately the reader's responsibility to remain updated with practice recommendations and decide the appropriateness of the evidence for each of their patients in their own unique clinical setting.

The neurologic tests of the orthopaedic examination are described in Chapter 3. Before proceeding with the tests and measures, the clinician must obtain a valid consent and a full explanation must be provided to the patient as to what procedures are to be performed and the reasons for these. The chosen tests used by the clinician must be based on the patient's history or the presentation. At times, a complete examination cannot be performed. For example, if the joint to be examined is too acutely inflamed, the clinician may defer some of the examinations to the subsequent visit.

Active Physiological Range of Motion of the Extremities

Active movements of the involved area are performed before passive movements. During the history, the clinician should have deduced the general motions that aggravate or provoke the pain. Any movements that are known to be painful are performed last. The range of motion examination should be used to confirm the exact directions of motion that elicit the symptoms. The diagnosis of restricted movement in the extremities can usually be simplified by comparing both sides, provided that at least one side is uninvolved. Under normal circumstances, the normal (uninvolved) side is tested first as this allows the clinician to establish a baseline, while also showing the patient what to expect. Active range of motion testing may be deferred if small and unguarded motions provoke intense pain, because this may indicate a high degree of joint irritability, or other serious condition. The normal active range of motion for each of the joints is depicted in Table 4-18.

Active range of motion testing gives the clinician information about the following:

• Quantity of available physiologic motion.
• Presence of muscle substitutions.
• Willingness of the patient to move.
• Integrity of the contractile and the inert tissues.
• Quality of motion. A painful arc during range of motion, with or without a painful limitation of movement, indicates the presence of a derangement.101 For example, there may be an arc of pain between 60 and 120 degrees on shoulder abduction, indicating an impingement of the structures under the acromion process or the coracoacromial ligament.
• Symptom reproduction.
• Pattern of motion restriction (e.g., capsular or noncapsular, opening or closing restriction—see later).

Capsular and Noncapsular Patterns of Restriction

Cyriax83 introduced the terms capsular and noncapsular patterns of restriction, which link impairment to pathology (Table 4-19). A capsular pattern of restriction is a limitation of pain and movement in a joint-specific ratio, which is usually present with arthritis, or following prolonged immobilization.83 It is worth remembering that a consistent capsular pattern for a particular joint might not exist and that these patterns are based on empirical findings and tradition, rather than on research.86,102

A noncapsular pattern of restriction is a limitation in a joint in any pattern other than a capsular one and may indicate the presence of a joint derangement, a restriction of one part of the joint capsule, or an extra-articular lesion that obstructs joint motion.83

A positive finding for joint hypomobility would be a reduced range in a capsular or noncapsular pattern. The hypomobility can be painful, suggesting an acute sprain of a structure, or painless, suggesting a contracture or an adhesion of the tested structure. Significant degeneration of the articular cartilage presents with crepitus (joint noise) on movement when compression of the joint surfaces is maintained.

While abnormal motion is typically described as being reduced, abnormal motion may also be excessive. Excessive motion is often missed and is erroneously classified as normal motion. To help determine whether the motion is normal or excessive, passive range of motion (PROM), in the form of passive overpressure, and the end-feel are assessed (see next section).

Full and pain-free active range of motion suggests normalcy for that movement, although it is important to remember that normal range of motion is not synonymous with normal motion.103 Normal motion implies that the control of motion must also be present. This control is a factor of muscle flexibility, joint stability, and central neurophysiologic mechanisms. These factors are highly specific in the body.104 A loss of motion at one joint may not prevent the performance of a functional task, although it may result in the task being performed in an abnormal manner. For example, the act of walking can still be accomplished in the presence of a knee joint that has been fused into extension. Because the essential mechanisms of knee flexion in the stance period and foot clearance in the swing period are absent, the patient compensates for these losses by hiking the hip on the involved side, by side bending the lumbar spine to the uninvolved side, and through excessive motion of the foot.

Single motions in the cardinal planes are usually tested first. These tests are followed by dynamic and static testing. Dynamic testing involves repeated movements. Static testing involves sustaining a position. Sustained static positions may be used to help detect postural syndromes.101 McKenzie advocates the use of repeated movements in specific directions in the spine and the extremities. Repeated movements can give the clinician some valuable insight into the patient's condition101:

• Internal derangements tend to worsen with repeated motions.
• Symptoms of a postural dysfunction remain unchanged with repeated motions.
• Pain from a dysfunction syndrome is increased with tissue loading but ceases at rest.
• Repeated motions can indicate the irritability of the condition.
• Repeated motions can indicate to the clinician the direction of motion to be used as part of the intervention. If pain increases during repeated motion in a particular direction, exercising in that direction is not indicated. If pain only worsens in part of the range, repeated motion exercises can be used for the part of the range that is pain free or that does not worsen the symptoms.
• Pain that is increased after the repeated motions may indicate a retriggering of the inflammatory response, and repeated motions in the opposite direction should be explored.

Combined motion testing may be used when the symptoms are not reproduced with the cardinal plane motions (flexion, extension, abduction, etc.), the repeated motions, or the sustained positions. Compression and distraction also may be added to all of the active motion tests in an attempt to reproduce the symptoms.

Active Physiological Range of Motion of the Spine

Active physiologic intervertebral mobility, or active mobility, tests of the spine were originally designed by osteopaths to assess the ability of each spinal joint to move actively through its normal range of motion, by palpating over the transverse processes of a joint during the motion (see also Position Testing of the Spine). Theoretically, by palpating over the transverse processes, the clinician can indirectly assess the motions occurring at the zygapophyseal joints at either side of the intervertebral disk. However, the clinician must remember that, although it is convenient to describe the various motions of the spine occurring in a certain direction, these involve the integration of movements of a multijoint complex.

The human zygapophyseal joints are capable of only two major motions: gliding upward and gliding downward. If these movements occur in the same direction, flexion or extension of the spine occurs, while if the movements occur in opposite directions, side flexion occurs.

Osteopaths use the terms opening and closing to describe flexion and extension motions, respectively, at the zygapophyseal joint. Under normal circumstances, an equal amount of gliding occurs at each zygapophyseal joint with these motions.

• During flexion, both zygapophyseal joints glide superiorly (open).
• During extension, both zygapophyseal joints glide inferiorly (close).
• During side flexion, one joint is gliding inferiorly (closing), while the other joint is gliding superiorly (opening). For example, during right side flexion, the right joint is gliding inferiorly (closing), while the left joint is gliding superiorly (opening).

By combining flexion or extension movements with side flexion, a joint can be “opened” or “closed” to its limits. Thus, flexion and right-side flexion of a segment assesses the ability of the left joint to maximally open (flex), whereas extension and left-side flexion of a segment assesses the ability of the left joint to maximally close (extend).

There is a point that may be considered as the center of segmental rotation, about which all segmental motion must occur. In the case of a zygapophyseal joint impairment (hypermobility or hypomobility), it is presumed that this center of rotation will be altered.

If one zygapophyseal joint is rendered hypomobile (i.e., the superior facet cannot move to the extreme of superior or inferior motion), then the pure motions of flexion and extension cannot occur. This results in a relative asymmetric motion of the two superior facets, as the end of range of flexion or extension is approached (i.e., a side-flexion motion will occur). However, this side-flexion motion will not be about the normal center of segmental rotation. The structure responsible for the loss of zygapophyseal joint motion, whether it is a muscle, disk protrusion, or the zygapophyseal joint itself, will become the new axis of vertebral motion, and a new component of rotation about a vertical axis, normally unattainable, will be introduced into the segmental motion. The degree of this rotational deviation is dependent on the distance of the impairment from the original center of rotation.

Because the zygapophyseal joints in the spine are posterior to the axis of rotation, an obvious rotational change occurring between full flexion and full extension (in the position of a vertebral segment) is indicative of zygapophyseal joint motion impairment.

By observing any marked and obvious rotation of a vertebral segment occurring between the positions of full flexion and full extension, one may deduce the probable pathologic impairment.

Passive Physiological Range of Motion of the Extremities

Passive motions are movements performed by the clinician without the assistance of the patient. Passive movements are performed in the anatomic range of motion for the joint and normally demonstrate slightly greater range of motion than active motion—the barrier to active motion should occur earlier in the range than the barrier to passive motion.

If the patient can complete the active physiological range of motion easily, without presenting pain or other symptoms, then passive testing of that motion is usually unnecessary. However, if the active motions do not reproduce the patient's symptoms, because the patient avoids going into the painful part of the range, or the active range of motion appears incomplete, it is important to perform gentle passive overpressure. Pain during passive overpressure is often due to the movement, stretching, or pinching of noncontractile structures. Pain that occurs at the mid-end range of active and passive movement is suggestive of a capsular contraction or a scar tissue that has not been adequately remodeled.101 Pain occurring at the end of PROM may be due to a stretching of the contractile structures, as well as noncontractile structures.106 Thus, PROM testing gives the clinician information about the integrity of the contractile and inert tissues, and with gentle overpressure, the end-feel. Cyriax83 introduced the concept of the end-feel, which is the quality of resistance at end range. To execute the end-feel, the point at which resistance is encountered is evaluated for quality and tenderness. Additional forces are needed as the end range of a joint is reached, and the elastic limits are challenged. This space termed the end-play zone requires a force of overpressure to be reached so that, when that force is released, the joint springs back from its elastic limits. The end-feel can indicate to the clinician the cause of the motion restriction (Tables 4-20 and 4-21).

Although some clinicians feel that overpressure should not be applied in the presence of pain, this is erroneous. Most, if not all, of the end-feels that suggest acute or serious pathology are to be found in the painful range, including spasm and the empty end-feel.

The end-feel is very important in joints that have only very small amounts of normal range, such as those of the spine. The type of end-feel can help the clinician determine the presence of dysfunction. For example, a hard, capsular end-feel indicates a pericapsular hypomobility, whereas a jammed or a pathomechanical end-feel indicates a pathomechanical hypomobility. A normal end-feel would indicate normal range, whereas an abnormal end-feel would suggest abnormal range, either hypomobile or hypermobile. An association between an increase in pain and abnormal pathologic end-feels compared with normal end-feels has been demonstrated.107

The planned intervention, and its intensity, is based on the type of tissue resistance to movement, demonstrated by the end-feel, and on the acuteness of the condition (Table 4-22).83 This information may indicate whether the resistance is caused by pain, muscle, capsule ligament, disturbed mechanics of the joint, or a combination.

The quantity and quality of movement refer to the ability to achieve end-range without deviation from the intended movement plane.

Both the passive and active physiological ranges of motion can be measured using a goniometer, which has been shown to have a satisfactory level of intraobserver reliability.108–110 Visual observation in experienced clinicians has been found to be equal to measurements by goniometry.111

The recording of range of motion varies. The American Medical Association recommends recording the range of motion on the basis of the neutral position of the joint being zero, with the degrees of motion increasing in the direction the joint moves from the zero starting point.112 A plus sign (+) is used to indicate joint hyperextension and a minus sign (–) to indicate an extension lag. The method of recording chosen is not important, provided the clinician chooses a recognized method and documents it consistently with the same patient.

Passive Physiological Range of Motion of the Spine

The passive physiologic intervertebral mobility, or passive mobility, tests use the same principles as the active physiologic intervertebral mobility tests to assess the ability of each joint in the spine to move passively through its normal range of motion, while the clinician palpates over the interspinous spaces. During extension, the spinous processes should approximate, whereas during flexion, they should separate.

If pain is reproduced, it is useful to associate the pain with the onset of tissue resistance to gain an appreciation of the acuteness of the problem. The passive mobility tests of the spine are described in the appropriate chapters.

Flexibility

The examination of flexibility is performed to determine if a particular structure, or group of structures, has sufficient extensibility to perform a desired activity. The extensibility and habitual length of connective tissue are factors of the demands placed upon it. These demands produce changes in the viscoelastic properties and, thus, the length–tension relationship of a muscle or muscle group, resulting in an increase or a decrease in the length of those structures. A decrease in the length of the soft-tissue structures, or adaptive shortening, is very common in postural dysfunctions. Adaptive shortening also can be produced by

• restricted mobility;
• tissue damage secondary to trauma;
• prolonged immobilization;
• disease;
• hypertonia. Hypertonic muscles that are superficial can be identified through observation and palpation. Observation will reveal the muscle to be raised, and light palpation will provide information about tension, as the muscle will feel hard and may stand out from those around it.

Flexibility can be measured objectively using standardized tests, or a goniometer. A more subjective test for flexibility includes an examination of the end-feel, which can detect a loss of motion resulting from excessive tension of the agonist muscle. Visual observation, which has been found to have a variability of 30% in patients with low back pain and sciatica, may also be used.113

Joint Integrity and Mobility

Joint integrity and mobility testing can provide valuable information about the status and the mobility of each joint and its capsule. Kaltenborn5 introduced the concept of motion restriction of a joint based on its arthrokinematics. In order for a joint to function completely, both the osteokinematic and arthrokinematic motions have to occur normally (see Chap. 1). It, therefore, follows that if a joint is not functioning completely, either the physiologic range of motion is limited compared with the expected norm or there is no PROM available between the physiologic barrier and the anatomic barrier. As previously mentioned, the assessment of the end-feel can help determine the cause of the restriction.57 In general, the physiologic motion is controlled by the contractile tissues, whereas the accessory motion is controlled by the integrity of the joint surfaces and the noncontractile (inert) tissues. This guideline may change in the case of a joint that has undergone degenerative changes, which can result in a decrease in the physiologic motions (capsular pattern of restriction). It is important that the intervention to restore the complete function of the joint be aimed at the specific cause.

Joint pain and dysfunction do not occur in isolation.114,115 Various measurement scales have been proposed for judging the amount of accessory joint motion present between two joint surfaces (see Chap. 10), most of which are based on a comparison with a comparable contralateral joint, using manually applied forces in a logical and precise manner.116 In the extremities, these tests are referred to as passive articular mobility, or joint glide tests. In the spine, these tests are referred to as the passive physiologic accessory intervertebral motion testing.

The passive articular mobility tests involve the clinician assessing the arthrokinematic, or accessory, motions using joint glides, and determining whether the glide is hypomobile, normal, or hypermobile (see Chap. 2).5–7

Accessory motions are involuntary motions. With few exceptions, muscles cannot restrict the glides of a joint, especially if the glides are tested in the open-packed position of a peripheral joint and, at the end of available range, in the spinal joints.

Thus, if the clinician assesses the accessory motion of the joint by performing a joint glide, information about the integrity of the inert structures will be given. There are two scenarios:

1. The joint glide is unrestricted. An unrestricted joint glide indicates two differing conclusions:

•     a. The integrity of both the joint surface and the periarticular tissue is good. If the joint surface and the periarticular structures are intact, the patient's loss of motion must be the result of a contractile tissue. The intervention for this type involves soft-tissue mobilization techniques designed to change the length of a contractile tissue.
•     b. The joint glide is unrestricted but excessive. The excessive motion may indicate a pathological hypermobility or instability, or it may be normal for the individual. In these cases, the end-feel can provide some useful information. The intervention for this type concentrates on stabilizing techniques designed to give secondary support to the joint through muscle action.

2. The joint glide is restricted. If the joint glide is restricted, the joint surface and the periarticular tissues are implicated as the cause of the patient's loss of motion, although as previously mentioned, the contractile tissues cannot definitively be ruled out. The intervention for this type of finding initially involves a specific joint mobilization to restore the glide. Once the joint glide is restored following these mobilizations, the osteokinematic motion can be assessed again. If it is still reduced, the contractile tissues are likely to be at fault. Distraction and compression can be used to help differentiate the cause of the restriction.

•     a. Distraction. Traction is a force imparted passively by the clinician that results in a distraction of the joint surfaces. If the distraction is limited, a contracture of connective tissue should be suspected.
• If the distraction increases the pain, it may indicate a tear of connective tissue and may be associated with increased range.
• If the distraction eases the pain, it may indicate an involvement of the joint surface.
•     b. Compression. Compression is the opposite force to distraction, and involves an approximation of joint surfaces.
• If the compression increases the pain, a loose body or an internal derangement of the joint may be present.
• If the compression decreases the pain, it may implicate the joint capsule.

Thus, by assessing these joint motions, the clinician can determine the

• cause of a limitation in a joint's physiologic range of motion;
• end-feel response of the tissues;
• stage of healing;
• integrity of the support structures (e.g., ligaments) of a joint (for example, the integrity of the anterior cruciate ligament is tested with the Lachman test).

Based on the information gleaned from the joint glide assessment, the clinician makes clinical decisions as to which intervention to use. If the joint glide is felt to be restricted, and there is no indication of a bony end-feel or severe irritability, joint mobilization techniques are used. If the joint glide is found to be unrestricted, the clinician may decide to employ a technique that increases the extensibility of the surrounding connective tissues, such as muscle energy, because abnormal shortness of these connective tissues, including the ligaments, the joint capsule, and the periarticular tissues, can restrict joint mobility.

Position Testing in the Spine

The position tests are screening tests designed by osteopaths to examine the relative position of a zygapophyseal joint, or joints, to the joint(s) below (see appropriate chapters). As with all screening tests, position testing is valuable in focusing the attention of the clinician to a specific area but is not appropriate for making a definitive statement concerning the movement status of the segment. However, when combined with the results of the passive and active movement testing, position tests help to form the working hypothesis.

Muscle Performance: Strength, Power, and Endurance

Strength measures the power with which musculotendinous units act across a bone-joint lever-arm system to actively generate motion, or passively resist movement against gravity and variable resistance.112

According to Cyriax, pain with a contraction generally indicates an injury to the muscle or a capsular structure.83 This suspicion can be confirmed by combining the findings from the isometric test with the findings of the passive motion and the joint distraction and compression tests (Table 4-23). Cyriax reasoned that if you isolate and then apply tension to a structure, you can make a conclusion as to the integrity of that structure.83 His work also introduced the concept of tissue reactivity. Tissue reactivity is the manner in which different stresses and movements can alter the clinical signs and symptoms. This knowledge can be used to gauge any subtle changes to the patient's condition.117

In addition to examining the integrity of the contractile and inert structures, strength testing may be used to examine the integrity of the key muscles (see Chap. 3). Pain with muscle testing may indicate a muscle injury, a joint injury, or a combination of both. Pain that occurs consistently with resistance, at whatever the length of the muscle, may indicate a tear of the muscle belly. Weakness with muscle testing must be differentiated between weakness throughout the range of motion (pathological weakness) and weakness that only occurs in certain positions (positional weakness). According to Cyriax,83,89 strength testing can provide the clinician with the following findings:

• A weak and painless contraction may indicate palsy or a complete rupture of the muscle–tendon unit. The motor disorder associated with peripheral neuropathy is first manifested by weakness and a diminished or absent tendon reflex (see Chap. 3).49
• A strong and painless contraction indicates a normal finding.
• A weak and painful contraction. A study by Franklin and colleagues87 indicated that the conditions related to this finding need to include not only serious pathology, such as a significant muscle tear or a tumor, but relatively minor muscle damage and inflammation such as that induced by eccentric isokinetic exercise.106
• A strong and painful contraction indicates a grade I contractile lesion.

Pain that does not occur during the test, but occurs upon the release of the contraction, is thought to have an articular source, produced by the joint glide that occurs following the release of tension.

The degree of certainty regarding the findings just described depends on a combination of the length of the muscle tested and the force applied. To fully test the integrity of the muscle–tendon unit, a maximum contraction must be performed in the fully lengthened position of the muscle–tendon unit. Although this position fully tests the muscle–tendon unit, there are some problems with testing in this manner:

• The joint and its surrounding inert tissues are in a more vulnerable position and could be the source of the pain.
• It is difficult to differentiate between damage to the contractile tissue of varying severity. The degree of significance with the findings in resistive testing depends on the position of the muscle and the force applied (Table 4-24). For example, pain reproduced with a minimal contraction in the rest position for the muscle is more strongly suggestive of a contractile lesion than pain reproduced with a maximal contraction in the lengthened position for the muscle.
• As a muscle lengthens, it reaches a point of passive insufficiency, where it is not capable of generating its maximum force output (see Chap. 1).

If the same muscle is tested on the opposite side, using the same testing procedure, the concern about the length of the muscle is removed, because the focus of the test is to provide a comparison with the same muscle on the opposite side, rather than to assess the absolute force output.

To assess strength, strength values using manual muscle testing (MMT) have traditionally been used between similar muscle groups on opposite extremities, or antagonistic ratios. This information is then used to determine whether a patient was fully rehabilitated. It should be noted that there is considerable variability in the amount of resistance that normal muscles can hold against. The application of resistance throughout the arc of motion (make test or active resistance test) in addition to resistance applied at only one point in the arc of motion (break test) can help in judging the strength of a muscle.106 During all testing, stabilization of the body part on which the muscle originates in addition to careful avoidance of substitution by other muscle groups are emphasized. Substitutions by other muscle groups during testing indicate the presence of weakness. It does not, however, tell the clinician the cause of the weakness.

Several scales have been devised to assess muscle strength. For example, Janda118 used a 0–5 scale with the following descriptions:

• Grade 5: N (normal). A normal, very strong muscle with a full range of movement and one that is able to overcome considerable resistance. This does not mean that the muscle is normal in all circumstances (e.g., when at the onset of fatigue or in a state of exhaustion). If the clinician is having difficulty differentiating between a grade 4 and a grade 5, the eccentric “break” method of muscle testing may be used. This procedure starts as an isometric contraction, but then the clinician applies sufficient force to cause an eccentric contraction or a “break” in the patient's isometric contraction.
• Grade 4: G (good). A muscle with good strength and full range of movement, and one that is able to overcome moderate resistance. The subjectivity involved in a grade 4 score is one of the major criticisms of MMT as the grading requires the clinician to assign an ordinal number to a subjective evaluation of resistance offered by the patient.
• Grade 3: F (fair). A muscle that can move through the complete range of movement against gravity only with no additional resistance applied. If the muscle strength is less than grade 3, then the methods advocated in muscle testing manuals must be used.106
• Grade 2: P (poor). A very weak muscle that is only able to move through the complete range of motion if the force of gravity is eliminated.
• Grade 1: T (trace). A muscle with evidence of slight contractility but demonstrates no effective movement.
• Grade 0. A muscle with no evidence of any contractility.

The grading systems for MMT produce ordinal data with unequal rankings between grades. For example, the grades 5 (normal) and 4 (good) typically encompass a large range of a muscle's strength, while the grades of 3 (fair), 2 (poor), and 1 (trace) include a much narrower range.106 If the popular methods to grade muscles are analyzed, the frailties and similarities become obvious. If the muscle strength is less than grade 3, these testing grades are useful, but it is the grades of 3 and higher that produce the most confusion. Some of the confusion arises from the descriptions of maximal, moderate, and minimal, or considerable, which removes much of the objectivity from the tests.

To be a valid test, strength testing must elicit a maximum contraction of the muscle being tested. The following strategies ensure that this occurs:

1. Placing the joint that the muscle to be tested crosses, in (or close to) its open-packed position. This strategy helps protect the joint from excessive compressive forces, and the surrounding inert structures from excessive tension.

2. Placing the muscle to be tested in a shortened position. This puts the muscle in an ineffective physiologic position and has the effect of increasing motor neuron activity.

3. Using gravity-minimized positions. This strategy avoids the effect of the weight of the moving body segment on force measurements. For example, to test the strength of the hip abductors, the patient is positioned in supine so that the muscle action pulls in a horizontal plane relative to the ground.106

4. Having the patient perform an eccentric muscle contraction by using the command “Don't let me move you.” Because the tension at each cross-bridge and the number of active cross-bridges is greater during an eccentric contraction, the maximum eccentric muscle tension developed is greater with an eccentric contraction than with a concentric one.

5. Breaking the contraction. It is important to break the patient's muscle contraction, in order to ensure that the patient is making a maximal effort and that the full power of the muscle is being tested. Although force values determined with make and break tests are highly correlated, break tests usually result in greater force values than make tests,122,123 so they should not be used interchangeably.

6. Holding the contraction for at least 5 seconds. Weakness resulting from nerve palsy has a distinct fatigability. The muscle demonstrates poor endurance, because usually it is only able to sustain a maximum muscle contraction for about 2–3 seconds before complete failure occurs. This strategy is based on the theories behind muscle recruitment, wherein a normal muscle, while performing a maximum contraction, uses only a portion of its motor units, keeping the remainder in reserve to help maintain the contraction. A palsied muscle, with its fewer functioning motor units, has very few, if any, motor units in reserve. If a muscle appears to be weaker than normal, further investigation is required, as follows:

•     a. The test is repeated three times. Muscle weakness resulting from disuse will be consistently weak and should not become weaker with several repeated contractions. In contrast, a palsied muscle becomes weaker with each contraction.
•     b. Another muscle that shares the same innervation is tested. Knowledge of both spinal and peripheral nerve innervation will aid the clinician in determining which muscle to select (see Chap. 3).

7. Comparing findings with uninvolved side. One study found no statistically significant difference in force between the dominant and nondominant lower extremities, but did find the difference between the dominant and nondominant upper extremities.124 Sapega125 recommends that the difference in muscle force between sides of greater than 20% probably indicates abnormality, while the difference of 10 to 20% possibly indicates abnormality.

As always, these tests cannot be evaluated in isolation but have to be integrated into a total clinical profile, before drawing any conclusion about the patient's condition.

Although the grading of muscle strength has its role in the clinic, and the ability to isolate the various muscles is very important in determining the source of nerve palsy, specific grading of individual muscles does not give the clinician much information on the ability of the structure to perform functional tasks. In addition, measurements of isometric muscle force are specific to a point or small range in the joint range excursion and, thus, cannot be used to predict dynamic force capabilities.128–130

More recently, the use of quantitative muscle testing (QMT) has been recommended to assess strength, as it produces interval data that describe force production. QMT methods include:

• The use of handheld dynamometers. Although more costly and time consuming than MMT, handheld dynamometry can be used to improve objectivity and sensitivity. Patients are typically asked to push against the dynamometer with a maximal isometric contraction (make test), or hold a position until the clinician and the dynamometer overpower the muscle producing an eccentric contraction (break tests).106 Normative force values for particular muscle groups by patient age and gender have been reported, with some authors including regression equations that take into account body weight and height.131

• The use of an isokinetic dynamometer. This is a stationary, electromechanical device that controls the velocity of the moving body segment by resisting and measuring the patient's effort so that the body segment cannot accelerate beyond a preset angular velocity.106 Isokinetic dynamometers measure torque and range of motion as a function of time, and can provide an analysis of the ratio between the eccentric contraction and concentric contraction of a muscle at various positions and speeds.137 This ratio is aptly named the eccentric/concentric ratio.138 The ratio is calculated by dividing the eccentric strength value by the concentric strength value. Various authors139,140 have demonstrated that the upper limit of this ratio is 2.0 and that lower ratios indicate pathology.138,141 Alternatively, the same recommendations for MMT advocated by Sapega125 can be used: a difference in muscle force between sides of greater than 20% probably indicates abnormality, while the difference of 10–20% possibly indicates abnormality. To ensure the validity of isokinetic dynamometry measurements, calibration of equipment is necessary and should be performed each day of testing, at the same speed and damp setting during the testing.142

One of the major criticisms of muscle testing is the over estimation of strength when a muscle is weak as identified by QMT, compared to the same muscle being graded as normal by MMT, such that a theoretical percentage score based on MMT is likely to grossly overestimate the strength of a patient.121 For example, Beasley143 showed that 50% of knee extensor strength needed to be lost before MMT was able to identify weakness.

Studies that compare the reliability of MMT and QMT often come to the conclusion that MMT may be consistent and reliable, but it is unable to detect subtle differences in strength.144,145 Thus, although MMT results are more consistent, the variation produced by QMT can appreciate differences in strength undetectable in MMT.121

Regardless of the type of muscle testing used, the procedure is innately subjective and depends on the subject's ability to exert a maximal contraction. This ability can be negatively impacted by such factors as pain, poor comprehension, motivation, cooperation, fatigue, and fear.

Motor Function

Motor function is the ability to demonstrate the skillful and efficient assumption, maintenance, modification, and control of voluntary postures and movement patterns.14 The criteria for simple motor patterns are that the movement69,118

• is performed exactly in the desired direction;
• is smooth and of a constant speed;
• follows the shortest and most efficient path;
• is performed in its full range.

The criteria for complex motor patterns are as follows69:

• Synchronization between the primary movers in the distal regions with those more proximal.
• Smooth propagation of motion from one region of the body to another.
• Absence of inefficient movement patterns or muscle recruitment.
• Optimal relationships between the speed of motion initiated in one region and the speed of motion in other regions.

The upper extremities can work together, when they are in direct or indirect contact with each other (clasping the hands together or holding an object with two hands), or separately. The lower extremities can work together off a stable base or separately. In the bilateral combinations, the two limbs are separated, but both are involved in the activity. The limbs may be moved in the same direction, termed symmetric (breaststroke swimming); in opposite directions, termed reciprocal (swimming the crawl); toward one side of the body (pulling on a rope above one side of the head), termed asymmetric; or toward opposite sides of the body (swimming side stroke), termed cross-diagonal or reciprocal asymmetric.147

Mass movement patterns involve combined motions of the joints within the kinetic chain, depending on the desired motion.148 For example, a mass pattern of the lower extremity could involve hip, knee, and ankle dorsiflexion, with the rotation and abduction–adduction component varying. Advanced movement patterns involve such combinations as hip extension, knee flexion, and plantar flexion, or hip flexion, knee extension, and dorsiflexion—motions that occur with normal gait.148

Aerobic Capacity and Endurance

Aerobic capacity endurance is the ability to perform work or participate in activity over time, using the body's oxygen uptake, delivery, and energy-release mechanisms (see Chap. 15).14 Clinical indications for the use of the tests and measures for this category are based on the findings from the history and systems review. These indications include, but are not limited to, pathology, pathophysiology, and impairment to14:

• cardiovascular system (e.g., abnormal heart rate, rhythm, and blood pressure);
• endocrine/metabolic system (e.g., osteoporosis);
• multiple systems (e.g., trauma and systemic disease);
• neuromuscular system (e.g., generalized muscle weakness and decreased endurance);
• pulmonary system (e.g., abnormal respiratory pattern, rate, and rhythm).

The aerobic capacity and endurance of a patient can be measured using standardized exercise test protocols (e.g., ergometry, step tests, time or distance walk or run tests, and treadmill tests) and the patient's response to such tests.14

Anthropometric Characteristics

Anthropometric characteristics are traits that describe body dimensions, such as height, weight, girth, and body fat composition.14 The use of an anthropometric examination and the subsequent measurements varies. Clearly, if a noticeable amount of effusion or swelling is present, these measurements serve as an important baseline from which to judge the effectiveness of the intervention.

Circulation

Circulation is defined by The Guide as the movement of blood through organs and tissues to both deliver oxygen and remove carbon dioxide and cellular byproducts.14 Circulation also involves the passive movement of lymph through channels. The examination of the circulation includes an examination of those cardiovascular signs not tested in the aerobic capacity and endurance portion, and the anthropometric characteristics portion of the examination, including the patient's physiologic response to position change, an inspection of the nail beds, capillary refill, and monitoring of the pulses of the extremities.

In general, the posterior (dorsal) pedis pulse is used in the lower extremities to assess the patency of the lower extremity vessels, whereas the radial pulse is used for the upper extremities.

Work, Environmental, and Home Barriers (Job, School, and Play)

Work, environmental, and home barriers are the physical impediments that keep patients from functioning optimally in their surroundings.14

Ergonomics and Body Mechanics

Ergonomics is the relationship among the worker; the work that is done; the actions, tasks, or activities inherent in that work (job, school, and play); and the environment in which the work (job, school, and play) is performed.14 Body mechanics are the interrelationships of the muscles and joints, as they maintain or adjust posture in response to forces placed on or generated by the body.

It is not within the scope of this text to detail the scientific and engineering principles related to ergonomics and the numerous tests used to quantify these measures. Ergonomics as it relates to posture is discussed within the related chapters.

Gait, Locomotion, and Balance

Gait analysis is an important component of the examination process (see Chap. 6) and should not be reserved only for those patients with lower extremity dysfunction. Although the act of walking is often taken for granted, normal and reciprocal gait requires a finely tuned series of reflexes.149 The examination of gait is performed to highlight any breakdown within these reflexes, including imbalances of flexibility or strength, or compensatory motions.150

Gait, like posture, varies between individuals, and a gait that differs from normal is not necessarily pathologic. The analysis of gait is described in Chapter 6.

Balance is an essential component for participation in sports and for activities of daily living (see Chap. 3). During the history, the patient may describe symptoms of dizziness, lightheadedness, a sense of impending faint, or poor balance. Ataxia is a discoordination or clumsiness of movement that is not associated with muscular weakness, but has very strong associations with CNS dysfunction (see Chap. 3).151 A sudden onset of unilateral deafness may be due to labyrinth artery infarction, possibly indicating an infarction in the vertebrobasilar system,152 Ménière's disease, acoustic neuroma, autoimmune disease of the inner ear, Friedrich's ataxia, vestibulocochlear nerve compression, diabetes mellitus, otosclerosis, or an adverse drug reaction.153 Nausea and vomiting are common complaints in balance disorders. The assessment of balance is discussed in Chapter 3.

Orthotic, Adaptive, Protective, and Assistive Devices

These devices are implements and equipments used to support or protect weak or ineffective joints or muscles and serve to enhance performance.14 Examples of such devices include canes, crutches, walkers, reachers, and ankle foot orthoses.

Posture

Posture describes the relative positions of different joints at any given moment.46 The postural examination gives an overall view of the patient's muscle function in both chronic and acute pain states. The examination enables the clinician to differentiate between possible provocative causes, such as structural variations, altered joint mechanics, muscle imbalances, and the residual effects of pathology. The assessment of posture is detailed in Chapter 6 and in the relevant chapters.

Work (Job, School, and Play), Community, and Leisure Integration and Reintegration

In short, this category refers to the process of assuming or resuming roles and functions.

Self-Care and Home Management (Including Activities of Daily Living and Instrumental Activities of Daily Living)

This portion of the examination addresses the patient's perception of his or her condition, namely issues regarding the patient's perception on their functional level and quality of life.

Palpation

Palpation is a fundamental skill used in a number of the tests and measures. Both Gerwin and colleagues154 and Njoo and Van der Does155 found that training and experience are essential in performing reliable palpation tests. Palpation, which can play a central role in the performance of several manual therapy techniques,156 is performed to:157,158

• check for any vasomotor changes such as an increase in skin temperature that might suggest an inflammatory process;
• localize specific sites of swelling;
• determine the presence of muscle tremors, and/or fasciculations;
• identify specific anatomic structures and their relationship to one another;
• identify sites of point tenderness. Hyperalgic skin zones can be detected using skin drag, which consists of moving the pads of the fingertips over the surface of the skin and attempting to sense resistance or drag.
• identify soft-tissue texture changes or myofascial restriction. Normal tissue is soft and mobile and moves equally in all directions. Abnormal tissue may feel hard, sensitive, or somewhat crunchy or stringy.159
• locate changes in muscle tone resulting from trigger points, muscle spasm, hypertonicity, or hypotonicity. However, a study by Hsieh and colleagues160 found that among non-expert physicians, physiatric or chiropractic, trigger point palpation is not reliable for detecting taut band and local twitch response, and only marginally reliable for referred pain after training. The most useful diagnostic test to detect these changes is to create a fold in the tissue, and to stretch it.161 The tissue should be soft and supple, and there should be no resistance to the stretch.
• determine circulatory status by checking distal pulses.
• detect changes in the moisture of the skin.

The pertinent palpation areas for each of the joints are described, within the relevant chapters.

Function

Functional testing is a complex and multifactorial process in which the clinician makes a determination about the patient's level of functional independence based on principles of physiology, biomechanics, and motor behavior:162

• Physiology. Relevant physiological issues include the functions of body structures and systems, the extent of the injury, and the patient's healing status, energy systems, adaptation, and overall fitness level.
• Biomechanics. Biomechanical considerations include functional anatomy, direction/planes of motion and stress, kinematics (time, distance, position, displacement, velocity), and kinetics (force, torque, mass, acceleration, inertia, momentum).
• Motor behavior. Motor behavior issues include proprioception, perception, transfer, practice, learning, control, coordination, and performance.

It is important for the clinician to determine what functional factors are important to the patient, and what functions are necessary for the patient to perform work-related, recreational, or social activities. It is worth remembering that insurance companies reimburse based on intervention goals that improve work-related and functional abilities, and not on those goals that enhance a patient's ability to perform recreational pursuits.

A number of variables affect function. These include age, gender, physical capacity (strength, power, flexibility, dexterity, agility, speed, muscular endurance, cardiovascular endurance, coordination, and skill), healing status (phase of healing, weight-bearing status, precautions/contraindications, and comorbidities), and psychological profile (motivation, fear, and coping mechanisms).162

Throughout this text, functional testing methods are outlined in each of the appropriate chapters. Part of the functional assessment includes an assessment of those muscles that are prone to weakness, which can provide the clinician with the following information163:

• Strength of individual muscles or muscle groups that form a functional unit.
• Nature, range, and quality of simple movement patterns.
• Relationship between the strength and the flexibility of a muscle or muscle group.
• The ability of the whole body to perform a task.

Muscle function testing, therefore, should address the production and control of motion in functional activities. Although there is general agreement about the role of the trunk and the pelvic musculature in normal functioning of the vertebral column, protection against pain, and recurrence of low back disorders,93,164,165 more research is needed to determine the role of functional strength in the extremities.

Special Tests

Special tests for each area are dependent on the special needs and structure of each joint. Numerous tests exist for each joint. With a few notable exceptions, the reliability of most orthopaedic testing is either poor or unproven. Therefore, the clinician is wise to avoid overreliance on labeling a specific test as positive or negative.166 Rather, the patient's response to provocative maneuvers should be carefully noted and be used to provide a framework within which the clinician builds a complete picture of the clinical entity.166 In addition, the clinician should use more than one examination maneuver to make the diagnosis. One study167 reported improved sensitivity, specificity, and positive predictive value with the utilization of combinations of tests rather than using tests in isolation.

The special tests are only performed if there is some indication that they would be helpful in arriving at a diagnosis. The tests help confirm or implicate a particular structure and may also provide information as to the degree of tissue damage.

In the joints of the spine, examples of special tests include directional stress tests (posterior–anterior pressures and anterior, posterior, and rotational stressing), joint quadrant testing, vascular tests, and repeated movement testing. Examples of special tests in the peripheral joints include ligament stress tests (i.e., Lachman for the anterior cruciate ligament), articular stress testing (valgus stress applied at the elbow), and glenohumeral impingement tests. Special tests can be categorized according to intent:

• Provocative tests. Provocative tests include those that are designed to put pressure on an involved structure and reproduce the pain that has brought the patient into the clinic, while ruling out involvement of other structures. Although palpation fits the criteria as a provocative test, its importance to the examination warrants its own section. Examples for other provocative tests include the Spurling's test (cervical foraminal encroachment test) to detect a potential cervical radiculopathy, the thoracic outlet tests, the neurodynamic mobilizations tests (e.g., the straight leg raise—see Chap. 11) that assess for neural adhesions and nerve root problems, and the selective tissue tension tests designed by Cyriax.90 These tests, which by their very nature are designed to reproduce the patient's symptoms, should be used judiciously, and only after consultation with the patient to describe the reasons for the testing.
• Clearing tests. The purpose of the clearing tests is to remove a structure or region as a potential source of the patient's problem. The clearing tests are typically used when a patient presents with symptoms in either the lower extremities or upper extremities. For example, in a patient complaining of shoulder pain, the clinician must determine if the symptoms are local, or are referred. To help in this decision-making process, the cervical spine must be “cleared” so it can be ruled out as a potential source. This can be done through a combination of neck side bending, rotation, and extension in an effort to reproduce the symptoms. If the symptoms are not reproduced with these maneuvers, the cervical spine can no longer be considered an obvious source of the symptoms. Because the cervical spine has the potential to refer pain throughout the entire upper extremity, it is always worth consideration as a cause of symptoms in the shoulder, the elbow, the wrist and the hand. Similarly, because the lumbar spine and the sacroiliac joint have the potential to refer symptoms into the lower extremities, they should always be considered in cases of hip, knee, and ankle and foot symptoms. In addition, neighboring joints should always be considered as potential causes of symptoms until cleared.

The special tests for each of the joints are described in the various chapters of this book, with emphasis placed on those that are evidence based. The interpretation of the findings from the special tests depends on the skill and experience of the clinician, as well as the degree of familiarity with the tests. While special tests are associated with false-positive and false-negative results, a positive test finding in conjunction with other aspects of the examination is highly suggestive of pathology.106

Reflex and Sensory Testing

Reflex and sensory testing is covered in Chapter 3. The neurological examination is only carried out if the clinician feels the nervous system is involved, or if the clinician is unsure as to whether there is any neurological involvement.

Neuromeningeal Mobility Tests

The neurodynamic mobility tests, described in Chapter 11, examine for the presence of any abnormalities of the dura, both centrally and peripherally. These tests are used if a dural adhesion or irritation is suspected. The tests employ a sequential and progressive stretch to the dura until the patient's symptoms are reproduced.12 Theoretically, if the dura is scarred, or inflamed, a lack of extensibility with stretching occurs. Because the sinuvertebral nerve innervates the dural sleeve, the pain caused by an inflamed dura is felt by the patient at multisegmental levels and is described as having an ache-like quality. If the patient experiences sharp or stabbing pain during the test, a more serious underlying condition should be suspected.

Evaluation

Once the examination is complete, the clinician should be able to add and subtract the various findings, determine the accuracy of the working hypothesis, and make an evaluation, which involves developing the diagnosis, the prognosis, and the realistic POC.168 According to Grieve,92 an evaluation is the level of judgment necessary to make sense of the findings, in order to identify a relationship between the symptoms reported and the signs of disturbed function. Thus, while the evaluation is used to determine the diagnosis, the prognosis, and the POC, it is the diagnosis that guides the intervention.

Clinical Decision Making

Patients may be referred to physical therapy with a nonspecific diagnosis, an incorrect diagnosis, or no diagnosis at all.170 Physical therapists are responsible for thoroughly examining each patient and then either treating the patient according to established guidelines, or referring the patient to a more appropriate healthcare provider.171 A diagnosis can only be made when all potential causes for the signs and symptoms have been ruled out, so the clinician should resist the urge to categorize a condition based on a small number of findings. The best indicator for the correctness of a diagnosis is the quality of the hypothesis considered, because if the appropriate diagnosis is not considered from the start, any subsequent inquiries will be misdirected.172 Ultimately, given the role of physical therapists as movement specialists, task analysis should form the basis of the diagnosis.173 Once impairments have been highlighted, a determination can be made as to the reason for those impairments, and the relationship between the impairments and the patient's functional limitations or disabilities.

Decision making encompasses the selection of tests during the examination process, interpretation of data from the detailed history and examination, establishment of the diagnosis, estimation of the prognosis, determination of intervention strategies, sequence of therapeutic procedures, and establishment of discharge criteria.169 The decision-making process is a multifaceted fluid process which combines tacit knowledge with accumulated clinical experience.174 The experienced clinician is able to recognize patterns and extrapolate information from them using forward reasoning, to develop an accurate working hypothesis.175 This is accomplished through an estimate of the proportional contribution of tissue pathology and impairment clusters to the patient's functional limitations.20 Using this information, the clinician puts a value on examination findings, considering relevant environmental, social, cultural, psychological, medical, and physical findings and clusters the information into recognizable, understandable, or identifiable diagnoses, dysfunctions, or classification syndromes.20 According to Kahney,176 the expert seems to do less problem solving than the novice, because the former has already stored solutions to many of the clinical problems previously encountered.177

One of the problems for the clinician is how to attach relevance to all of the information gleaned from the examination. This judgment process can be viewed as a continuum. At one end of the continuum is the novice who uses very clear-cut signposts, while at the other end there is the experienced clinician who has a vast bank of clinical experiences from which to draw.177 Experts are able to see meaningful relationships, possess enhanced memory, are skilled in qualitative analysis, and have well-developed reflection skills.174 This combination of skills allows the expert to systematically organize the information to make efficient and effective clinical decisions.

What differentiates diagnosis by the physical therapist from diagnosis by the physician is not the process itself but the phenomena being observed and clarified.178 Sackett et al.98 proposed three strategies of clinical diagnosis:

• Pattern recognition. This is characterized by the clinician's instantaneous realization that the patient conforms to a previously learned pattern of disease.
• History and physical examination. This method requires the clinician to consider all hypotheses of the potential etiology.
• Hypothetico-deductive method. In this method, the clinician identifies early clues and formulates a short list of potential diagnoses.

The clinician's knowledge base is critical in the evaluation process.172 Experienced clinicians appear to have a superior organization of knowledge, and they use a combination of hypothetico-deductive reasoning and pattern recognition to derive the correct diagnosis or working hypothesis.172

A number of frameworks have been applied to clinical practice for guiding clinical decision making and providing structure to the healthcare process.179–185 While the early frameworks were based on disablement models, the more recent models have focused on enablement perspectives using algorithms. An algorithm is a systematic process involving a finite number of steps that produces the solution to a problem. Algorithms used in healthcare allow for clinical decisions and adjustments to be made during the clinical reasoning and decision-making process because they are not prescriptive or protocol driven.174 The most commonly used algorithm in physical therapy is the hypothesis-oriented algorithm for clinicians (HOAC) designed by Rothstein and Echternach.182 The HOAC is designed to guide the clinician from evaluation to intervention planning with a logical sequence of activities, and requires the clinician to generate working hypotheses early in the examination process, the latter of which is a strategy often used by expert clinicians.

When integrating evidence into clinical decision making, an understanding of how to appraise the quality of the evidence offered by clinical studies is important. One of the major problems in evaluating studies is that the volume of literature makes it difficult for the busy clinician to obtain and analyze all of the evidence necessary to guide the clinical decision-making process.16 The other problem involves deciding whether the results from the literature are definite enough to indicate an effect other than chance. Judging the strength of the evidence becomes an important part of the decision-making process.

The standard for the assessment of the efficacy and value of a test or intervention is the clinical trial, that is, a prospective study assessing the effect and value of a test or intervention against a control in human subjects.186 Unfortunately, many of the experimental studies that deal with physical therapy topics are not clinical trials, because there is no control to judge the efficacy of the test or intervention, and there are no tests or interventions from which to draw comparisons.187 The best evidence for making decisions about interventions comes from randomized controlled trials, systematic reviews, and evidence based clinical practice guidelines (Table 4-25).188 The ideal clinical trial includes a blinded, randomized design and a control group. It may be possible to discriminate between high- and low-quality trials by asking three simple questions188:

1. Were subjects randomly allocated to conditions? Random allocation implies that a nonsystematic, unpredictable procedure was used to allocate subjects to conditions.

2. Was there blinding of assessors and patients? Blinding of assessors and patients minimizes the risk of the placebo effect and the “Hawthorne effect,” an experimental artifact that is of no clinical utility, where patients report better outcomes than they really experienced because they perceive that this is what is expected from them.189

3. Was there adequate follow-up? Ideally, all subjects who enter the trial should subsequently be followed up to avoid bias. In practice, this rarely happens. As a general rule, losses to follow-up of less than 10% avoid serious bias, but losses to follow-up of more than 20% cause potential for serious bias.

Numerous physical therapy tests exist that are designed to help the clinician rule out some of the many possible diagnoses. Regardless of which test is chosen, the test must be performed reliably by the clinician in order for the test to be a valuable guide. Reliability describes the extent to which test or measurement is free from error. A test is considered reliable if it produces precise, accurate, and reproducible information.16 Two types of reliability are often described:

• Interrater. Determines whether the same single examiner can repeat the test consistently.
• Intrarater. Determines whether two or more examiners can repeat a test consistently.

Reliability is quantitatively expressed by way of an index of agreement, with the simplest index being the percentage agreement value. The statistical coefficients most commonly used to characterize the reliability of the tests and measures are the intraclass correlation coefficient (ICC) and the kappa statistic (κ), both of which are based on statistical models190:

• The ICC is a reliability coefficient calculated with variance estimates obtained through an analysis of variance (Table 4-26).191 The advantage of the ICC over correlation coefficients is that it does not require the same number of raters per subject, and it can be used for two or more raters or ratings.191
• The κ statistic is a chance-corrected index of agreement that overcomes the problem of chance agreement when used with nominal and ordinal data.192 With nominal data, the κ statistic is applied after the percentage agreement between testers has been determined. However, with higher scale data, it tends to underestimate reliability.193 Theoretically, the κ statistic can be negative if agreement is worse than chance. Practically, in clinical reliability studies, the κ statistic usually varies between 0.00 and 1.00.193 The κ statistic does not differentiate among disagreements; it assumes that all disagreements are of equal significance.193
• Standard error of measurement (SEM). The SEM reflects the reliability of the response when the test is performed many times and is an indication of how much change there might be when the test is repeated.193 If the SEM is small, then the test is stable with minimal variability between tests.193

Test validity is defined as the degree to which a test measures what it purports to be measuring, and how well it correctly classifies individuals with or without a particular disease.17–19 A test is considered to have diagnostic accuracy if it has the ability to discriminate between patients with and without a specific disorder.194

In order to determine if a test is both reliable and valid, the test must be examined in a research study and, preferably, multiple studies.

Validity is directly related to the notion of sensitivity and specificity. The sensitivity and specificity of any physical test to discriminate relevant dysfunction must be appreciated to make meaningful decisions.195 Sensitivity is the ability of the test to pick up what it is testing for, and specificity is the ability of the test to reject what it is not testing for.

• Sensitivity represents the proportion of patients with a disorder who test positive. A test that can correctly identify every person who has the disorder has a sensitivity of 1.0. SnNout is an acronym for when sensitivity of a symptom or sign is high, a negative response rules out the target disorder. Thus, a so-called highly sensitive test helps rule out a disorder. The positive predictive value is the proportion of patients with positive test results who are correctly diagnosed.
• Specificity is the proportion of the study population without the disorder that test negative.196 A test that can correctly identify every person who does not have the target disorder has a specificity of 1.0. SpPin is an acronym for when specificity is extremely high, a positive test result rules in the target disorder. Thus, a so-called highly specific test helps rule in a disorder or condition. The negative predictive value is the proportion of patients with negative test results who are correctly diagnosed.

Once the specificity and sensitivity of the test is established, the predictive value of a positive test versus a negative test can be determined if the prevalence of the disease/dysfunction is known. For example, when the prevalence of the disease increases, a patient with a positive test is more likely to have the disease (a false-negative is less likely). A negative result of a highly sensitive test will probably rule out a common disease, whereas if the disease is rare, the test must be much more specific for it to be clinically useful.

The likelihood ratio (LR) is the index measurement that combines sensitivity and specificity values and can be used to gauge the performance of a diagnostic test, as it indicates how much a given diagnostic test result will lower or raise the pretest probability of the target disorder.97,196

Four measures contribute to sensitivity and specificity (Table 4-27):

• True positive. The test indicates that the patient has the disease or the dysfunction, and this is confirmed by the gold standard test.
• False positive. The clinical test indicates that the disease or the dysfunction is present, but this is not confirmed by the gold standard test.
• False negative. The clinical test indicates absence of the disorder, but the gold standard test shows that the disease or dysfunction is present.
• True negative. The clinical and the gold standard test agree that the disease or dysfunction is absent.

These values are used to calculate the statistical measures of accuracy, sensitivity, specificity, negative and positive predictive values, and negative and positive LRs, as indicated in Table 4-28. Another way to summarize diagnostic test performance using Table 4-27 is via the diagnostic odds ratio (DOR): DOR = true/false = (a∗d)/(b∗c). The DOR of a test is the ratio of the odds of positivity in disease relative to the odds of positivity in the nondiseased. The value of a DOR ranges from 0 to infinity, with higher values indicating better discriminatory test performance. A value of 1 means that a test does not discriminate between those patients with the disorder and those without.

The quality assessment of studies of diagnostic accuracy (QUADAS)200 is an evidence-based quality assessment tool currently recommended for use in systematic reviews of diagnostic accuracy studies (DAS). The aim of DAS is to determine how good a particular test is at detecting the target condition. DAS allow the calculation of various statistics that provide an indication of “test performance”—how good the index test is at detecting the target condition. These statistics include sensitivity, specificity, positive and negative predictive values, positive and negative LRs, and diagnostics odds ratios. The QUADAS tool is a list of 14 questions which should each be answered “yes”, “no”, or “unclear” (Table 4-29). A score of 10 or greater of “yes” answers is indicative of a higher quality study, whereas a score of less than 10 “yes” answers suggests a poorly designed study. Throughout this text, the QUADAS score is used (if known) to evaluate the various physical therapy examination tests.

Prognosis

The prognosis is the predicted optimal level of function that the patient will attain within a certain time frame. The prognosis represents a synthesis, based on an understanding of the extent of pathology, premorbid conditions, the ability of surrounding tissue structures to compensate in the short or long term, the healing processes of the various tissues, the patient's age, foundational knowledge, theory, evidence, experience, and examination findings, and takes into account the patient's social, emotional, and motivational status.20,173 This information helps guide the intensity, duration, and frequency of the intervention and aids in justifying the intervention.

The patient's aspirations and patient-identified problems, together with those problems identified by the clinician, determine the focus of the goals.173 The patient and clinician should come to an agreement regarding the most important problems, around which care should be focused, and together establish relevant goals.173 Patient education and patient responsibility become extremely important in determining the prognosis.

Plan of Care

The POC is organized around the patient's goals. The physical therapist's POC consists of consultation, education, and intervention. Intervention (see Chap. 8) is organized into three categories173:

1. Remediation. Consists of enhancing skills and resources or reversing impairments and assumes that the potential for change exists in the system and the person.

2. Compensation or adaptation. Refers to the alteration of the environment or the task and is the approach taken when it is determined that remediation is not possible.

3. Prevention. Refers to the management of anticipated problems.

Progress, and Reexamine

The selection of intervention procedures, and the intervention progression, must be guided by continuous reexamination of the patient's response to a given procedure, making the reexamination of patient dysfunction before, during, and after each intervention essential.201

At each visit, the clinician must reexamine the patient's status. To evaluate progress, comparisons are made between the findings from the initial examination and subsequent visits. There are three possible scenarios following a reexamination:

1. The patient's function has improved. In this scenario, the intensity of the intervention may be incrementally increased.

2. The patient's function has diminished. In this scenario, the intensity and the focus of the intervention must be changed. Further review of the home exercise program may be needed. The patient may require further education on activity modification and the use of heat and ice at home. The working hypothesis must be reviewed. Further investigation is needed.

3. There is no change in the patient's function. Depending on the time that has elapsed since the last visit, there may be a reason for the lack of change. This finding may indicate the need for a change in the intensity of the intervention. If the patient is in the acute or subacute stage of healing, a decrease in the intensity may be warranted to allow the tissues more of an opportunity to heal. In the chronic stage, an increase in intensity may be warranted.

The developing health-care system of the last decade has dramatically limited patients' access to rehabilitation services and has increased the accountability of the health-care provider.202 This development has placed a burden on the physical therapy profession to make the necessary changes to deal effectively with health-care reform, so that physical therapists become more accountable for their professional performance and more cost-effective in their provision of patient care.202 It is important that examination and intervention techniques continue to be verified through peer-reviewed research, patient outcome databases, and an increased efficiency and effectiveness.203,204

Documentation

Documentation in health care includes any entry into the patient/client record. This documentation, considered a legal document, becomes a part of the patient's medical record. The SOAP (Subjective, Objective, Assessment, Plan) note format has traditionally been used to document the examination and intervention process.

• Subjective: information about the condition from patient or family member.
• Objective: measurement a clinician obtains during the physical examination.
• Assessment: analysis of problems including the long and short-term goals.
• Plan: a specific intervention plan for the identified problem(s).

The purposes of documentation are as follows:205

• To document what the clinician does to manage the individual patient's case.
• To record examination findings, patient status, intervention provided, and the patient's response to treatment.
• To communicate with all other members of the health-care team—this helps provide consistency among the services provided. This includes communication between the physical therapist and the physical therapist assistant.
• To provide information to third-party payers, such as Medicare and other insurance companies who make decisions about reimbursement based on the quality and completeness of the physical therapy note.
• To help the physical therapist organize his/her thought processes involved in patient care.
• To be used for quality assurance and improvement purposes and for issues such as discharge planning.
• To serve as a source of data for quality assurance, peer and utilization review, and research.

• 1. Give a definition of empathy.

• 2. Differentiate between the terms examination and evaluation.

• 3. What are the three components of the examination?

• 4. What is the difference between a leading question and a neutral question?

• 5. What is the purpose of the systems review?

Answers