(BQ) Part 2 book Orthopaedic manual therapy diagnosis has contents: Supplementary data, diagnosis and treatment planning, palpatory examination, active examination, examination of the pelvic region, examination of the thoracic spine, examination of the temporomandibular joints,... and other contents.
CHAPTER Supplementary Data, Diagnosis, and Treatment Planning RADIOGRAPHY AND OTHER IMAGING STUDIES BIOPSY When making a manual diagnosis, it is important to be The manual therapy examination may yield findings that aware of any physical anomalies, morphologic changes, and suggest tissue biopsy would be advisable Examination of fractures However, the first two cannot be objectively es tissues and tissue Huids is one of the ways of establishing tablished by physical examination, and the last cannot al whether or not manual therapy is ind icated ways be identified with sufficient diagnostic certainty Radiographs are therefore needed to provide definite an swers They serve two purposes: they provide either a sup LABORATORY TESTS plementary or a definitive contribution to the physical examination, and they explam its findings In cases where relative or absolute counterindications for When requesting radiographs, it is important to be able manual therapy are suspected, laboratory tests can often to justify the request When interpreting the radiographs, give a definitive answer The results of any previous labora uniform criteria should be used to gain a valid result This tory tests should be taken into account, together with any plus the fact that a great deal of experience is needed to in treatment that was preSCribed at the time, for example, in terpret radiographs makes a good working relationship \vith sulin, antihypertensives, or anticoagulants the radiologist both desirable and necessary Finally, although CT and MRI scans are too expensive for routine use, they can provide definite answers as to whether or not manual therapy is indicated OTHER SPECIAL MEDICAL TESTS An accurate diagnosis may not be possible without input ELECTRODIAGNOSTlC STUDIES from other medical specialties such as gynecology; rheuma tology; urology; ear, nose, and throat CENT); internal medi Electrocardiograms, electroencephalograms, and elec cine; and psychiatIy In manual diagnOSiS, the relationship tromyograms can be produced and interpreted only by the between the internal organs and the spinal segments with appropriate which they are associated is also important: dysfunction in medical specialists Electromyography and nerve conduction velocity studies can be an important ad an internal organ can result in a presenting predominant junct to manual assessment and are sometimes necessary pain in another structure that is related to the same segment for differential diagnosis It is important when examining the patient to identify which 231 232 SUPPLEMENTARY DATA, DIAGNOSIS AND TREATMENT PLANNING , structure is the cause of the pathologic loop (pathogenetic TRIAL TREATMENT sensitivity diagnosis; Gutmann, 1970) The therapist must also pay attention to any pathology in secondary stmctures that are related to the segment because these can continu ously reactivate the vicious cycle Internal medicine thus can contribute not only to diagnosis but also to therapy The outcome of the trial treatmenl may be negative Pos sible reasons for this include inaccurate diagnOSiS, failure to choose the light therapy, or failure to administer it properly; under these circumstances, it may be necessary to restart the diagnostic process, adjust the therapy, or improve on its O VERALL ASSESSMENT delivery On the other hand, the outcome of the trial may be successful, in which case the probable diagnosis becomes definite and the trial therapy becomes the chosen therapy During this assessment, data from the maxlInally com prehenSive examination are evaluated in relation to each other with the goal of deriving an appropriate kinesiologic DEFINITIVE TREATMENT diagnosis The definitive treatment "'rill need continual adjustment KINESIOLOGIC DIAGNOSIS Once the kinesiologic diagnosis has been made, the treat ment plan can be drawn up This is followed by the first treatment session, which is regarded as a trial treatment dUling the patient's recovery to take into account his or her changing condition CHAPTER 10 History and Examination: Practical Considerations side to be examined is determined by the axial rotation TERMINOLOGY component IpSilateral, contralateral These terms refer to the positioning Functional mechanism Before describing in chapters 13-18 of the therapist's hands in relation to the side or direction the various regions of the spine and the temporo of movement to be examined 1n this context, ipsilateral mandibular joints, as well as the practical clinical exami means on the side or in the direction of movement to be nation procedures used in testing three-dimensional examined, and contralateral means the other side Dur movement, we must look at the functional mechanisms ing the examination of three-dimensional function, the that enable movement in the sagittal, frontal, and trans direction of movement to be examined is determined by verse (cardinal) planes separately in the chapter section the axial rotation component titled "Functional Aspects." The reason for doing so is that the literature offers little or no SCientifically sup Position of the patient during examination Weight-bearing ex ported information about the complicated mechanisms aminations of the thoracic and lumbar spine are carried that underlie three-dImensional movement and the out in a slightly flexed position unless this is prevented by dysfunction of the lumbar spine stresses it places on tissues The whole is more than the sum of the parts and is different from it Nevertheless, Therapist starting position During examination of weight separate analyses of the different cardinal plane move bearing three-dimensional function of the cervical, tho ments and the stresses they place on different tissues can racic, and lumbar spine, the therapist stands at the side provide some inSight-by extrapolation-into the mech being examined; this is determined by the direction of anisms and stresses involved in three-dimensional spinal rotation movement Performance of examination During weight-bearing three dimensional examination of the lumbar spine, the pa Order of examination The general principle for regional and segmental active-assisted examination tient's center of gravity should remain as close as possible is that three above the point of support dimensional movements involVing sidebending and ip silateral rotation are described before three-dimensional movements involving sidebending and contralateral MANUAL THERAPY DOCUMENTATION rotation Side being examined-side not being examined These terms refer to the starting position of the therapist with regard Table 10-1 can be used as a gUide to which items to the side or the direction of movement to be examined should be documented during the diagnosis and manage During examination of three-dimensional function, the ment process in orthopaediC manual therapy 233 234 10 Table 10-1 HISTORY AND EXAMINATION: PRACTICAL CONSIDERATIONS Steps in the Orthopaedic Manual Therapy Diagnosis and Management Process Data Steps Details of patient and referring physician Patient personal information Patient insurance information Date referral received Details of referral and referral source • Diagnosis on referral • Purpose of referral • Proposed treatment Treating manual therapist History taken by manual therapist Patient's reason for seeking out treatment Examination by manual therapist Complaint: nature/cause/location/severity/course Patient expectations Patient activities: Occupation/education/sports/hobbies Relevant medical details Relevant psychosocial details Other care and support Assistive devices used by the patient Results of examinations: Conclusions • Inspection • Palpation • Neurologic examination • Movement examination • Other measurements and tests Conclusions, with explanation Decision whether or not to treat Details outside the scope of manual therapy Treatment plan Impairments amenable to treatment Treatment goals Frequency of treatment Number of treatments Length of treatment sessions Details of intervention: Type/form/dosage /Iocation information Advice and lifestyle guidance Appointments with patient Assistive devices Multidisciplinary appointments and referrals Treatment evaluation Documentation Details of treatment process Treatment results Results of discussions with: referral source/colleagues/other disciplines Final treatment session Reason for termination of treatment Date of report to referral source Details of post-discharge care Examination Strategy EXAMINATION STRATEGY • • A clear formulation of the general and specific goals of the manual therapy examination is basic to a methodical • • and systematic approach to treatment (Hagenaars, Bernards, and Oostendorp, 1996) The taking of the history and the subsequent physical examination are the crucial elements in 235 Anatomic classification Medical classification Manual therapy classification Psychological classification The manual therapist identi Anatomic Classification fies the follOwing: meeting those aims • General Objectives • • The location of the disorder or lesion The affected tissue The nature of the lesion The manual therapist can make reasoned statements It is important to identify the damaged tissue to assess about the following factors: the adaptive capability of the area Three kinds of tissue • • The appropriateness of the manual therapy referral patient • • • may be distinguished: Appropriate manual therapy goals for the individual • ing bone marrow, and endothelial tissue) The strategy for attaining those goals • Appropriate manual therapy methods The most appropriate manual therapist section) Medical ClasSification diagnostic methods used are as follows: • The manual therapist can identify and make reasoned statements about the following factors: • • The factors that were responsible for the onset of the patient's disorder (disease), or the damage to the tis sue or organ History Physical examination Additional examinations (X-ray, CT scan, MRl, labo ratory tests, etc.) The disorder (disease) affecting the patient, or the tis sue or organ that is damaged The results of the medical diagnosis can be important for the manual therapist in determining adaptive potential and whether there are any absolute or relative contraindications for manual therapy The factors responSible for the patient's complaint Manual T herapy Classification (request for help) • Medical classification is based on the International Classification of Diseases (lCD) The General Second-Order Objectives • Recurrent mitotic tissue Intermittent cell division (col lagenous connective tissue) Before a statement of general objectives can be made, the general second-order objectives must be known (see next • Postmitotic tissue No cell division (muscle and nerve tissue) • • Mitotic tissue Continued cell division (blood, includ Whether the disorder (disease) or the damage to the tissues or organ is following a normal or an atypical course; the nature of any abnormality in the course, and the factors that have influenced it Dysfunctions are clas sified as local or segmental Where the dysfunction is seg mental, there will be a complex set of dysfunctions in the tissues and organs innervated by one spinal nerve together with the gray communicating ramus These are most likely to be expressed as changes in the mechanical behavior of Disorders (Diseases): Lesions in Tissues or Organs connective tissue (mobility, endfeel) Psychological ClasSification As already discussed in more detail in Chapter 4, disor The follOWing factors are important in this context: ders (diseases) and lesions of tissues or organs may be clas sified according to classification systems: any of the follOwing diagnostiC • Ability to learn and to modify behavior in the short or long term 236 10 • HISTORY AND EXAMINATlON: PRACTlCAL CONSIDERATIONS Relevant personal characteristics, such as the following: lnternallexternal locus of control Attribution Causes The factors that were/are responsible for the onset of the disorder, or for the lesIons in organs and tissues, may be of Coping style (active/passive/avoiding) two kinds: Anxiety • Depression • Aggression Stress Trauma Imbalance between load and load-bearing capacity Presenting Complaint Nonspecific arousal There are three ways in which the patients sickness be Intelligence Will power/motivation • Social interaction havior (presenting complaint) may be related to the physi cal factors: • Inventarization 'When information has been obtained under the preceding four headings, the therapist can evalu ate the following: • Capacity for local adaptation: • Age Gender Condition Constitution • Local impediments: Positioning (position of vertebrae and sacroiliac joint) Circulatory disturbances (rupture, constricted blood vessel, edema) • General impediments Medical disorders Systemic diseases Disorders of organs that must be functioning well to enable adaptation of the neuromusculoskeletal system Individual patterns of posture and movement, which must sometimes be modified in the interest of local • Course The nature of the disorder and the damage to the tissues or organ must first be Identified It may then be possible to establish whether the dysfunction (disease) is following a normal or an atypical course, and to identify any atypical features and their possible causes Tissues and organs vary in theIr capacity to recover and the length of time this takes (de Morree, 1993; Junqueira et aI., 1995) The course of a disorder can be atypical in nature and/or duration; this is influenced by both local and general impediments The history and the results of the physical exammation must be available before the second-level objectives can be decided Patient History The history should contain the folloVving sections: • • that creates unfavorable conditions for change • Complaint is related both to the disorder and its con sequences and to other unrelated problems adaptation Aspects of life, or any affective coloring by the patient Complaint is not related to the dysfunctIon and its consequences Cell death Tissue type Complaint is related to the dysfunction and its conse quences • Inventory of the patient's health problems The point in time when the first symptoms appeared List of the factors that were responsible for the onset of the disorder and the symptoms This involves ana The manual therapist must be able to recogmze the lyzing load in relation to load-bearing capacity, both general symptoms of stress and of strong nonspecific at the local level (tissues and organs) and at the global arousal to identify these factors level (the whole person) Examination Strategy 237 of the course of the complaints and the of the present status • Inventory Time Line Health Problems infonnation The The first step is to establish the time when the fIrst 15 symptoms and symptoms has This will show whether the and whether it has suffered from the complaint then tries to discover what the been recurrent The arose; cause was and in what circumstances the whether any treatments what its course was how were canied out, and how they were treatment lasted, and whether it the successfuL Complaints and Symptoms • Causes Pain: Times when the the causes may be of two kinds: As stated Location, nature, refenal pattern appears and disappears trauma and imbalance between load and Continuous or intermittent, diurnal/nocturnal Trauma factors and the patient has suffered trauma, the thera of the mechanism of pist needs to form a Any other influences tissues or organs The factors are the direction of the forces that caused the lesion and the loca tion of the impact Nature of appears or Times when Load factors and List the factors that were responsible for the on set of the disorder and the complaint This is produced capacity at the load in relation to Any other influences tissues and organs (local) and at the level of the abnormalities: whole person For the purposes of the manual therapy the physical load factors are classIfied or Times when the disturbances appear and factors and load General Physical Load other influences To form an initial will ask about the the items: IJ'HHC.'''_ dysfunction: Changes in • alcohol in • '-'HaH,"' '''' in skin • m Work-related stress, sports, hobbies muscle tone Medications and stImulants Current illnesses Local PhYSical Load Impairment, Disability, and Handicap come clear from the from an possible It should be whether the so how this contributes to a Local loads whether thennal, or chemical-that exceed the limits of the physical load-bearing unit or the level of can lead to disturbance in a kinesio on the central nervous system and the 10 238 HISTORY AND EXAMINATION: PRACTICAL CONS!DERATIONS input, the disturbance may result seg elsewhere within • Previous surgery • Present svstemic disorders nO,OOlles, informa are both lm may be asked to elicit the and of sport, number of der what conditions the number of hours devoted to of conditions in which this time spent can lead to distur of several kinesio • Have you • Have you had any serious mnesses? • Have you ever had a serious accident? • Have you ever taken any medicines? W hich • Have you • Have you ever had • Have you suffered in the past from the complaints had an that you have now of the central the had • Are you from may result Factors that can lower 1I1i:lapl;:,l asks about the course of the com should reveal what as follows: disturbance was and in to viral or bacterial infections what order and under what circumstances it may be T he limits on exceeded bv the • Trauma • Sudden • Persistent • Reduced functional movement • Increased in posture and movement habits of one-sided or mance of movements with one side of the body and social circumstances can be threatening to the extent that they exceed Information is needed about the followim! factors: • Regional/Segmental • Family situation • SOCial """"J'V!'.'L • Re of one or more units within a biomechanical chain the re- segments Both local and can be reduced Work situation Load-Bearing Capacity is the gional capac the Previous trauma, disturbances in the caused reduced circulation and Load-Bearing Capacity bearing mation The information about load- • during the manual therapy exam can be classified Previous disturbances in organs as or in neuroanatomicallv related segments related segments ment or in ical items • Anomalies in the affected area or • Previous illnesses organs and in the same neuromusculoskeletal in the Examination Strategy This is the Thoracic/Segmental Load-Bearing Capacity load-bearing capacity of the autonomic segments and their The follOwing questions are useful for elUCidating the course of the complaint: innervation area The load-bearing capacity of these seg ments can be lowered by the following factors: • Previous or current complaints affecting the internal • When did the current complaint begin? • Where did the present complaint begin? • organs or neuromusculoskeletal systems in the same segments or in neuroanatomically related segments • Threats that exceed psychological load-bearing capacity Psychological Load-Bearing Capacity disturbances or current threats to general well-being Non specific arousal can elicit a nonspecific reaction in the cen • combined with persisting nociceptive input, this can cause Has improvement been continuous since then? • Have there been times when the complaint became worse again? • When did it become worse? • What might have caused the deterioration? • Was the deterioration followed by improvement? • At what point did the improvement begin? • are changes specific to organs and tissues These conditions Have other complaints developed in addition to the primary one? a lasting rise in the tonic activity of the sympathetic auto nomic nervous system The recognizable symptoms of this When did the improvement begin? • tral nervous system; this is called nonselectivity Persistent nonspecific arousal can lower load-bearing capacity When Has there been any improvement since the onset of the complaint? Psychological load bearing capacity can be lowered by previous psychological 239 • What are these additional complaints? • When did the additional complaints arise? can be responsible both for the onset of the complaint and for its maintenance andJor spread To establish whether the The answers to these questions will show the pattern of patient is in a state of nonspecific arousal, the therapist development over a given period Three different patterns should ask whether the patient is suffering from any of the are possible: follOwing • Difficulty in falling asleep, restless sleep, night terrors, night sweats • Poor appetite, nausea • Irritability, feeling harassed, feeling bloated • Poor concentration, aimless activity • Hyperventilation, palpitations, swings in blood pres sure • Hyperhydrosis, loss of interest, and general fatigue • Progressive improvement • Mixed picture • Spread of the illness or the pattern of complaints If either the second or the third pattern applies, the prac titioner will need to explore whether the load placed on the damaged tissues is inappropriate, and whether there is a de gree of nonselectivity in the central nervous system Present Status To assess the patients present condition, it is essential to Course supplement the history with information about the com Recording the Course of the Patient's Complaints and the Illness plaints at the time of presentation The course of a complaint or an illness can be atypical in physiologic andJor patholOgiC terms The atypi Interpretation All the data obtained in the history cal features of the course may be qualitative or have to must be organized and interpreted before proceeding to in with its progression over time In cases where the course of spection and physical examination The following kinds of recovery is atypical, this may be due to the follOWing: information are needed about the illness, or the damaged organ or tissue: • • Local impediments such as inappropriate loading of the tissues • Location General impediments such as nonselectivity of the • Location of the original complaint • Distribution central nervous system 240 • • 10 HISTORY AND EXAMINATION: PRACTICAL CONSIDERATIONS Factors responSible for onset and development • cal presentation, and can a manual therapist identify Factors lhat influence the pattern of complaints The practitioner should be able to make an overall Judg such a picture with a high level of confidence? • ment and a provisional differential diagnosis based on inter pretation of the information recorded If the referral for manual therapy proves to have been inappropriate, this finding is reported to the referrer, together with an explana tion If, however, the referral appears at this stage to be ap propriate, the therapist will proceed to observation and physical examination to check and refine the information contained in the history Does the suspected illness have a characlerislic clini Is this clinical presentation specifiC to this illness? If the answers to these questions are positive, the level of confidence can be increased even further by means of ap propriate tests When the results of the examination have been recorded and interpreted, a general opinion is formed and a provi sional diagnosis made The diagnosis will determine whether manual therapy is indicated, whether it is ab solutely or relatively contraindicated, or whether it is con traindicated on functional grounds Observation If manual therapy is indicated, the therapist must assess The purpose behind the observation strategy is to con firm or supplement the details in the history In most cases, a general observation is followed by a regionaVlocal obser vation focused on the reported dysfunction (see the follow ing section titled "Observation") what results can reasonably be expected The next question is whether manual therapy alone will suffice, or whether a multidiSCiplinary approach should be considered If the next step is to be manual therapy, the therapist proceeds to a trial treatment The definitive treatment follows if the trial treat ment yields positive results If the outcome of the trial treat ment is negative, either the diagnostic process must be Physical examination started afresh or the therapeutiC approach must be modified It should be clear from the history which region should be examined and which segments are likely to be related to the disorder For a description of examination procedures, OBSERVATION please see the appropriate chapters The examination must perform the follOwing functions: • Check symptoms that were named or indicated by the patient during the taking of the history; list symp toms that were not named, but which on theoretical grounds could be present • Provide additional support During the observation, any abnormalities in shape or position and any speCial characteristics should be noted Observation covers the head, shoulder girdle, upper limbs, trunk, pelviC girdle, and lower limbs It is particularly im portant to assess the relationships among the different parts of the neuromusculoskeletal system conclusions Cleland et aL (2006) established interrater reliability for reached so far about illness or damage to tissues or for the visual assessment of posture as a component for the devel organs opment of a clinical prediction rule on the indications for thoracic spine manipulation in patients with mechanical Checking the History The reasons for checking the details in the history are these: • ing scale, they reported 81 % agreement for the assessment of forward head posture but a K value of -0.1 (95% Cl: -0.2-0.0) as a result of limited variation, that is, 90% prevalence Visual assessment of excessive shoulder protrac Possible loss of information resulting from inadequate communication between therapist and patient • neck pam (Cleland et aL, 200n Using a dichotomous rat Incomplete information because of differences in in terpretation between therapist and patient tion yielded 95% agreement and a 051-1.0) Observation for yielded 90% agreement (K = K excessive of 0.83 (95% Cl: C7-T2 kyphosis 0.79, terrater agreement for observation for excessive or de creased kyphosis at T3-T5 was 90% and 82% with K values of 0.69 (95% Cl 03-1.0) and 0.58 (95% CI 22-0.95) Additional Support for Conclusions For excessive and decreased kyphosis at T6-TlO, these val ues were 95% and 95% with K values of 0.9 (95% Cl: Two questions should be asked at this point: 0.74-1.0) and 0.9 (95% Cl: 073-1.0), respectively 564 INDEX Peret, C, 301 23 Pelvic inclination Performance of examination, 233 Pelvic inlet, 18 Periosteal receptors, 156,156 320-321 Pelvic Pelvic Periosteal renex 174 18-23 19-20, 20 sacroiliac and measurable findings on, 136t Periosteum, 18 Pelvic Peripheral movement trajectory, 41-42 Peripheral nerves Pelvic parameters, 17-18,19 186 lesions Pelvic region examination, 309-349 examination of sacroiliac joint, 325-340 of shoulder and trunk, 450t examination of the coccyx, 342-343 upper limbs supplied examination of the pubic 45H neurologic 341-342 instability of the sacroiliac ioint 343-349 187,191 Peroneal muscles, 159,167 Peroneal nerve 309-323 inspectlOn of, 324-325 293 location of pressure Pelvic tilt 324,324 inspection and examination U IlIU", common , location of pressure Pelvic sacral foramina, 17 and examination Peroneus longus, lumbar scoliosis and, 318 Peroneus longus Pelvic torsion 316-317,317 Peroneus tertius 317 Pharynx,499 of, 324-325,325 Phi coefficients, 116t and,317 relationship between fixation of sacroiliac Phillips, D R., 376,377,381,384 Pelvic torsion test, 347, 348 capacity of connective tissues and, 61, 64 Pelvic types, 311-313 for, 227 high assimilation pelvis, 311-312, 312 normal oelvis 312, 312 of components of 125 neurolOgic/neurovascular examination and, 212-213 assessment and observational criteria, 243t orientation and lateral, 251t pOSition, ventral, 247t 125 resting 191 disorders Piezoelectric effect, 68 functional aspects of, 309-311 Pinwheel sensory examination examination: cervical, 451-452, segmental of, 324-325 452 pelvic tilt, 324,324 torsion, 324-325,325 examination: lumbar, 373,374 laxity of dorsal ligaments of, 310 Piriformis test, 148 149,149,331,331 knnnecting rod as kinetic legs of different lengths and, 318 Tnntnr_"pn