Chapter 8

The Examination and Evaluation

Overview

The examination process involves a complex

relationship between the clinician and
patient
The aim of the examination process is to
provide an efficient and effective exchange,
and to develop a rapport between the
clinician and patient
The success of this interaction involves a
myriad of skills
The Patient

The patient serves as perhaps the

most valuable resource to the clinician
Each interaction with a patient is an
opportunity to increase knowledge,
skill, and understanding
Communication

Communication between the clinician

and 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
The examination and
evaluation
The success of any rehabilitation
intervention depends on the quality
and accuracy of the examination and
the subsequent evaluation
An examination refers to the gathering of
data and information concerning a topic
An evaluation refers to the making of a value
judgment based on the collected data and
information
The Examination

The examination consists of three

components of equal importance:
The history
The systems review
The tests and measures
Observation

Throughout the history, systems

review, and tests and measures,
collective observations form the basis
for diagnostic deductions
Examination

History
The history usually precedes the systems
review and the tests and measures
components of the examination, but it
may also occur concurrently
It is estimated that 80% of the necessary
information to explain the presenting
patient problem can be provided by a
thorough history
Examination

History of current condition

This portion of the history taking can
prove the most challenging, and involves
the gathering of both positive and
negative findings, followed by the
dissemination of the information into a
working hypothesis
Examination

Systems review
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
Examination

Scanning examination
The purpose of the scanning examination
is to help rule out the possibility of
symptom referral from other areas, and
to ensure that all possible causes of the
symptoms are examined
Used when there is no history to explain
the signs and/or symptoms, or when the
signs and/or symptoms are unexplainable
Examination

Tests and measures

The tests and measures component of
the examination, which serves as an
adjunct to the history and systems
review, involves the physical examination
of the patient
The decision about which tests to use
should be based on the best available
research evidence
Tests and measures
Pain
Pain is a disturbed sensation that causes
suffering or distress
The following factors must be investigated:
Onset
Intensity
Location
Perception
Quality
Behavior
Nature
Tests and measures

Range of motion
The range of motion examination should
determine the exact directions and types
of motion that elicit the symptoms
Active
Passive
Active range of motion

Active range of motion testing gives

the clinician information about:
The quantity of available physiological motion
The presence of muscle substitutions
The willingness of the patient to move
The integrity of the contractile and inert
tissues
The quality of motion
Symptom reproduction
The pattern of motion restriction
The pattern of motion
restriction
Cyriax gave us the terms capsular and non-
capsular pattern of restriction
Capsular: a limitation of pain and movement in a
joint specific ratio, which is usually present with
arthritis, or following prolonged immobilization
Non-capsular: a limitation in a joint in any
pattern other than a capsular one. May indicate
the presence of either a derangement, a
restriction of one part of the joint capsule, or an
extra-articular lesion, that obstructs joint motion
Passive Range of Motion

Passive range of motion testing gives the

clinician information about the integrity of
the contractile and inert tissues, and the
end-feel
Pain that occurs at the end-range of active
and passive movement is suggestive of a
capsular contraction, or scar tissue that has
not been adequately remodeled
Passive versus active
ROM
According to Cyriax, if active and
passive motions are limited/painful in
the same direction, the lesion is in the
inert tissue, whereas if the active and
passive motions are limited/painful in
the opposite direction, the lesion is in
the contractile tissue
End feel

Cyriax introduced the concept of the

end-feel, which can be defined as the
quality of resistance felt by the
clinician at end range
The end-feel can indicate to the
clinician the cause of the motion
restriction
Joint mobility testing
Joint integrity and mobility testing can
provide valuable information as to the
status and the mobility of each joint and its
capsule
One of three conclusions can be drawn from
the passive mobility tests:
The joint is determined to be normal
The joint motion is determined as being
excessive
The joint motion is determined as being reduced
Strength testing

According to Cyriax, strength testing

can provide the clinician with the
following findings:
A weak and painless contraction
A strong and painless contraction
A weak and painful contraction
A strong and painful contraction
Strength testing

A number of grading systems exist to

test muscle strength using manual
resistance
Reflex integrity
Reflex integrity is defined as the intactness
of the neural path involved in a reflex
Deep tendon reflex. Deep tendon reflex (DTR)
tests utilize the muscle spindle to determine the
state of both the afferent and efferent peripheral
nervous systems, and the ability of the CNS to
inhibit the reflex
Pathological. The presence of pathological
reflexes is suggestive of CNS (upper motor
neuron) impairment, and requires an appropriate
referral
Sensory integrity

Sensory integrity is the intactness of cortical

sensory processing. It includes:
Proprioception
Pallesthesia (the ability to sense mechanical
vibration)
Stereognosis (the ability to perceive, recognize
and name familiar objects)
Topognosis (the ability to localize exactly a
cutaneous sensation)
Posture

Like good movement, good posture is a

subjective term based on what the clinician
believes to be correct based on ideal models
Good posture may be defined as the
optimal alignment of the patients body that
allows the neuromuscular system to perform
actions requiring the least amount of energy
to achieve the desired effect.
Palpation
Palpation is performed to:
Check for any vasomotor changes such as an increase
in skin temperature that might suggest an
inflammatory process
Localize specific sites of swelling
Identify specific anatomical structures and their
relationship to one another
Identify sites of point tenderness
Identify soft tissue texture changes or myofascial
restriction
Locate changes in muscle tone resulting from, trigger
points, muscle spasm, hypertonicity, or hypotonicity
Determine circulatory status by checking distal pulses
Detect changes in the moisture of the skin
Special Tests

These tests are only performed if

there is some indication that they
would by helpful in arriving at a
diagnosis
The tests are used to help confirm or
implicate a particular structure and
may also provide information as to the
degree of tissue damage
Neuromeningeal Mobility
Tests
The neurodynamic mobility tests examine
for the presence of any abnormalities of the
dura, both centrally and peripherally
These tests, which employ a sequential and
progressive stretch to the dura until the
patients symptoms are reproduced, are
used if a dural adhesion or irritation is
suspected
Imaging Studies

The results from imaging studies

should be used in conjunction with
other clinical findings
In general, imaging tests have a high
sensitivity (few false negatives), but
low specificity (high false-positive rate)
The Evaluation

According to Grieve, an evaluation is the

level of judgment necessary to make sense
of the clinical findings in order to identify a
relationship between the symptoms
reported and the signs of disturbed function
One of the problems for the clinician is how
to attach relevance to all of the information
gleaned from the examination
Clinical Decision Making

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
Physical therapy
diagnosis
Making a physical therapy diagnosis
involves a combination of hypothesis
testing and pattern recognition
The physical therapy diagnosis is a label
ascribed to a cluster of signs and
symptoms.
A diagnosis can only be made when all
potential causes for the symptoms
have been ruled out
Prognosis

The prognosis is the predicted level of

function that the patient will attain
within a certain time frame
This prediction helps guide the
intensity, duration, and frequency of
the intervention, and aids in justifying
the intervention