extra notes

1. Dr Jay Ebert
Dr Jay Ebert 1
Interview & Assessment
-Overview-
Jay Ebert
PhD ESSAM
Accredited Exercise Physiologist
Musculoskeletal Rehabilitation
Patient Assessment & Evaluation
S.O.A.P.I.E.R.
• Subjective
• Objective
• Analysis
• Plan
• Intervention
• Evaluation
• Review
Not the role of the
EP to diagnose!
Subjective Assessment
A ‘complete’ injury & medical history is essential
Injury History
• mechanism of injury?
Pain History
• onset: acute/delayed (following trauma)?
• location: acute, referred, generalized ache? – ‘BODY CHART’
• irritability
• how easily is the condition aggravated?
• are there relieving factors (ie. rest, certain postures)?
• severity (visual analogue scales?)
• previous history (& response to previous treatments)?
• PRO measures (general & specific Q’s)
S.O.A.P.I.E.R.
What is Pain?
“an unpleasant sensory & emotional experience
associated with actual or potential tissue damage
or described in terms of such damage”
(International Association for the Study of Pain: IASP)
Acute vs Chronic Pain
• Acute: occurs soon after injury, lasts during the affected
tissue recovery time
• Chronic: persists beyond tissue healing phase, or after
reasonable treatments have been unsuccessful
• Visceral
• Neuropathic
• Radicular Pain
• Somatic
*Pain may be ‘local’, ‘referred’ or both
Body Pain

2. Dr Jay Ebert
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Body Pain
Visceral
• Compression in & around internal organs, abdominal cavity
• Generalized aching/squeezing, can have ‘radiating’ pattern
Neuropathic
• Nerve damage/lesions
• Burning or tingling sensation
• Can be continuous or episodic (‘electric shocks’)
Radicular
• Pain associated with nerve root
compression or irritation
• Narrow band of sharp, shooting pain
• Dermatomal distribution
Somatic
• Pain generated from a somatic
structure (muscle, tendon, joint, disc)
• Pain perceived in one area, originating
from another
• Static, dull ache, generally constant
• Muscle (trigger points) or jts
• Brain ‘misinterprets’ pain source
Body Pain
Referred Pain
-Common Locations-
(Brukner & Khan)
Pain Location Pain Type Pain Source
Occipital
headache
Radicular ↑Cx
Somatic TP's in upper traps, SCM
Shoulder
Radicular ↓Cx, ↑Tx
Somatic TP's in SS, IS
Chest
Radicular Tx
Somatic TP's in pec major, intercostals
Sacroiliac
Radicular Thoracolumbar junction (TCLJ) (L4-5)
Somatic TP's in quad lumborum
Groin
Radicular ↑Lx, sacroiliac jt, TCLJ
Somatic TP's in gluts, adductors
Hamstrings,
buttocks
Radicular Lx, sacroiliac jt
Somatic TP's in gluts, piriformis
Lateral
thigh/knee
Radicular Lx
Somatic TP's in glut min, TFL
Radicular = pain associated with
nerve root compression
Somatic = pain in one area,
originating from another Musculoskeletal Pain
• Joints & Ligaments
• Stimulation of nociceptive nerve endings
• chemical (inflammation)
• mechanical (movement)
• Muscles, Tendons & Fascia
• Stimulation of nociceptive nerve endings
• acute damage
• in association with other injuries (ie. ↑ muscle spasm/tension &
abnormal movement to protect underlying problem)
• Neural Structures (ie. nerve impingement)
Pain Measurement
• Subjective
• Visual Analogue Scale – VAS
(Handbook of Pain Assessment, Turk 1992)
• General pain Q’s
• Specifically designed (& validated) patient-reported
outcome (PRO) tools for particular pathology
• Be aware of the ‘perception’ of pain vs ‘actual’ pain
Subjective Assessment
Behaviour of Symptoms
• Aggravating & relieving factors?
• movements/postures that aggravate/ease condition
• functional limitations
• will assist in exercise prescription/progression
• 24 hour behaviour
• am, pm, throughout day
• stiffness, pain, fatigue
• sleeping positions/patterns etc.
• Associated symptoms?
• effusion, instability, tingling, numbness etc.
• Relationship of pain/symptoms to underlying pathology
• important in developing program stages/goals
can use as
measurement
tool for progress
may also dictate best
times for activity

3. Dr Jay Ebert
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Previous Injury, Treatments & Outcome
• injections, medications, other (ie. chiropractic)
• exercise therapy - check what and how performed, outcomes?
Ongoing Medical History
• other conditions
• hypertension, overweight/obesity, asthma, diabetes, arthritic conditions,
other health risk factors or previous injuries
• assessment of other pre-disposing risk factors (ie. smoking, depression)
• do these provide contraindications for aspects of your program?
• exercise history
• current medications
• radiological examinations
Subjective Assessment
Physical Activity Readiness
Questionnaire (PAR-Q)
• cardiovascular issues
• angina, dizziness, BP
• bone, jt, muscle disease
• age
• pregnancy
• medications
Adult Pre-Exercise
Screening System (APSS) Medications
• Complete & accurate medical history is essential
• can these medications potentially ‘mask’ exercise
related symptoms?
• Medical Information Management System (MIMS)
• MediMedia Australia
• bi-monthly & annual publications, EMIMS
Common Musculoskeletal
Radiological Examinations
Standard X-rays
• first study ordered in skeletal evaluation
(widely available, quick and relatively cheap)
• uses radiation passed through tissues
• passes through less dense matter (air,
water, soft tissue)
• absorbed by dense matter (bones, tumours)
• for evaluation of joint space & fractures
Common Musculoskeletal
Radiological Examinations
Computed Tomography (CT) Scan
• uses X-rays in conjunction with
computing algorithms to image body
(3D reformation)
• better resolution of fracture lines
• evaluates degree of articular
displacement

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Magnetic Resonance Imaging (MRI)
• strong magnetic field & ↑ frequency
radio-waves
• most optimal soft tissue contrast
• cross-sectional pictures in all planes
Common Musculoskeletal
Radiological Examinations
Ultrasound
• no exposure to ionizing radiation
• inexpensive & non-invasive
• superficial soft tissues, foreign bodies, ganglion cysts,
fluid collections, dynamic tendon assessment, ruptures,
tendonitis, muscle tears
• preferred for tendon imaging
• positioning needles during steroid injections
Common Musculoskeletal
Radiological Examinations
Nuclear Medicine Bone Scan
• nuclear scanning test to find
abnormalities in bone
• bone cancers, sources of bone pain &
abnormal bone, diagnose fracture not
seen on X-ray
• injection of radioactive tracers
• tracers migrate to injured area (based
on altered bone turnover/metabolism)
Common Musculoskeletal
Radiological Examinations Objective Assessment
• Observation (static & dynamic)
• Biomechanics
• Posture
• Palpation
• ROM
• Specific Pathological Functional Tests
• tests for specific conditions
• neural tension test (ie. slump test)
• Muscle & Limb Length
• Strength, Function & Fitness
‘specific regional assessment will be undertaken throughout lectures’
S.O.A.P.I.E.R.
Objective Assessment
-Observation-
Static
• biomechanical alignment & asymmetry
• eg. hip internal rotation/ foot pronation
& patellofemoral pain
• atrophy or hypertrophy
• effusion
Dynamic
• alignment
• movement patterns/deficiencies
• biomechanical assessment VIDEO – Dynamic
Gait Assessment
VIDEO – Dynamic
Scapula Assessment
Objective Assessment
-Biomechanics-
• How do poor biomechanics
affect/contribute to the condition?
• ie. PFPS associated with genu valgum,
lateralised TT’s, hyperpronation (foot), ↑ tibial
torsion, ↑ femoral anteversion & inclination
• ie. patella tendinopathy & tight quads
Outcomes of biomechanical assessment
will dictate program objectives?

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Objective Assessment
-Posture-
• Landmarks
• Soft tissues
• muscle, tendon, ligaments etc.
• proximal (ie.insertion) & distal
(ie. muscle belly)
• Joints
Objective Assessment
-Palpation-
Passive & Active
• goniometers &/or inclinometers?
• single & multiple plane/combined movements
• aggravate or ease symptoms?
• pain onset & movement abnormalities
• joint &/or muscle stiffness
• compare both sides
Objective Assessment
-ROM-
Specific pathological functional tests
• tests for specific conditions
• eg. knee: ACL laxity, meniscal damage
• eg. shoulder: ‘empty can’, ‘lift-off’,
resisted movements
• neural tension tests
• assess contribution of neural tissue
abnormality to pain/symptoms
• SLR, slump, ULTT
Objective Assessment
-Specific Tests-
• Muscle Length Assessment
• hamstrings, hip flexors etc.
• Limb Length Assessment
• lower limb: must ensure it is not a
functional leg length discrepancy
(ie. tight psoas, quadratus)
• look for secondary compensations
(ie. scoliosis, muscular imbalance)
Objective Assessment
-Muscle & Limb Length-
• Resisted Movements
• evaluate strength & pain
• compare both sides
• Specific Tests of Strength
• strength & ‘quality’ of muscle activation
• eg. isokinetic dynamometry, 3RM tests
• Functional Activities
• dependent on pathology & patient
• eg. 6-min walk test, sit-to-stand, squat &
hop tests
Objective Assessment
-Strength & Function-
VIDEO – Squat &
Hop Assessment

6. Dr Jay Ebert
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Analysis, Goal Planning &
Intervention
• General aim of the Exercise Program
• control/prevent pain while normalising movement
patterns during functional, client orientated activities
• General Components of Rehabilitation
• Flexibility & ROM
• Muscle conditioning (ie. endurance, strength)
• Cardiovascular fitness
• Neuromuscular control
• Functional exercises
• Sport skills
• Psychology
• Correcting abnormal biomechanics
S.O.A.P.I.E.R.
Brukner & Khan
Motor re-education & muscle activation
Proprio-
ception
Strength
Flexibility
Skill
Acquisition
Return
to Sport
• A successful ‘exercise program’ will depend on;
• appropriate education & explanation
• of underlying pathology, healing process, program rationale
• realistic time-frames
• realistic short (ie. crutches/brace) & long-term (sport) goals
• detailed evaluation is imperative to ‘individualisation’
• must be patient centered & functional
• reparative (ie. exercises) & preventative (ie. address ergonomics)
• must encourage self responsibility & management
• precise exercise prescription (one-on-one supervision)
• supervised vs home program vs combination
S.O.A.P.I.E.R.
Analysis, Goal Planning &
Intervention
• ‘Home’ Exercise Programs
• careful instruction/education/prescription
is essential
• modified activity progression
• ensure household equipment/facilities
are safe & appropriate
• requires less time between reviews
Analysis, Goal Planning &
Intervention Evaluation & Review
• When?
• will depend on goals
• allow enough time for changes, though still maintaining
patient motivation
• How?
• subjective/objective tools selected in the initial evaluation
• Did the program make a ‘functional’ difference?
• measures/outcomes should reflect patient needs
S.O.A.P.I.E.R.
Nutritionist
Patient’s
Family
Multidisciplinary Team
PATIENT
Orthopaedic
Surgeon
Orthopaedic
Fellow
Registrar
Theatre Nurses
Anesthetist
Inpatient
Physiotherapists
OT’s
Ward Nurses
Podiatrist
Orthotist
Radiologist
GP
Exercise Physiologist
Remedial Massuer
OtherAllied Health Professionals
Physiotherapist
Insurance
Company
Sample ‘Generic’ Assessment Form

7. Dr Jay Ebert
Dr Jay Ebert 7
• Clinical Sports Medicine (Brukner & Khan)
• Explain Pain (Butler, D & Moseley G. Noigroup Publications, 2003)
• Handbook of Pain Assessment (Turk DC, Melzack R. NY: Guilford Press, 1992)
• ACSM’s Resource Manual for Guidelines for Exercise Testing & Prescription
• Australian Sports Commission (1998) Screening Test Protocols. Australian
Sports Commission, Canberra ACT
• ESSA’s Student Manual for Health, Exercise and Sport Assessment
• MIMMS (Medical Information Management System) Annual
Helpful Resources