ASSESSMENT MUSCULOSKELETAL ASSESSMENT

response in terms of accuracy. A good example of why it’s important to ask this question is demonstrated by the case of a female client who complains of low back pain of insidious gradual nature and in her past history reveals she has had a hysterectomy. What needs to be established is why did she have a hysterectomy (was it due to cervical cancer – which can lead to spinal secondary metastases)? This can be ascertained by asking whether the client is still under the medical team for this, or whether she been discharged (i.e. is clear of the condition). This may help to change the potential worrying diagnosis of spinal cancer to one of remote possibility (note it does not dismiss it). Linked closely to PMH is the question of medication. It may be useful to see if the client is taking any medication for the current condition, and whether or not it is beneficial. However it is also another way of establishing whether there are any other underlying illnesses or diseases not disclosed in the previous questions. As there are a plethora of possible medications that clients use, we are particularly on the lookout for anticoagulants and long-term cortico- steroid use. This is because in the latter case, ligaments and joints may become damaged by such medication. In the case of the former, potentially violent or high impact treatment/ rehabilitation processes may cause bleeding that is not easy to stop (8).

OBJECTIVE EXAMINATION The next stage in the examination process is the beginning of the objective examination and it should begin with a general inspection of the affected area.

Inspection This is an opportunity to inspect the site of lesion briefly looking for evidence of the following: l Bony deformity l Colour changes l Wasting l Swelling

Bony deformity could indicate joint subluxation, dislocation, fracture, or postural changes, whilst colour changes may indicate presence of bleeding or signs of inflammation. Musculature associated with the site of lesion may

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indicate the presence of long-standing problems, or even neurological issues. Swelling would indicate the presence of an inflammatory process. This is followed up by an initial brief palpation of the area specifically looking for: n Heat – indicating presence of inflammation n Swelling - indicating presence of inflammation n Synovial thickening – indicating presence of long standing inflammation n Pulses (not tenderness or pain) – indicating blood flow to through the area. It is only once this initial

observation phase is complete that the actual objective testing and measurement should begin. It is always necessary to establish whether the client feels any symptoms whilst at rest, before beginning any testing.

Objective testing n Active movements (if appropriate) for willingness to move n Passive movements for pain, range and end-feel (passive stretching/ squeezing may occur to inert tissues) n Resisted movements for pain and power (isometric contraction of contractile tissue components without passive stretching). The number and variety of these tests will be specific to particular joint regions of the body. It may be appropriate to include some neurological tests such as testing of reflexes, strength tests for myotomes, and sensation loss for dermatomes, particularly in spinal assessments where nerve roots may be involved in the lesion. It is only after completion of all these tests that palpation would be performed to localise the lesion further, and in some more difficult conditions, further additional tests may be performed, for example x-rays, scans, blood tests.

THE AUTHOR

Julian Hatcher qualified as a physiotherapist in 1987 and worked for 10 years both within the NHS, and privately specialising in sports (mainly Rugby League) and orthopaedic medicine before moving into higher education as a lecturer at the University of Salford. He became a Fellow of Orthopaedic Medicine in 2000 and has been teaching with Orthopaedic Medicine Seminars since then. In 2007, Julian completed his MPhil studies into proprioceptive acuity in ACL deficient people. He is currently programme leader for the BSc (Hons) Sports Rehabilitation programme at the University of Salford, which he helped establish in 1996. He is a member of ACPOM and a founding member of BASRaT.

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SUMMARY The Cyriax model presents subjective and objective assessment as an initial observation followed by a logical sequence of questions and a physical assessment based on a system of selective tension of the tissues. It is not meant to be a definitive method of assessment, however, it should help the manual therapist to reach a diagnosis in around 90% of cases. It must also be stated that this is only the basic assessment, there are many additional tests that can be added to the end of each of these assessments. Please note that the information

given here is designed to be an accompaniment to learning, and is no substitute for practical learning and role-play which has been shown to significantly improve the diagnostic skills of practitioners (8).

online

References 1. Cyriax J. A Textbook of Orthopaedic Medicine Volume 1: Diagnosis of soft tissue lesions. ISBN 0702009350. To order http://bit.ly/8X8fZd

2. Orthopaedic medicine seminars hosted by the Society of Orthopaedic Medicine and Association of Chartered Physiotherapists in Orthopaedic Medicine

3. Butler DS. Mobilisation of the Nervous System. ISBN 0443044007. To order http://bit.ly/ahgxR0

4. Travell JG and Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 2. ISBN 0683083678. To order http://bit.ly/bIDxXV

5. Travel JG and Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 1. ISBN 0683083635. To order http://bit.ly/cYVFIa

6. Butler DS. The Sensitive Nervous System. ISBN 0975091026. To order http://bit.ly/c6oBNt

7. Grieve GP. Mobilisation of the Spine: a Primary Handbook of Clinical Method 5th Ed. Churchill Livingstone. London

8. Smith cc, Newman L et al. A Comprehensive New Curriculum to Teach and Assess Resident Knowledge and Diagnostic Evaluation of Musculoskeletal Complaints. Medical Teacher 2005;27(6):553-558.