Assessment ProtocolDr. Michael Gillespie

Doctor of Chiropractic

Anatomic and Biomechanical Principles

It is necessary to understand normal anatomy and healthy biomechanical relationships to accurately evaluate orthopedic and neurological conditions.

Understand the relationship between structure and function.

Anatomical and biomechanical variants can be present with a particular patient.

Clinical Assessment Protocol

Patient History

Inspection / observation

Palpation

Range of Motion

Orthopedic and Neurologic Testing

Diagnostic Imaging

Functional Testing

DocumentationEvaluate progress.

Share information with other practitioners.

Insurance records.

Malpractice.

SOAP NotesSubjective – Patient History

Objective – Observation and Testing

Assessment – Based on compilation of findings

Plan – Further testing and / or treatment

Patient HistoryA thorough patient history can often lead to a

proper diagnosis with no further testing.

Emphasize the aspect of the patient history with the greatest clinical significance.

Acquire all of the patient’s history whether or not something seems relevant at the time.

Patient HistoryKeep the patient focused on the problem.

Listen carefully.

Do not lead the patient towards answers.

Closed-Ended HistoryQuestion and Answer Format.

Written Forms

Open-Ended HistoryDialogue between patient and examiner.

Identify other problems that are either directly or indirectly related to the presenting complaint.

Address the patient’s fears and concerns.

Develop rapport.

Keep the patient focused on the presenting problem.

OPQRST MnemonicOnset of complaint

Provoking or Palliative concerns

Quality of pain

Radiation to particular areas

Site and Severity of complaint

Time frame complaint

History – Other FactorsFamily History

Occupational History

Social History

Observation / InspectionGeneral Appearance

Functional Status

Body Type

Postural deviationsGaitMuscle guardingCompensatory movementsAssistant devices

Inspection – three layersSkin

Subcutaneous tissue

Bony structure

Skin InspectionBruisingScarringTrauma or surgeryChanges in color

Vascular changes of inflammationVascular deficiency – pallor or cyanosis

Pigmented areas / Hairy areasChange in textureOpen wounds – traumatic or insidious

Detection of Malignant Melanoma

Asymmetry MM lack symmetry

Irregular Borders MM have notched, indented, scalloped, or indistinct

borders

Color Changes MM have uneven coloration, may contain several colors

Diameter MM are typically greater than 6mm (0.25 in)

Elevation

Subcutaneous Soft Tissue Inspection

Evaluate for inflammation and swelling

Atrophy

Increase in size Edema, articular effusion, muscle hypertrophy

Nodules, lymph nodes, or cysts

Compare b/l symmetry, utilize circumferential measurements

Bony Structure InspectionEvaluate bony structure when gait or

range of motion is altered.

Evaluate the spineScoliosisKyphosisLordosisPelvic tiltShoulder height

Evaluate for congenital and traumatic bone deformities

Genu Varus

Genu Valgus

PalpationPalpate the patient in conjunction with

inspection.

Begin with a light touch.Dysesthesia.Hypoesthesia.Hyperesthesia.Anesthesia.

Skin PalpationEvaluate skin temperature

High – inflammationLow – vascular insufficiency

Adhesions

Subcutaneous Soft Tissue Palpation

Subcutaneous soft tissue – fat, fascia, tendons, muscles, ligaments, joint capsules, nerves, blood vessels.

Palpate with more pressure than with skin.

Palpate for tenderness and swelling or edema.

Tenderness Grading ScaleGrade I - Patient complains of pain

Grade II - Patient complains of pain and winces

Grade III - Patient winces and withdraws the joint

Grade IV – Patient will not allow palpation of the joint

Types of SwellingImmediately after injury, hard and warm

Contains blood

8 to 24 hours after an injury, boggy or spongyContains synovial fluid

Tough and dryCallus

Types of SwellingThickened and leathery

Chronic swelling

Soft and fluctuatingAcute

HardBone

Thick and slow movingPitting edema

PulsePalpate for pulse rate, rhythm, and amplitude

Normal healthy resting pulse rate for an adult is 60 – 100 bpm

Palpating Bony StructuresDetection of alignment problems

Dislocations, luxations, subluxations, fractures

Identify ligaments and tendons that attach to the bones

Detect bony enlargements

Range of MotionPassive

Active

Resisted

Passive Range of MotionThe examiner moves the body part without the

patient’s help.

Note normal, increased, or decreased movement.

Note pain.Capsular or ligamentous lesion on side of

movement and / or muscular lesion on side opposite of movement.

Six Range of Motion Pain Variations

1. Normal mobility with no pain.No lesion – normal joint.

2. Normal mobility with pain.Minor ligament sprain or capsular lesion.

3. Hypomobility with no pain.Adhesion.

Six Range of Motion Pain Variations

4. Hypomobility with pain.Acute ligament sprain or capsular lesion.

Guarding from muscle spasm.

5. Hypermobility with no pain.Complete tear with no fibers intact where pain can

be elcited.

6. Hypermobility with pain.Partial tear with some fibers still intact.

Sprain Vs. StrainSprain - A sprain is an injury involving the

stretching or tearing of a ligament (tissue that connects bone to bone) or a joint capsule, which help provide joint stability.

Strain - Strains are injuries that involve the stretching or tearing of a musculo-tendinous (muscle and tendon) structure.

End FeelEvaluate for end feel after determining the

degree of passive range of motion.

Passively move the joint to the end of its range of motion and then apply slight overpressure to the joint.

Active Range of MotionYields information regarding the patient’s

general ability and willingness to use a body part.

Assessment value is limited.

Note the degree of motion as well as pain elicited.

Crepitus should be noted.

Inclinometers and goniometers are used to measure range of motion.

Inclinometer

Goniometer

Resisted Range of MotionResisted range of motion assesses

musculotendinous and neurologic structures.

Musculotendinous injuries tend to be more painful than they are weak.

Neurologic injuries tend to be more weak than they are painful.

Muscle Grading Scale5 – Complete range of motion against gravity

with full resistance.

4 – Complete range of motion against gravity with some resistance.

3 – Complete range of motion against gravity.

2 – Complete range of motion with gravity eliminated.

1 – Evidence of slight contractility.

0 – no evidence of contractility.

Resistant Range of Motion Reactions

Strong with no pain – Normal.

Strong with pain – lesion of muscle or tendon.

Weak and painless – neurological lesion or complete rupture of a tendon or muscle.

Weak and painful – partial tear of muscle or tendon. Fracture, neoplasm, and acute inflammation are possibilities.