Dr. Michael Gillespie

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Orthopedic Neurological Evaluation

• Dr. Michael Gillespie
• Doctor of Chiropractic

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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.

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Clinical Assessment Protocol

• Patient History
• Inspection / observation
• Palpation
• Range of Motion

• Orthopedic and Neurologic Testing
• Diagnostic Imaging
• Functional Testing

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Documentation

• Evaluate progress.
• Share information with other practitioners.
• Insurance records.
• Malpractice.

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SOAP Notes

• Subjective Patient History
• Objective Observation and Testing
• Assessment Based on compilation of findings
• Plan Further testing and / or treatment

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Patient History

• A 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 patients history whether or
  not something seems relevant at the time.

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Patient History

• Keep the patient focused on the problem.
• Listen carefully.
• Do not lead the patient towards answers.

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Closed-Ended History

• Question and Answer Format.
• Written Forms

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Open-Ended History

• Dialogue between patient and examiner.
• Identify other problems that are either directly
  or indirectly related to the presenting
  complaint.
• Address the patients fears and concerns.
• Develop rapport.
• Keep the patient focused on the presenting
  problem.

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OPQRST Mnemonic

• Onset of complaint
• Provoking or Palliative concerns
• Quality of pain
• Radiation to particular areas
• Site and Severity of complaint
• Time frame complaint

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History Other Factors

• Family History
• Occupational History
• Social History

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Observation / Inspection

• General Appearance
• Functional Status
• Body Type
• Postural deviations
• Gait
• Muscle guarding
• Compensatory movements
• Assistant devices

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Inspection three layers

• Skin
• Subcutaneous tissue
• Bony structure

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Skin Inspection

• Bruising
• Scarring
• Trauma or surgery
• Changes in color
• Vascular changes of inflammation
• Vascular deficiency pallor or cyanosis
• Pigmented areas / Hairy areas
• Change in texture
• Open wounds traumatic or insidious

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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

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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

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Bony Structure Inspection

• Evaluate bony structure when gait or range of
  motion is altered.
• Evaluate the spine
• Scoliosis
• Kyphosis
• Lordosis
• Pelvic tilt
• Shoulder height
• Evaluate for congenital and traumatic bone
  deformities

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Genu Varus
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Genu Valgus
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Palpation

• Palpate the patient in conjunction with
  inspection.
• Begin with a light touch.
• Dysesthesia.
• Hypoesthesia.
• Hyperesthesia.
• Anesthesia.

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Skin Palpation

• Evaluate skin temperature
• High inflammation
• Low vascular insufficiency
• Adhesions

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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.

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Tenderness Grading Scale

• Grade 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

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Types of Swelling

• Immediately after injury, hard and warm
• Contains blood
• 8 to 24 hours after an injury, boggy or spongy
• Contains synovial fluid
• Tough and dry
• Callus

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Types of Swelling

• Thickened and leathery
• Chronic swelling
• Soft and fluctuating
• Acute
• Hard
• Bone
• Thick and slow moving
• Pitting edema

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Pulse

• Palpate for pulse rate, rhythm, and amplitude
• Normal healthy resting pulse rate for an adult is
  60 100 bpm

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Palpating Bony Structures

• Detection of alignment problems
• Dislocations, luxations, subluxations, fractures
• Identify ligaments and tendons that attach to the
  bones
• Detect bony enlargements

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Range of Motion

• Passive
• Active
• Resisted

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Passive Range of Motion

• The examiner moves the body part without the
  patients 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.

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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.

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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.

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Sprain Vs. Strain

• Sprain - 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.

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End Feel

• Evaluate 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.

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End Feel Evaluation
Table 1-1 Page 6
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Active Range of Motion

• Yields information regarding the patients
  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.

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Inclinometer
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Goniometer
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Resisted Range of Motion

• Resisted 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.

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Muscle Grading Scale

• 5 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.

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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.