PHED 30303

1
PHED 30303

• Fall 2005

2
Unit 1Principles and Concepts of Evaluations

• An evaluation is an ongoing process used by all
  health care professionals. It involves
  communication with patients, observation,
  palpation, integration, and action. The Trainer
  or Therapist must evaluate a patient each time
  they see him/her. The patients first visit should
  begin with the initial evaluation.
• This helps to establish rapport with the patient
  and set a baseline for determining a treatment
  program.

3
(No Transcript)
4
Reasons for an Evaluation

• 1. For baseline measurement to compare to future
  data
• 2. To help rule out differential diagnosis
• 3. To define and understand the mechanism
  etiology of the injury
• 4. To define the musculoskeletal problems
  involved
• 5. To help the professional devise a treatment
  program
• 6. To provide a means to document evidence of the
  patients problems and progress

5
Legalities of Evaluations

• An evaluation is a professional document which
  may be used in a Court of law. In the athletic
  setting, ie. Training room The records keep
  are valid because they are kept under the
  direction of the team physician.
• In a clinical setting, under the current Texas
  law, a pt may make an evaluation upon a referral
  from a physician. The trainer that works in the
  clinical setting must do so with a pt and have
  them
• Co-sign any evaluations.
• This is one of several differences in the
  athletic and therapy practice acts

6

• Evaluations should be
• Written in ink
• White out should not be used. Strike out
  errors and initial them. (written files only)
• Complete the subjective, objective,
  assessment, and the plan portions of your
  evaluations.
• Sign the evaluations with your signature and you
  are responsible for keeping good records. Form
  good habits now !!

7
(No Transcript)
8
SOAP Notes

• Subjective information
• This is the first of 4 parts to the evaluation.
  Subjective information includes the patients
  accounts of why they came to see you and what
  their problems are. Listen carefully to the
  patient but remember that the professional
  controls the conversation and asks the questions.
  Always ask open needed questions. Do not ask yes
  or no questions.
• A. Case history
• How does the affected area feel now, latter in
  the day, or at night have the patient relate
  their symptoms to you pain, numbness, stiffness,
  etc.
• Have them describe the area of pain or its
  radiation .
• Loss of a.d.l. functions activities of daily
  living

9

• B. Behavior of symptoms
• When do they present, prior to activity, after,
  etc.
• Is the pain constant or intermittent
• What eases the pain, what aggravates your
  discomfort

10
Pain descriptions and related structures (table
1-1)

• Cramping, dull, aching pain Muscular
• Sharp, shooting pain Nerve root
• Sharp, bright, lightning like Nerve
• Burning, pressure like, stinging
• or aching Sympathetic nerve
• Deep, nagging, dull Bone
• may be nocturnal
• Sharp, severe, intolerable Bone, fracture
• Throbbing, diffuse Vasculature

11
(No Transcript)
12
Nerve Root System

• 31 nerve roots
• Cervical, thoracic, lumbar, sacral, coccygeal
• Anterior - ventral root
• Posterior - dorsal root
• they combine to make a single nerve root or
  spinal nerve

13

• Each root has two components
• somatic portion - innervates the skeletal muscle
  and provides sensory input from the skin, fascia,
  muscles and joints
• Visceral portion - innervates the autonomic
  nervous system
• The roots combine to form a nerve plexus such as
  the brachial plexus.
• The sensory distribution for each root is the
  dermatome. The peripheral nerves that supply the
  extremities also have motor, sensory, and
  sympathetic responses.

14

• Myotomes are groups of muscles that are
  controlled by a single nerve root.
• Sclerotomes are an area of bone or fascia that
  are supplied by a single nerve root.
• Referred pain
• This is somewhat confusing and inconclusive,
  however, the causes of referred pain may be
• Misinformation by the brain as to the source of
  the painful impulses
• Inability of the brain to interpret a summation
  of noxious stimuli

15
C. Previous symptoms

• How did the injury occur (etiology)
• Have they been in the emergency room or in the
  hospital for this injury or others
• Were x-rays taken, did they have surgery for this
  condition
• Was the injury a sudden one or did it occur
  gradually
• How long have you had the symptoms

16
D. Special questions

• What is the patients general state of health, are
  they currently taking any medications, do they
  have some unusual diet, what is there age,
  occupation, has anyone in their family had a
  similar condition, this relates to heredity, have
  they had any other accidents or surgeries.
• Try to assess how well adjusted the patient is to
  their injury.
• Are they nervous, over anxious, scared. Document
  any abnormal behavior.

17
II. Objective information

• This information is collected by the
  professional. It is observable, tangible, and
  producible. It may consist of measurements,
  comparisons of rt. To left. Comparisons of normal
  values, computerized tests etc. Objective
  information is recorded in inches, pounds,
  degrees, m\sec, severity of spasm, amount of
  swelling, etc. some practitioners may prefer to
  use the metric system. Be consistent
• Objective info also includes treatments,
  techniques, rehab exercises and handouts given to
  the patient.

18
A. Observe

• Observe the patient as they walk in.
• Do they limp, use crutches, braces
• Do you notice atrophy or swelling, scars
• Do a gait evaluation, and spinal curve or
  lateral shift.

19
B. Posture - have the patient remove their outer
clothing

• 1. Anterior view shoulder levels, neck
  rotation, side bending,
• ASIS levels hip , knee caps, tibial bowing,
  genu recurvatum,
• Arch levels, toes, etc.
• 2. Posterior view shoulder level, rounding, rib
  cage
• Prominence, scapular levels, sacral defects, and
  buttock levels.
• Pronation or supination of the ankles
• 3. Side view spinal curve, cervical curve,
  shoulder rounding,
• Thoracic or lumbar curves, back knees - genu
  recurvatum
• Foot problems
• 4. Leg length where applicable
• Apparent leg length, from the umbilicus to the
  medial malleolus, true leg length from the ASIS
  to the medial malleolus. Always compare rt. To
  left

20
C. Passive range of motion

• The practitioner moves the patient through the
  range of motion. The patient does not use their
  muscles. Measure the degrees in the range of
  motion. Notice the end point feeling.

21
D. Active R.O.M

• patients neuromuscular ability to move his/her
  limbs through a measurable R.O.M. use a
  goniometer to take objective measurements. Line
  up the arms of the device with the bones of the
  joint being measured. Check bilaterally. Restrict
  motion of the joints above and below the involved
  joint using over pressure

22

• E. Accessory motion - check the related
  movements of the associated joints

23
F. Perform a manual muscle test mmt

• Grades of muscle tests
• 5 Normal, full rom with resistance
• 4 Good, full rom, can support moderate resistance
• 3 - Fair, full rom against gravity
• light resistance
• - no resistance, with gravity
• 2- Poor, partial rom with
• against gravity
• -gravity eliminated
• 1 Trace, palatable contraction
• 0 Zero, no muscular reaction

24

• G. Flexibility of hams, quads, pecs, back erector
  spinae, etc.
• H. Girth around swollen areas. Pick your
  landmarks and always measure from the same place.
• I. Structural tests for ligaments, joint
  mobility, and menisci varus-valgus, anterior
  drawer, McMurray, Apley's, apprehension,
• J. Palpate muscle spasm, areas of point
  tenderness, trigger points, and the mobility of
  the tissue.
• K. Circulation check. Nail beds, pulse, bp,
  temperature of tissue, color of limb.
• L. Neurological check. Reflexes, numbness,
  tingling, pin prick tests, proprioception,
  kinesthesia

25
M. Reflexes

• Pathological reflexes
• Babinski - positive response if there is
  extension of the big toe and spreading of the
  other 4 toes, indicative of upper cord lesion.
• Biceps reflex
• Triceps reflex
• Brachioradialis
• Patellar reflex
• Achilles

26

• You do not always need to check all of these
  factors. Use only the tests that you need to make
  your decisions. If you have any doubts, perform
  more tests and document your findings carefully.

27
III. Assessment

• This is your idea about the involved tissues,
  prognosis, and time limits. You must then put all
  of these factors together for designing your
  prescription for the patient.
• A. Define all of the problems involved in all
  areas
• B. Make short term goals which are designed to
  achieve a certain amount of progress in a certain
  time.
• C. Make long term goals which are the ultimate
  expectations for the recovery. Prognostic
  estimates within a certain time limit.
• Example moderate edema, left lateral ankle. Stg.
  Decrease edema to normal with i.c.e.s. and egs,
  air bag. Recheck in one week.
• Ltg. Return to activity without swelling in I
  month.

28
IV. Plan

• This is the carrying out the treatment programs
  indicated by the evaluation. If you need to
  update programs or contact the dr.-- document it
  here. This section helps other people working
  with your patient. Know what to do next visit or
  if there needs to be changes.
• Take your time, get the info you need and take as
  long as you need - split the evaluation into two
  days. Always make sure your patient feels
  comfortable and is tolerating the movements well.
  Explain and demonstrate movements. The evaluation
  forms at the end are examples -there are hundreds
  or evaluation forms.

29
Evaluation Progression

• History
• Observation
• Palpation
• Stress
• (HOPS)