The evaluation process in rehabilitation By: Fatemeh Javadi

Introduction On-site evaluation at the time of injury (on-field) On-site evaluation just following injury (sideline) Off-site evaluation that involves the injury assessment and rehabilitation plan Follow-up evaluation during the rehabilitation process to determine the patient's progress Preparticipation physical evaluation (preseason screening)

THE SYSTEMATIC DIFFERENTIAL EVALUATION PROCESS Subjective evaluation : information on the injury history and the symptoms experienced by the patient. objective evaluation : observation and inspection, acute injury palpation, ROM assessment , muscle strength testing, special tests, neurological assessment, subacute or chronic injury palpation, and functional testing.

Subjective Evaluation History of Injury impression of the injury Site of injury mechanism of injury previous injuries general medical health open-ended questions with simple terminology

Subjective Evaluation cont. Patient’s impression How the injury occurred ( on patient’s own words) Where the injury is located How they feel

Subjective Evaluation cont. Site of injury area where the injury occurred or pain is located point with one finger Differentiating between provoked tissue and normal tissue to identify the pathological tissue

Subjective Evaluation cont. Mechanism of injury single traumatic force (macrotrauma) or repeated forces (microtrauma) In an acute injury : identify the body position at time of injury, direction of applied force, magnitude of applied force In a recurrent or chronic injuries: identify what factors influence the patient's symptoms, such as changes in training, routine, equipment use, and posture.

Subjective Evaluation cont. Pop = joint subluxation, ligament tear Clicking = cartilage or meniscal tear Locking = cartilage or meniscal tear (loose body) Giving way = reflex inhibition of muscles in an attempt to minimize muscle or joint loading

Subjective Evaluation cont. Previous injury what anatomic structures were previously injured? How often has the injury recurred? How was the previous injury managed? (Surgery, medication) Have there been any residual effects since the original injury?

Subjective Evaluation cont. Secondary pathology may be present in cases of recurrent injury, such as reduced soft-tissue elasticity, muscle contracture, weakness of surrounding musculature, increased joint laxity

Behavior of Symptoms To explore specific details of the symptoms discovered during the history PQRST: P = provocation or cause of symptoms Q = quality or description of symptoms R = region of symptoms S = severity of symptoms T = time symptoms occur or recur

Provocation of symptoms detailed mechanism-of-injury description musculoskeletal pain: worse with movement and better with rest. excessive inflammation : constant and not alleviated with rest.

Quality of symptoms Nerve pain: sharp, bright, shooting (tingling), along line of nerve distribution Bone pain: deep, nagging, dull, localized Vascular pain: diffuse, aching, throbbing, poorly localized, may be referred Muscular pain: hard to localize, dull, aching, may be referred

Region of symptoms Pain that radiates to other areas: nerve compression or active trigger points in the myofascial tissue. Localized symptoms in a small area: minor injury or chronic injury Diffuse symptoms : more severe injury

Severity of symptoms information relative to perceived severity of symptoms is an unreliable indicator of injury severity. comparisons of the patient's progress during rehabilitation

Timing of symptoms Symptoms with a slow and insidious onset that tend to progressively worsen over time: repetitive microtrauma. sudden, identifiable onset of symptoms : macrotrauma Response of symptoms to activity or rest: Joint adhesion = pain during activity. decreases with rest Chronic inflammation and edema = initial morning pain and stiffness. reduced with activity

Timing of symptoms cont. Joint congestion = pain that progressively worsens throughout the day with activity Acute inflammation = pain at rest and pain that is worse at the beginning of activity in comparison to the end of activity Bone pain or systemic disorders = pain that is not influenced by either rest or activity Peripheral nerve entrapment = pain that tends to worsen at night Intervertebral disc involvement = pain that increases with forward or lateral trunk bending

Objective Evaluation Observation and Inspection Overall appearance Specific body regions Patient’s movement patterns Muscle guarding Antalgic movements Facial expressions Bilateral comparison

Objective Evaluation cont. Postural alignment Malalignment: Muscle tightness, weakness, imbalance, bony deformity

Objective Evaluation cont. Signs of trauma Gross deformity of bone or joint line: Fx, joint Dx Visible swelling (rapid/gradual) , bleeding, signs of infection Atrophy of surrounding muscles: chronic injury

Skin color and texture: red (inflammation) blue (cyanosis, indicating vascular compromise) black-blue (contusion) shiny, lost elasticity or hair: peripheral nerve lesion

Palpation Purpose: localize pathological tissue Gentle, above & below the site of injury, communicate with patient Begins from distal Specific sequencing Minimizing patient movement

Palpation cont. Point tenderness Trigger points Increased temperature Change in tissue density/calcification Crepitus: damage to tendon, cartilage, bursa, joint, bone

Special Tests Range of Motion Active Passive Resistive First on uninjured limb Differentiate between inert and contractile tissue pathology

Inert tissue pathology: patient reports pain (typically near the end of ROM) occurring during both active and passive ROM in the same direction of movement. Contractile tissue pathology: patient reports pain in the same direction of motion during active ROM, then reports pain in the opposite direction of motion during passive ROM. It occurs due to increased tension placed on the tissue.

Active ROM Location of pain Painful arc Overpressure may be applied at the end ROM to assess end-point feels, if active ROM is full and pain-free Limited ROM: swelling, joint capsule tightness, agonist muscle weakness/inhibition, or antagonist muscle tightness/contracture

Passive ROM Reduced ROM during active compared to passive testing: deficiency in the contractile tissue. Contractile tissue deficiency: muscle spasm or contracture, muscle weakness, neurological deficit, or muscle pain

Capsular patterns of motion Irritation to the joint capsule may cause a progressive loss of available motion in different cardinal planes of motion. capsular pattern of the glenohumeral joint:limitation to external rotation, followed by abduction and internal rotation capsular pattern indicates a total joint reaction that may involve muscle spasm, joint capsule tightening (most common), and possible osteophyte formation.

Noncapsular patterns of motion irritation to structures located outside of the joint capsule Ligamentous adhesion : occurs after injury. movement restriction in one plane. full pain-free range in other planes. Internal derangement : sudden onset of localized pain resulting from the displacement of a loose body within the joint. motion restriction in one plane. normal, pain-free motion in the opposite direction.

3. Extra-articular lesion : adhesions occurring outside the joint 3. Extra-articular lesion : adhesions occurring outside the joint. Movement in a plane that stretches that adhesion results in pain, whereas motion in the opposite direction is pain-free and non restricted

Accessory motion & joint play (Arthrokinematic motion) Motion occurring between joint surfaces Roll, glide, spin Hypo/hypermobility joint stiffness, quality of motion, end-feel, and pain Reduced arthrokinematic motions: joint capsule or ligamentous adhesions and tightness

Resistive Strength Testing assess the state of contractile tissue (muscle, tendon). patient performs an isometric contraction while the athletic trainer performs a break test. The break test assesses the amount of isometric force the patient can generate prior to allowing joint motion

1. Midrange-of-motion muscle testing Isolation of contractile tissue Focuses on muscle groups

2. Specific muscle testing assess the strength and integrity of specific muscles the joint is placed in various positions in an attempt to isolate stress on the muscle of interest. Note any pain and grade muscle strength

Muscle Imbalances Agonist muscle tightness and hyperactivity combined with inhibition and weakness of the antagonist muscles results in disruption of the normal force-couple relationship between these muscles, hence a muscle imbalance

hyperactivity in the agonist muscle cause inhibition of the antagonist muscle : Sherrington's law of reciprocal inhibition. Reciprocal inhibition causes decreased neural drive to the antagonist muscle, which ultimately facilitates a functional weakness of the antagonist muscles.

Joint tends to position in the direction of tight agonist muscle Normal postural alignment adversely affect Agonist muscle move into more shortened position Antagonist muscle is lengthened from its normal position fewer cross bridges reduced force capacity

To compensate for weakness of the antagonist muscle group, greater reliance on muscles that act as synergists to the weakened muscles: synergistic dominance increases the risk of injury to these muscles

Movement group muscles: Prone to developing tightness (hyperactive) More active during functional movements (hyperactive) More active when the individual becomes fatigued or when performing new movement patterns (hyperactive)

Stabilization group muscles: Prone to developing inhibition and weakness (reduced force capacity) Less active during functional movements (reduced force capacity) Easily fatigued during dynamic movements (reduced force capacity)

restoring normal balance between muscles is accomplished by first stretching the tight muscle to restore normal range of motion before attempting to strengthen the weak antagonist muscle

Thank you for your attention