OBJECTIVE ASSESSMENT
Following the subjective assessment it is important to highlight
the main findings and determine the SIN factor. A hypothesis may be reached as
to the cause of the patient’s symptoms and the testing procedures are performed
in order to support or refute the physiotherapist’s hypothesis.
General observation
Observe the person’s gait and general demeanour on entering the
department.
Local observation
Note any localised swelling at the joint. This may be measured with
a tape measure around the joint or limb circumference. Note any asymmetry of
joint contours, redness of the overlying skin suggesting local inflammation,
atrophy and asymmetry of musculature, deformity, and malalignment
of the joint or joints. Compare one joint closely with the other
side whenever possible.
Posture
Observe any asymmetry of posture in standing, walking and sitting.
Poor posture is frequently a precursor to muscle imbalance, selective tightness
and weakness through over- or under-use of specific muscles. The result
of prolonged poor postural habits may lead to an acceleration of
certain pathologies such as adhesive capsulitis, shoulder impingement syndrome,
spinal pain and arthritis. Poor posture is frequently the cause of aches and
pains and may be correctable in the early stages and improved in later stages.
Correction may prevent recurrence or acceleration of specific pathologies.
Palpation
Palpate for the following:
• tenderness;
• heat (use the back of your hand
– it is more sensitive to heat changes);
• swelling;
• muscle spasm.
Assessment of movement
Active movements
These are movements performed by the patient’s voluntary
muscular effort.
Passive movements
These are movements performed by an external source, such as the
physiotherapist or a pulley system. There are two types of passive movements.
• Physiological movements are
movements that could be performed actively by the patient (e.g. flexion of the
knee or abduction of the shoulder joint).
• Accessory movements cannot be
performed actively by the patient (e.g. they incorporate glide, roll or spin
movements that occur in combination as part of normal physiological movements).
An example of an accessory movement is an anterior–posterior glide at the knee
joint.
Resisted movements
These are performed against the resistance of the physiotherapist or
weights by the patient’s own effort. Assessment of range of movement
Measurement of joint range using a goniometer
Active movement may be assessed by the use of a goniometer or,
alternatively, by visual estimation. It is measured in degrees and it is useful
to practise using the goniometer by measuring the hip, knee and ankle joints
in various positions. Either the 360° or 180° universal goniometers
may be used. Ensure adequate stabilization of adjacent joints prior to taking
the measurements and locate the appropriate anatomical landmarks as accurately as
possible. For details on specific joint measurements using the goniometer,
refer to the appropriate joint assessment. Physiological and accessory passive
movements are measured in terms of the above and by the end-feel respectively.
Differentiation tests
If a lesion is situated within a non-contractile structure such as
ligament, then both the active and passive movements will be painful and/or restricted
in the same direction. For example, both the active and passive movement
of inversion will produce pain in the case of a sprained lateral
ankle ligament. However, if a lesion is within a contractile tissue such as a
muscle, then the active and passive movements will be painful and/or restricted
in
opposite directions (Cyriax 1982). For example, a ruptured quadriceps
muscle will be painful on passive knee flexion (stretch) and resisted knee
extension (contraction).
End-feel
During passive movements, the end-feel is noted. Different joints
and different pathologies have different endfeels. The quality of the resistance
felt at the end of range has been categorised by Cyriax (1982). For example:
• bony block to movement or a
hard feel is characteristic of arthritic joints;
• an empty feel, or no resistance
offered at the end of range, may be a result of severe pain associated with infection,
active inflammation or a tumour;
• a springy block is characterised
by a rebound feel at the end of range and is associated with a torn meniscus
blocking knee extension;
• spasm is experienced as a
sudden, relatively hard feel associated with muscle guarding;
• a capsular feel shows a hardish
arrest of movement.
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