Posture can be examined in both sitting and standing. The patient’s symptoms are aggravated while sitting for long periods of time. It is well recognized that prolonged positioning in "poor" posture can lead to mechanical problems, dysfunction and pain, from structures that are mechanically stressed (Macy 2000). An informal examination is assessed while taking the subjective, as the patient is unaware that they are being observed and is in a more natural state and position. Neck position, muscle wasting and spinal curvatures are noted as well as postural compensation. If the symptoms change by altering an asymmetrical posture, this suggests that the posture is related to the problem. (Petty 2001)
Poor posture may be the cause of this patient’s pain due to muscles being over or under worked. The patient describes pain A as a constant toothache, initially suggesting musculoskeletal involvement, a problematic muscle. He complains that his symptoms appear after half an hour of painting, but when he paints overhead, with arm in n elevated position, pain appears after only 10 minutes. The physiotherapist may consider damage to upper trapezius, as it is involve in this movement. This muscle also originates from the upper cervical region, there by strengthening the suspicion for a connection (Kenyon J & Kenyon K 2004).
Range of movement
A detailed examination is made of the quality and range of active and passive physiological joint movement. A comparison of both sides is made to distinguish between ‘normal’ movements. As a physiotherapist, it is good practice to clear all joints above and below the problematic joint (Atkins & Kesson 2005). In this case the cervical spine, shoulder, elbow and wrist would be assessed. Abnormalities i.e. joint stiffness, pain, decreased range would be highlighted and give an indication what movements and structures were producing symptoms. The clinician must look out for the patient using trick movements due to pain caused during normal movements. If this is not noted then an inaccurate reading could be made and the origin of the pain not identified (Clarkson 2000).
This table highlights the main movements that would be tested.
MUSCLE STRENGTH
When assessing muscle strength it is important to note any changes in the patient’s facial expression, which may be a reproduction of the presented pain. Resisted Isometric tests examine the contractile unit for pain and strength. Though there is no joint movement, isometric muscle contraction will cause compression and joint shearing and muscle atrophy will be observed (Petty 2001). Resisted muscle tests could also be used to test myotomes, if a neurological problem was suspected. This will be discussed in more detail later.
NEUROLOGICAL TESTING
Neurological examination involves carrying out specific diagnostic tests to examine the integrity of the nervous system and rule out any neurological causes. The physiotherapist would test myotomes, dermatomes, reflexes. A myotome being a group of skeletal muscles innervated by a particular spinal nerve and a dermatome being an area of skin that is supplied by a particular spinal nerve (Crossman & Neary 2000).
The shoulder joint and structures around it are derived from the C5 segment. Lesions of any of these structures will cause pain to be referred into the C5 dermatome which extends into the anterolateral aspect of the arm and forearm. This patient does not suffer from pins and needles or numbness but complains of a burning sensation down his arm which could suggest some form of neurological involvement (Gelb 2005).
For this patient, only upper myotomal tests are needed to be carried out. It involves testing the conduction of the nerve fibers by resisted isometric muscle tests, checking for a neuromuscular involvement. Nerve roots C5-T1 are tested for the cervical region. Light touch test is performed on the dermatomes to test for loss of skin sensation. A positive test would give an indication of nerve impingement (Gelb 2005). Reflexes must also be tested if nerve involvement is suspected. Reflexes test the efficiency of the spinal reflex arc. If there is a certain amount of compression on the nerve, the reflex will be reduced or even absent (Atkins & Kesson 2005). Nerves are also palpated.
Neurodynamic testing may be preformed in order to stimulate and move neural tissue in order to clinically evaluate mobility to find the neural tissue that is responsible for the production of the patient’s symptoms, and examine the mobility of the nervous system. The physiotherapist could carry out upper limb tension tests (1, 2a or 2b.) The aim is to stimulate and move neural tissue in order to clinically evaluate mobility and sensitivity to stress (Shacklock 1995).
Palpation
Palpation is used by the Physiotherapist to assess prominence of bone, soft tissue, skin texture, temperature, muscle spasm and tenderness (Petty 2001). In this particular case the cervical spine and upper shoulder would be examined. The patient complains of stiffness in the morning, suggesting inflammation in the shoulder region. Palpation would allow the physiotherapist to check for problematic muscles. Torn fibers in the trapezius may be considered, which in turn is compressing on a nerve and pain is getting referred down the lateral aspect of the arm (Atkins & Kesson 2005).
Accessory joint movements
It is important to examine accessory joint movements as they occur during all physiological movements. There is a restriction of the accessory range of movement then this can affect the physiological movements (Petty 2001). The physiotherapist would carry out accessory joint movements of the spine once neurological testing ruled out, as this type of movement could put pressure on the nerve and increase patient’ symptoms. The quality and range of movement, behavior of pain are noted. For this particular patient accessory joint movements would be tested on the glenohumeral joint and cervical spine, as musculoskeletal involvement is suspected in the upper shoulder region
Contraindications and precautions
When carrying out any of the above techniques it is important that the physiotherapist considers the patient’s safety as their main priority. Precautions and contraindications should be considered initially, in order for the physiotherapist to perform an appropriate and safe treatment.
Conclusion
Once all the above steps have been carried out, the objective examination is finished. From both the subjective and objective assessments, the physiotherapist should have gathered enough information to enable them to make an appropriate clinical impression. It is vital to make note of any unusual findings in the examination, as each patient presents differently. It is important not to assess in a rigid manner. It is vital for a physiotherapist to identify what structures are associated with the patient’s condition and identify the exact location of pain. This will give a better understanding of the problem and treatment therefore would be focused on the origin and would be more beneficial for recovery.
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