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Scan exam
This document outlines the components and purpose of a scanning examination performed in physical therapy. The scanning exam is used to ensure issues are within the scope of physical therapy and rule out serious pathology. It involves observation of gait and posture, vital signs, functional movement testing, tissue tension testing, palpation, neurological exams, and special tests. The purpose is to detect gross loss of function and movement control in order to guide further physical therapy diagnosis and treatment.
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Scan exam
- 1. The Scanning Examination JakeShockley PT, OCS, COMT Physical Therapy Central 2013
- 2. Purpose of theScanning Exam âą To ensure patient presentations are within the scope of physical therapy practice â Ruling out âseriousâ pathology âą Neurological compromise â Upper and lower motor neuron lesions âą Severe ligamentous instability âą Acute fracture âą Any acute or sub-acute lesions with significant inflammatory response âą Briefly consider the presence of regional interdependence (Rob Wainner) or victims and culprits (Erl Pettman) within the quadrant â Cervical or thoracic spine playing a role in the development of rotator cuff tendonitis
- 3. Purpose of theScan âą To detect gross loss of function, ROM, and movement control. âą The scanning examination should be negative most of the time which means you will need further testing to determine your PT diagnosis. âą The scan alone can help identify common orthopedic lesions that present acute and or sub-acute. Below are a few⊠â Lumbar disc herniation â Spinal stenosis â Rotator cuff tendonitis â Cervical radiculopathy
- 4. Components of theScan âą Observation âą Vital signs âą Functional movement testing âą Selective Tissue Tension testing âą Specific palpation âą Neurological exam âą Dural and neural tissue tension tests âą General stress tests âą Special tests
- 5. Observation âą Look forthe obvious⊠â Gait deviation âą Break down cardinal planes â Sagittal â flexion vs. extension » Loss of or significant vertical rise â Frontal â abduction vs. adduction » Trendelenberg sign â Transverse â external vs. internal rotation » Excessive lumbopelvic rotation â Stance and swing; tolerance, quality, quantity, and position of lower extremity â Postural deviation â Difficulty with transitional movement â Scars, structural deformities, skin creases
- 6. Vital Signs âą Bloodpressure âą Heart rate âą Respiratory rate âą Pulse â Central and peripheral
- 7. Functional Movement Testing âąUpper quadrant â Apleyâs test â Grip strength âą Lower quadrant â Functional squat â Single leg stance â Walk on heels (L4), toes (S1)
- 8. Selective Tissue TensionTesting âą AROM -> Passive overpressure -> resistance. â Cardinal planes âą Flexion âą Extension âą Side bending âą Rotation â Quadrants âą Flexion âą Extension
- 9. Specific Palpation âą Specificpalpation of the painful area distinguishing structures â Muscle belly â trigger point(s) â Musculotendonous junction â Tendonoperiosteal junction â Bony landmarks â Joint line â Nerve trunks
- 10. Neurological Exam âą MyotomeTesting â Upper Quadrant âą C3 â Cervical lateral flexion âą C4 â Shoulder elevation âą C5 â Shoulder abduction and ER âą C6 â Elbow flexion, forearm supination, wrist extension âą C7 â Elbow extension, wrist/finger flexion âą C8 â Thumb extension, wrist ulnar deviation âą T1 â Finger abduction or adduction âą Myotome Testing â Lower Quadrant âą L1-2 â hip flexion âą L3 â knee extension, hip adduction âą L4 â ankle dorsiflexion âą L5 â Great toe extension, ankle eversion, hip abduction. âą S1 â hip extension âą S1-2 knee flexion âą Fatigable weakness â Neurological weakness will fatigue quickly with repeated myotomal testing
- 11. Neurological Exam âą DermatomeTesting â Upper Quadrant âą C2 â Suboccipital âą C3 â Submandibular angle âą C4 â Upper Trapezius âą C5 â Lateral deltoid âą C6 â Tip of thumb âą C7 â Tip of middle finger âą C8 â Fifth finger âą T1 â Ulnar side forearm âą T2 â Axilla âą Dermatome Testing â Lower Quadrant âą L1 â Groin âą L2 â Anterior medial thigh âą L3 â supra patella âą L4 â Dorsum of medial leg and foot âą L5 â Dorsum of middle 3 toes, medial arch âą S1 â Lateral foot, 5th toe, posterior leg âą S2 â Posterior thigh âą S3 â posterior medial thigh
- 12. Neurological Exam âą DTRs âUQ âą C4 - Levator scapula âą C5 â Deltoid âą C6 â biceps, brachiorad âą C7 â Triceps âą C8 â Ext Pollicis Longus âą T1 â Hypothenar â LQ âą L3 â hip adductors, patella tendon âą L4 â Anterior tibialis âą L5 â Fibularis longus, EDM âą S1 â Achilles tendon âą Upper motor neuron tests â Hoffmanâs â flick middle finger, watching for index and thumb flexion reflex. â Babinski â scraping movement with end of reflex hammer plantar surface calcaneus to forefoot. â Clonus â quick passive movement with hold. A positive is more than 3 beats âą Wrist extension âą Ankle plantar flexion.
- 13. Neural and Duraltissue testing. âą Upper Quadrant â Median â Ulnar â Radial â Slump âą Lower Quadrant â SLR â Prone knee bend â Slump
- 14. General Stress Tests âąSpine â Central P/As â Unilateral P/As âą Extremities â Valgus/varus, anterior, posterior, rotatory â Quadrant testing
- 15. Special Tests âą UpperQuadrant â Cervical â Spurlingâs, traction, figure eight â Shoulder â Empty can, OâBrians, Neers impingement â Elbow â quadrant test, Active floor push-up sign, Cozenâs test, Tinnelâs sign, Flexion compression test (ulnar nerve)
- 16. Special Tests âą LowerQuadrant â Lumbopelvic â SI gapping/compression, lumbar traction, prone lumbar torsion, prone instability test, SLR, treadmill test â Hip â Standing rotation, FABERS, FADIR, Stitchfieldâs (ASLR) â Knee â Thessalyâs, joint line tenderness test, Appleyâs compression test, patellar step test, Homanâs sign â Foot/ankle â talar swing, navicular drop
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- 20. Cyriax Terminology âą Strongand painful â think minor muscle lesion âą Strong and pain free â muscle is clear âą Weak and painful â think major muscle lesion âą Weak and pain free â neurological lesion or full thickness tear
- 21. Maitland Mobilization Grades âąGrade I - Small amplitude rhythmic oscillating mobilization in early range of movement âą Grade II - Large amplitude rhythmic oscillating mobilization in midrange of movement âą Grade III - Large amplitude rhythmic oscillating mobilization to point of limitation in range of movement âą Grade IV - Small amplitude rhythmic oscillating mobilization at end range of movement âą Grade V (Thrust Manipulation) - Small amplitude, quick thrust at end range of movement Reference: http://www.physio-pedia.com/Manual_Therapy
- 22. SINSS âą Severity âintensity of patients complaint âą Irritability â the amount of activity to aggravate/alleviate symptoms âą Nature â the source of the patientâs pain âą Stage â acute, sub-acute, chronic âą Stability â better, same or worsening
- 23. Resources âą Treatment BasedClassification â Password: OUHSC âą Clinical Prediction Rule â Password: OUHSC âą Physical Therapy Central â Resource Page for regional interdependence articles and more. âą Subacromial Impingement Syndrome
Editor's Notes
- #3Â Article for Regional Interdependence
- #8Â After observing the patient upon entering the room and during the patient interview functional movement testing can began if appropriate. Frequent repositioning should be avoided throughout the entire exam if possible to minimize patient discomfort and exacerbation. We want you to learn how to administer all applicable test per patient case that is allowed in a given position such as sitting or lying. This presentation attempts to follow a natural, comfortable positioning of the patient for the lower quadrant and upper quadrant combined. Apleyâs and grip testing can be performed in sitting and initiated directly after the patient interview. The lower quadrant functional movement testing is performed in standing. Remain close to patient or have patient close to table to re-stabilize patient if loss of balance occurs. Walking on toes or heel raises can be used for S1 myotome testing and walking on heels for L4 myotome testing. Again pay attention to and note significant deviations or restricted movement during these test.
- #9Â Next is the selective tissue tension testing created by Cyriax. These test involve spinal AROM with passive overpressure and then resistance. This order of testing can give you a lot of information for the orthopedic patient so you may appreciate more of the subtleties compared to the previous test. Start with the cardinal planes. Using cervical rotation in sitting for example, ask the patient to turn as far as comfortable to the right. If that position does not reproduce their pain then add overpressure. At the end of their rotation gentle add overpressure noting end feel and pain response. If appropriate (so if you assumed a muscle tear was present from the patient interview) you can then add resistance near the painful position to assess muscles for pain and weakness. So with the patient turned to the right ask them to turn to the left into your hand which blocks any movement to the left, causing an isometric contraction. If the left rotators are painful in this lengthened position you can than retest with the neck in neutral. Caution with the more acute neck patient during resistance test as quick, unguarded movement should be avoided. Once all cardinal planes are assessed quadrants can be checked by asking the patient to move in the combined movements. If the cardinal planes are significantly limited and painful quadrants may not be necessary or appropriate. The STTT can be initiated directly after the UQ functional testing in sitting or directly after the LQ functional testing in standing.
- #10Â You will be assessing skin temperature, texture and feel. Is the skin warm and boggy or firm. With palpation, can you reproduce the patients pain. If so, what are you palpating â the muscle, nerve or bone ? This is where you need to know your anatomy and landmarks.
- #11Â During the myotomal testing you will be assessing muscle strength or as we like to say âgradeâ. You want to determine if the strength is normal 5/5 or weak and then how weak with the muscle grades. Then I want you to decide why the muscle is weak, is it because it is an arthritic shoulder and pain turns off the muscle, is it painful and weak and what is painful. The joint, the muscle or another structure?Review Cyriaxtermin
- #22Â You will use the grades to communicate the depth and speed of the mobilization. You can use + or ++ or +++ to be more descriptive as well as minus. You will also decide from the SINSS which grade to use.
- #23Â Provide Bryan Dennison summary of SINSS