Scan exam
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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 Jake Shockley PT, OCS, COMT Physical Therapy Central 2013
- 2. Purpose of the Scanning Exam • To ensure patient presentations are within the scope of physical therapy practice – Ruling out “serious” pathology • Neurological compromise – Upper and lower motor neuron lesions • Severe ligamentous instability • Acute fracture • Any acute or sub-acute lesions with significant inflammatory response • Briefly consider the presence of regional interdependence (Rob Wainner) or victims and culprits (Erl Pettman) within the quadrant – Cervical or thoracic spine playing a role in the development of rotator cuff tendonitis
- 3. Purpose of the Scan • To detect gross loss of function, ROM, and movement control. • The scanning examination should be negative most of the time which means you will need further testing to determine your PT diagnosis. • The scan alone can help identify common orthopedic lesions that present acute and or sub-acute. Below are a few… – Lumbar disc herniation – Spinal stenosis – Rotator cuff tendonitis – Cervical radiculopathy
- 4. Components of the Scan • Observation • Vital signs • Functional movement testing • Selective Tissue Tension testing • Specific palpation • Neurological exam • Dural and neural tissue tension tests • General stress tests • Special tests
- 5. Observation • Look for the obvious… – Gait deviation • Break down cardinal planes – Sagittal – flexion vs. extension » Loss of or significant vertical rise – Frontal – abduction vs. adduction » Trendelenberg sign – Transverse – external vs. internal rotation » Excessive lumbopelvic rotation – Stance and swing; tolerance, quality, quantity, and position of lower extremity – Postural deviation – Difficulty with transitional movement – Scars, structural deformities, skin creases
- 6. Vital Signs • Blood pressure • Heart rate • Respiratory rate • Pulse – Central and peripheral
- 7. Functional Movement Testing • Upper quadrant – Apley’s test – Grip strength • Lower quadrant – Functional squat – Single leg stance – Walk on heels (L4), toes (S1)
- 8. Selective Tissue Tension Testing • AROM -> Passive overpressure -> resistance. – Cardinal planes • Flexion • Extension • Side bending • Rotation – Quadrants • Flexion • Extension
- 9. Specific Palpation • Specific palpation of the painful area distinguishing structures – Muscle belly – trigger point(s) – Musculotendonous junction – Tendonoperiosteal junction – Bony landmarks – Joint line – Nerve trunks
- 10. Neurological Exam • Myotome Testing – Upper Quadrant • C3 – Cervical lateral flexion • C4 – Shoulder elevation • C5 – Shoulder abduction and ER • C6 – Elbow flexion, forearm supination, wrist extension • C7 – Elbow extension, wrist/finger flexion • C8 – Thumb extension, wrist ulnar deviation • T1 – Finger abduction or adduction • Myotome Testing – Lower Quadrant • L1-2 – hip flexion • L3 – knee extension, hip adduction • L4 – ankle dorsiflexion • L5 – Great toe extension, ankle eversion, hip abduction. • S1 – hip extension • S1-2 knee flexion • Fatigable weakness – Neurological weakness will fatigue quickly with repeated myotomal testing
- 11. Neurological Exam • Dermatome Testing – Upper Quadrant • C2 – Suboccipital • C3 – Submandibular angle • C4 – Upper Trapezius • C5 – Lateral deltoid • C6 – Tip of thumb • C7 – Tip of middle finger • C8 – Fifth finger • T1 – Ulnar side forearm • T2 – Axilla • Dermatome Testing – Lower Quadrant • L1 – Groin • L2 – Anterior medial thigh • L3 – supra patella • L4 – Dorsum of medial leg and foot • L5 – Dorsum of middle 3 toes, medial arch • S1 – Lateral foot, 5th toe, posterior leg • S2 – Posterior thigh • S3 – posterior medial thigh
- 12. Neurological Exam • DTRs – UQ • C4 - Levator scapula • C5 – Deltoid • C6 – biceps, brachiorad • C7 – Triceps • C8 – Ext Pollicis Longus • T1 – Hypothenar – LQ • L3 – hip adductors, patella tendon • L4 – Anterior tibialis • L5 – Fibularis longus, EDM • S1 – Achilles tendon • Upper motor neuron tests – Hoffman’s – flick middle finger, watching for index and thumb flexion reflex. – Babinski – scraping movement with end of reflex hammer plantar surface calcaneus to forefoot. – Clonus – quick passive movement with hold. A positive is more than 3 beats • Wrist extension • Ankle plantar flexion.
- 13. Neural and Dural tissue testing. • Upper Quadrant – Median – Ulnar – Radial – Slump • Lower Quadrant – SLR – Prone knee bend – Slump
- 14. General Stress Tests • Spine – Central P/As – Unilateral P/As • Extremities – Valgus/varus, anterior, posterior, rotatory – Quadrant testing
- 15. Special Tests • Upper Quadrant – Cervical – Spurling’s, traction, figure eight – Shoulder – Empty can, O’Brians, Neers impingement – Elbow – quadrant test, Active floor push-up sign, Cozen’s test, Tinnel’s sign, Flexion compression test (ulnar nerve)
- 16. Special Tests • Lower Quadrant – Lumbopelvic – SI gapping/compression, lumbar traction, prone lumbar torsion, prone instability test, SLR, treadmill test – Hip – Standing rotation, FABERS, FADIR, Stitchfield’s (ASLR) – Knee – Thessaly’s, joint line tenderness test, Appley’s compression test, patellar step test, Homan’s sign – Foot/ankle – talar swing, navicular drop
- 17. APPENDIX
- 20. Cyriax Terminology • Strong and painful – think minor muscle lesion • Strong and pain free – muscle is clear • Weak and painful – think major muscle lesion • Weak and pain free – neurological lesion or full thickness tear
- 21. Maitland Mobilization Grades • Grade I - Small amplitude rhythmic oscillating mobilization in early range of movement • Grade II - Large amplitude rhythmic oscillating mobilization in midrange of movement • Grade III - Large amplitude rhythmic oscillating mobilization to point of limitation in range of movement • Grade IV - Small amplitude rhythmic oscillating mobilization at end range of movement • Grade V (Thrust Manipulation) - Small amplitude, quick thrust at end range of movement Reference: http://www.physio-pedia.com/Manual_Therapy
- 22. SINSS • Severity – intensity of patients complaint • Irritability – the amount of activity to aggravate/alleviate symptoms • Nature – the source of the patient’s pain • Stage – acute, sub-acute, chronic • Stability – better, same or worsening
- 23. Resources • Treatment Based Classification – Password: OUHSC • Clinical Prediction Rule – Password: OUHSC • Physical Therapy Central – Resource Page for regional interdependence articles and more. • Subacromial Impingement Syndrome
Editor's Notes
- Article for Regional Interdependence
- 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. Apley’s 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.
- 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.
- 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 – the muscle, nerve or bone ? This is where you need to know your anatomy and landmarks.
- During the myotomal testing you will be assessing muscle strength or as we like to say “grade”. 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
- 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.
- Provide Bryan Dennison summary of SINSS