Assessment Protocol

Dr. Michael Gillespie Doctor of Chiropractic

Anatomic and Biomechanical Principles

It is necessary to understand normal anatomy and
healthy biomechanical relationships to accurately evaluate orthopedic and neurological conditions.

Understand the relationship between structure and

function.

Anatomical and biomechanical variants can be present

with a particular patient.

Clinical Assessment Protocol

Patient History Orthopedic and Neurologic
Testing

Inspection / observation
Palpation Range of Motion

Diagnostic Imaging Functional Testing

Documentation
Evaluate progress.

Share information with other practitioners.

Insurance records. Malpractice.

SOAP Notes
Subjective Patient History

Objective Observation and Testing

Assessment Based on compilation of findings Plan Further testing and / or treatment

Patient History
A thorough patient history can often lead to a proper
diagnosis with no further testing.

Emphasize the aspect of the patient history with the

greatest clinical significance.

Acquire all of the patients history whether or not

something seems relevant at the time.

Patient History
Keep the patient focused on the problem.

Listen carefully.
Do not lead the patient towards answers.

Closed-Ended History
Question and Answer Format.

Written Forms

Open-Ended History
Dialogue between patient and examiner.

Identify other problems that are either directly or

indirectly related to the presenting complaint.

Address the patients fears and concerns.

Develop rapport.
Keep the patient focused on the presenting problem.

OPQRST Mnemonic
Onset of complaint

Provoking or Palliative concerns

Quality of pain Radiation to particular areas Site and Severity of complaint Time frame complaint

History Other Factors

Family History

Occupational History
Social History

Observation / Inspection
General Appearance

Functional Status
Body Type Postural deviations

Gait Muscle guarding Compensatory movements Assistant devices

Inspection three layers

Skin

Subcutaneous tissue
Bony structure

Skin Inspection

Bruising

Scarring
Trauma or surgery Changes in color
Vascular changes of inflammation Vascular deficiency pallor or cyanosis

Pigmented areas / Hairy areas Change in texture Open wounds traumatic or insidious

Detection of Malignant Melanoma

Asymmetry
MM lack symmetry

Irregular Borders
MM have notched, indented, scalloped, or indistinct borders

Color Changes
MM have uneven coloration, may contain several colors

Diameter
MM are typically greater than 6mm (0.25 in)

Elevation

Subcutaneous Soft Tissue Inspection

Evaluate for inflammation and swelling

Atrophy
Increase in size
Edema, articular effusion, muscle hypertrophy

Nodules, lymph nodes, or cysts Compare b/l symmetry, utilize circumferential

measurements

Bony Structure Inspection

Evaluate bony structure when gait or range of
motion is altered.

Evaluate the spine

Scoliosis Kyphosis Lordosis Pelvic tilt Shoulder height

Evaluate for congenital and traumatic bone

deformities

Genu Varus

Genu Valgus

Palpation
Palpate the patient in conjunction with inspection.

Begin with a light touch.

Dysesthesia. Hypoesthesia. Hyperesthesia. Anesthesia.

Skin Palpation
Evaluate skin temperature
High inflammation Low vascular insufficiency

Adhesions

Subcutaneous Soft Tissue Palpation

Subcutaneous soft tissue fat, fascia, tendons,
muscles, ligaments, joint capsules, nerves, blood vessels.

Palpate with more pressure than with skin.

Palpate for tenderness and swelling or edema.

Tenderness Grading Scale

Grade I
- Patient complains of pain

Grade II

- Patient complains of pain and winces

Grade III - Patient winces and withdraws the joint Grade IV Patient will not allow palpation of the joint

Types of Swelling
Immediately after injury, hard and warm
Contains blood

8 to 24 hours after an injury, boggy or spongy

Contains synovial fluid

Tough and dry

Callus

Types of Swelling
Thickened and leathery
Chronic swelling

Soft and fluctuating

Acute

Hard
Bone

Thick and slow moving

Pitting edema

Pulse
Palpate for pulse rate, rhythm, and amplitude

Normal healthy resting pulse rate for an adult is 60

100 bpm

Palpating Bony Structures

Detection of alignment problems
Dislocations, luxations, subluxations, fractures

Identify ligaments and tendons that attach to the bones Detect bony enlargements

Range of Motion
Passive

Active
Resisted

Passive Range of Motion

The examiner moves the body part without the patients
help.

Note normal, increased, or decreased movement. Note pain.

Capsular or ligamentous lesion on side of movement and
/ or muscular lesion on side opposite of movement.

Six Range of Motion Pain Variations

1. Normal mobility with no pain.
No lesion normal joint.

2. Normal mobility with pain.

Minor ligament sprain or capsular lesion.

3. Hypomobility with no pain.

Adhesion.

Six Range of Motion Pain Variations

4. Hypomobility with pain.
Acute ligament sprain or capsular lesion. Guarding from
muscle spasm.

5. Hypermobility with no pain.

Complete tear with no fibers intact where pain can be
elcited.

6. Hypermobility with pain.

Partial tear with some fibers still intact.

Sprain Vs. Strain

Sprain - A sprain is an injury involving the stretching or
tearing of a ligament (tissue that connects bone to bone) or a joint capsule, which help provide joint stability.

Strain - Strains are injuries that involve the stretching or

tearing of a musculo-tendinous (muscle and tendon) structure.

End Feel
Evaluate for end feel after determining the degree of
passive range of motion.

Passively move the joint to the end of its range of

motion and then apply slight overpressure to the joint.

Active Range of Motion

Yields information regarding the patients general
ability and willingness to use a body part.

Assessment value is limited. Note the degree of motion as well as pain elicited.

Crepitus should be noted.

Inclinometers and goniometers are used to
measure range of motion.

Inclinometer

Goniometer

Resisted Range of Motion

Resisted range of motion assesses musculotendinous
and neurologic structures.

Musculotendinous injuries tend to be more painful than

they are weak.

Neurologic injuries tend to be more weak than they are

painful.

Muscle Grading Scale

5 Complete range of motion against gravity with
full resistance.

4 Complete range of motion against gravity with

some resistance.

3 Complete range of motion against gravity. 2 Complete range of motion with gravity
eliminated.

1 Evidence of slight contractility. 0 no evidence of contractility.

Resistant Range of Motion Reactions

Strong with no pain Normal.

Strong with pain lesion of muscle or tendon.

Weak and painless neurological lesion or complete
rupture of a tendon or muscle.

Weak and painful partial tear of muscle or tendon.

Fracture, neoplasm, and acute inflammation are possibilities.