Scan Exam

1. The Scanning Examination Jake Shockley PT, OCS, COMT, FAAOMPT Physical Therapy Central 2014

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 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 Scanning Exam To detect gross loss of function, ROM deficits, and movement control deviations. The scanning examination should be negative most of the time which means the patient appears appropriate for physical therapy but 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 Traumatic arthritis Spinal stenosis Rotator cuff tendonitis Cervical radiculopathy

4. Components of the Scanning Exam 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 T esting 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 UQ Dermatome Testing 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 of forearm T1 axilla LQ Dermatome Testing 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, 5 th toe, posterior leg S2 posterior thigh S3 posterior medial thigh

12. Neurological Exam DTRs UQ C4 - L evator 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 W rist extension A nkle plantar flexion. Cranial nerve exam

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 Check out the “CORE” app by Clinically Relevant Technologies.

17. Biomechanical Exam Spine PPIVM PAIVM Extremities Isolated passive ROM Accessory movement

18. 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

19. Cyriax Terminology Strong and pain free – muscle is clear Strong and painful – think minor muscle lesion Weak and painful – think major muscle lesion Weak and pain free – neurological lesion or full thickness tear

20. Maitland Mobilization Grades Mobilization 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 Asterisk signs http://www.physio-pedia.com/ Manual_Therapy

21. Thank You Appendix Regional Interdependence Model

22. References North American Institute of Orthopaedic Manual Therapy – Differential Diagnosis in Orthopedic Physical Therapy  1/1/08-1/3/08, 2/15/08-2/17/08 21 Contact Hours. Instructors: Jim Meadows, PT, FCAMT . Sueki , Derrick G., Joshua A. Cleland, and Robert S. Wainner . "A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications."  Journal of Manual and Manipulative Therapy  21.2 (2013). Print. http ://www.physio-pedia.com/Manual_Therapy