肌肉骨骼物理治疗评定的原则.pdf

Peripheral Joints subjective examination 肌肉骨骼物理治疗评定的原则肌肉骨骼物理治疗评定的原则 Principles of Musculoskeletal Physiotherapy AssessmentPrinciples of Musculoskeletal Physiotherapy Assessment 第一部分 主观检查和客观检查 Part I Subjective Objective Examination Dr Grace Szeto Contributions by Dr Ella Yeung Department of Rehabilitation Sciences The Hong Kong Polytechnic University Kunming July 2009 Peripheral Joints subjective examination 完整的肌肉骨骼评定完整的肌肉骨骼评定 Total musculoskeletal assessmentTotal musculoskeletal assessment 病史Patient history 观察Observation 运动检查 主动和被动 Examination of movements active and passive 附属运动 关节摆弄 Accessory movements joint play 肌力检查Muscle tests 特殊检查Special tests 神经系统检查Neurological examination 触诊Palpation 诊断性检查结果 影像学 血检等 Diagnostic test results imaging blood test etc Peripheral Joints subjective examination 资料收集资料收集 Data Gathering 资料收集资料收集资料收集资料收集 Data GatheringData Gathering 资料分析资料分析 Data Analysis 资料分析资料分析资料分析资料分析 Data AnalysisData Analysis 确定问题确定问题 Problem Identification 确定问题确定问题确定问题确定问题 Problem IdentificationProblem Identification 目标目标 Aims Objectives 目标目标目标目标 Aims ObjectivesAims Objectives 物理治疗计划物理治疗计划 Physiotherapy Plan 物理治疗计划物理治疗计划物理治疗计划物理治疗计划 Physiotherapy Physiotherapy PlanPlan 治疗方法治疗方法 Intervention 治疗方法治疗方法治疗方法治疗方法 InterventionIntervention 评估评估 Evaluation 评估评估评估评估 EvaluationEvaluation 物理治疗过程物理治疗过程物理治疗过程物理治疗过程Physiotherapy ProcessPhysiotherapy Process Peripheral Joints subjective examination 诊断程序Diagnostic Process 做一个益智拼图游戏 Putting together a jigsaw puzzle 将小片信息拼在一起 构建成一个整体病人 的图片Piecing together small bits of information to build an overall picture of the patient Peripheral Joints subjective examination 主观和客观检查的目标Aims of S E 症状的来源Source s of the symptoms 原因Contributing factors causes 严重性和激惹性Severity and Irritability 物理检查和治疗的慎用症和禁忌症Precautions and contraindications to physical examination and treatment 预后Prognosis 处理Management 进步 再次评估标记Progress Reassessment asterisk Peripheral Joints subjective examination 主观检查的组成主观检查的组成 Components of S EComponents of S E 主要问题和身体图Main problem and Body chart 症状表现 Behavior of symptoms 加剧症状的活动 姿势aggravating activities positions 缓解症状的活动和姿势relieving activities positions 24小时变化情况24 hour picture 特殊问题 Special Questions 病史History 现病史present history 过去史past history 社会史Social History Peripheral Joints subjective examination 主要问题主要问题 身体图身体图 Main Problem Body ChartMain Problem Body Chart 主要问题 与症状相关的 与功能相关的 或 与病理相关的Main problem symptom related or function related or pathology related 如果是近期创伤 首先了解近期病史 If recent trauma take recent history first 现阶段 你的主要问题是什么 At this stage what is your main problem 如果答案是不能做一些活动 例如 不能下蹲 确定为什么 疼痛 僵硬 肌力减弱 If answer unable to do some activity e g unable to squat clarify why Pain stiffness weakness Peripheral Joints subjective examination 身体图身体图 Body ChartBody Chart 所有症状 ALL symptoms 严重性严重性Severity 区域区域Area 性质性质Nature 深度深度Depth Peripheral Joints subjective examination 身体图身体图 Body Chart Body Chart S A N DS A N D 严重性严重性 如如VAS量表 量表 10分之几分之几 注 老年病人有时比较困难 Severity in terms of VAS scale out of 10 note sometimes difficult for elderly patient 区域区域 准确位置 用手指指出并确定准确位置 用手指指出并确定 Area exact area use fingers to identify and clarify 性质性质 疼痛的类型疼痛的类型 钝痛 尖锐疼痛 烧灼痛 持续性 持 续痛或间歇痛 Nature type of pain dull ache sharp pain burning pain constancy is the pain constant or intermittent 深度深度 深的或是表浅的深的或是表浅的 Depth deep or superficial Peripheral Joints subjective examination 身体图身体图 Body ChartBody Chart 记录最严重的区域 Record Worst Area 如果有多个区域 如果有多个区域 编号编号 Number if multiple areas 不同症状之间的不同症状之间的关系关系 Relationship between different symptoms 相邻关节如果正常 打上 Joints above and below if clear 针刺和麻木针刺和麻木P N s and numb Peripheral Joints subjective examination 症状表现症状表现 Behavior of SymptomsBehavior of Symptoms 选择1或2个使症状加剧的活动 Select 1 or 2 activities which aggravate 确定严重性和激惹性Establish severity and irritability 多少How much 多严重How severe 持续时间How long lasting 按轻 中 重度或0 10分Grade mild moderate severe or 0 10 scale 分析运动分析运动ANALYSE THE MOVEMENT Peripheral Joints subjective examination 症状表现症状表现 Behavior of SymptomsBehavior of Symptoms 你可以问You can ask 因为 你不能做什么 What are you unable to do because of 阻碍你做什么 What does prevent you from doing 你什么时候会出现 感到 When do you experience feel your 你做多少 活动 会引起疼痛出现 How much of activity can you do before you experience pain 你做 时会出现多严重的疼痛 How much pain did you get when you do 做什么可以减轻你的疼痛 活动 姿势 药物 What can you do to ease your pain activity position medication 疼痛会持续多长时间 How long does the pain last for Peripheral Joints subjective examination 症状之间的关系症状之间的关系 Relationship between symptomsRelationship between symptoms 你可以问 You can ask 你觉得X和Y之间有关联吗 为什么 Do you feel that x and y are related Why 当X加重时 Y怎么样 When x is worse what happens to y 当Y加重时 X怎么样 When y is worse what happens to x Peripheral Joints subjective examination 症状表现症状表现 Behavior of SymptomsBehavior of Symptoms 举例Example 行走60分钟诱发髋部疼痛 VAS2分 休息5分 钟疼痛完全缓解Walking for 60 min reproduce 2 10 of hip pain pain completely subsided after 5 min rest 行走10分钟诱发髋部疼痛 VAS8分 休息3小 时后疼痛缓解Walking for 10 min reproduce 8 10 of hip pain pain subsided after 3 hours of rest Peripheral Joints subjective examination 与关节 病理有关的特殊问题 Specific questions relating to joint pathology 髋 腿交叉 剪脚趾 坐低凳Hip crossing legs cutting toe nails sitting on low chair 膝 锁住 无力 跪 上下楼梯 扭转运动Knee locking giving way kneeling walking up and down stairs twisting movement 踝和足 走坑洼路面 跳跃 跑 蹲Ankle and foot walking on uneven surface jumping running squatting 肩 梳头 套衫 扣内衣 放东西到架子上Shoulder combing hair tucking in shirt doing up bra putting something on shelf 肘 写字 扭门锁 开门 烫衣 紧握 携物 前 臂支撑Elbow writing turning key opening door ironing gripping carrying and leaning on forearm 腕和手 写字 纽扣 握电话 开瓶盖Wrist and hand writing buttoning of clothes gripping telephone handle opening jars Peripheral Joints subjective examination 2424小时变化模式小时变化模式 24 hour pattern24 hour pattern 夜间症状 炎症性与机械性Symptoms at night inflammatory vs mechanical 躺下即痛 体位影响 不负重 枕头 床垫 容易重新入睡 必须起床 夜间疼痛加重 小 心 Pain when first in bed effect of position NWB pillows mattress easily back to sleep have to get up worse at night Beware 晨起症状 休息的影响Symptoms in the morning effect of rest 醒后即现和起床时出现first thing and upon rising 日间症状Symptoms during the day 下午或傍晚时症状Symptoms at the end of the day Peripheral Joints subjective examination 问题问题 QuestionsQuestions 你的疼痛在夜间是什么样 会痛醒你吗 What is your pain like at night time Does it wake you up 你的疼痛在早上醒来 起床之前是什么样 有 疼痛吗 僵硬吗 持续多长时间 What is your pain like first thing in the morning before getting out of bed Any pain Stiffness How long 你的疼痛在日间是什么样 What happens to your pain during the day 如果疼痛与某些活动相关 评估这些活动 Assess if pain is proportional to certain activities Peripheral Joints subjective examination 特殊问题特殊问题 Special QuestionsSpecial Questions 要谨慎的问题 红旗 Precautionary Questions Redflag 一般健康状况 你的健康状况如何 高血压 糖尿病 心脏病 结核 大手术等 G H how is your general health high blood pressure diabetes heart disease TB major surgery etc 最近不明原因的体重减轻 排除癌肿 Recent unexplained weight loss to rule out malignancy 药物和效果Medication and effects 最近的X光片Recent XR Peripheral Joints subjective examination 现病史现病史Present HistoryPresent History 何时 如何When How 外伤 Traumatic 自发Spontaneous 受伤机制Mechanism of injury 立刻出现疼痛的区域 和程度 Degree and area of immediate pain 首先发现的疼痛 区域Area of pain first noticed 诱发因素Predisposing factors 后来的进展 Progress since 后来的进展 Progress since Peripheral Joints subjective examination 诱发因素诱发因素 Predisposing factorsPredisposing factors 举例Examples 不寻常的活动Unusual activity 重体力活动Heavy activity 持续姿势Sustained posture 病毒Virus 过度疲劳 身体 精神 Overtired physically mentally 寒冷 潮湿 干燥Cold damp draughts 家族性Familial Peripheral Joints subjective examination 现病史现病史 Present HistoryPresent History 每个每个症状的历史History of EACH EACH symptom 治疗的效果 如有接受了治疗 Effect of treatment if any Peripheral Joints subjective examination 既往史既往史 Previous HistoryPrevious History 第一次发病的详情 原因 期限 治疗 First episode in detail cause duration treatment 发作情况Successive bouts 频率Frequency 原因Cause 恢复比例Recovery rate 治疗Any treatment 间歇期Between bouts Peripheral Joints subjective examination 社会史社会史 Social HistorySocial History 婚姻状况 家庭责任 家庭支持Marital status family responsibilities family support 生活方式 工作 爱好 娱乐 Lifestyle work hobbies recreation 个性特点 适应疼痛的能力 改变生活方式 Personality profile ability to cope with pain altered lifestyle 病人期望和对健康的个人责任Patient expectation and personal responsibility for health Peripheral Joints subjective examination 星号标记星号标记 Asterisk Asterisk 标记强调可以用作再次评估的任何结果 Highlight any findings that could possibly be used for reassessment 举例 加重 缓解活动 夜间疼痛Examples aggravating easing activities night pain 行走10分钟 多少 诱发髋部疼痛8分 严 重程度 休息3小时后疼痛缓解 持续多 长时间 Walking for 10 min i e how much reproduce 8 10 i e how severe of hip pain pain subsided after 3 hours of rest i e how long lasting Peripheral Joints subjective examination 需要考虑 需要考虑 Points to consider Points to consider 具体Be specific 系统Be systematic 开放性问题 只在病人有困难时建议 Open questions suggest only if patient has difficulty 改良问题 如老年人 Modify questions e g elderly 不应忽略可能引起目前主诉的任何问题Account for ALL symptoms that possibly contribute to the presenting complaint Peripheral Joints subjective examination 参考资 参考资 ReferenceReference Maitland GD 1991 Peripheral Manipulation 3rd ed London Butterworth Heinemann Chapter 4 on Examination pp 20 27 Peripheral Joints subjective examination 主观检查之后主观检查之后 After Subjective ExaminationAfter Subjective Examination 首先做出一个假设 根据症状表现和受伤机制 Form an hypothesis first based on behavious of symptoms and mechanism of injury 可能是关节问题 肌肉问题 神经问题 Is it likely to be a joint problem Muscle problem Nerve problem 用客观检查来确认假设Confirm hypothesis with Objective Examination 主观检查和客观检查必须相符 SE and OE should match Peripheral Joints subjective examination 客观检查客观检查 Objective ExaminationObjective Examination 观察Observation 功能性运动Functional movements 主动运动Active movements 被动运动Passive movements 附属运动Accessory movements 肌肉测试Muscle tests 特别测试Special tests 神经系统检查Neurological examination 触诊Palpation Peripheral Joints subjective examination 观察观察 ObservationObservation 姿势Posture 运动的意愿 运动质量Willingness to move quality of movement 身体排列 对称Body alignment symmetry 骨性轮廓 正常 Bony contours normal 肌肉外形Muscle bulk 肿胀 淤青 纹理Swelling bruising texture 双侧比较Compare both sides 前后左右4面观察Look from all 4 sides Peripheral Joints subjective examination 功能性运动功能性运动 Functional movementsFunctional movements 行走Walking 下蹲Squatting 坐到站Sit to stand 上下楼梯Up down stairs 上肢 如伸手向上够物Upper limb e g reaching up for something 穿脱衣服Taking off putting on clothes 1 请病人做出动作Ask patient to simulate the action 2 在活动中可能包含了哪些关节或运动 What joints or movements are likely to be involved in the activity 3 询问有关问题 评估激惹性Ask questions to assess irritability Peripheral Joints subjective examination 主动运动主动运动 Active MovementsActive Movements 单一平面上的运动 屈曲 伸展 外展 内收 外旋 内旋 Single plane movements F E Abd Add LR RR 复合运动Combined movements 留意3件事 Look for 3 things 1 疼痛发生在什么时候 什么范围When and where the pain occurs during range 2 运动范围 Range of movement 主动主动 被动被动 加压加压 终末感觉终末感觉 Active Active Passive Passive Overpressure Overpressure endfeelendfeel 3 运动质量 运动 线条 速度 限制 痉挛等Quality of movement line of movement speed restriction spasm etc Peripheral Joints subjective examination 被动运动被动运动 Passive MovementsPassive Movements 单一平面上的运动 屈曲 伸展 外展 内收 外旋 内旋Single plane movements F E Abd Add LR RR 复合运动Combined movements 留言3件事 Look for 3 things 1 疼痛发生在什么时候 什么范围When and where the pain occurs during range 2 运动范围 Range of movement 主动主动 被动被动 加压加压 终末感觉终末感觉 Active Active Passive Passive Overpressure Overpressure endfeelendfeel 3 运动质量 运动 线条 速度 限制 痉挛等Quality of movement line of movement speed restriction spasm etc 主动和被动运动有什么区别 为什么重复一样的检查 主动和被动运动有什么区别 为什么重复一样的检查 What is the difference between active and passive movements Why repeat the same Peripheral Joints subjective examination 加压和终末感加压和终末感 Overpressure and Overpressure and EndfeelEndfeel 正常正常Normal 骨对骨Bone on bone 软组织挤压感Soft tissue approximation 组织牵拉感Tissue stretch 异常Abnormal 开始时肌肉痉挛Early muscle spasm 后期肌肉痉挛Late muscle spasm 硬关节囊Hard capsular 软关节囊Soft capsular 骨性感觉Bony 空洞感Empty 弹性受阻Springy block 举例举例Example 伸肘Elbow extension 屈膝Knee flexion 直腿抬高 手指伸直SLR finger extension 受伤后保护性痉挛Protective spasm after injury 不稳定引起的痉挛Spasm caused by instability 冻结肩Frozen shoulder 滑膜炎 软组织肿胀Synovitis soft tissue edema 骨刺Osteophyte 急性肩胛下滑囊炎 大关节不稳 脱位 Acute subacromial bursitis gross joint instability dislocation 半月板撕裂 韧带松弛Meniscus tear ligamentous laxity Peripheral Joints subjective examination 附属运动 关节摆弄 附属运动 关节摆弄 Accessory Movements Joint Play Accessory Movements Joint Play 基础是解剖知识Foundation is understanding of anatomy 关节结构Joint structure 关节面的形状 自由度Shape of joint surfaces degrees of freedom 球 囊关节Ball and socket joint 凹凸面Concave convex surfaces 前后 后前 内侧 外侧 滚动A P P A medial lateral rolling 生理运动时如何发生相应的附属运动 How do they correspond to Physiological movements 固定一面 活动其他面Hold one surface move the other Peripheral Joints subjective examination 肌肉检查肌肉检查 Muscle testsMuscle tests 测试肌肉力量To test muscle power 测试肌肉收缩是否引起疼痛To test if muscle contraction causes pain 测试牵拉肌肉是否引起疼痛To test if muscle stretch causes pain 留意 Look for 1 肌肉收缩是否引起疼痛 强度 定位和质量 Whether the contraction causes pain pain intensity location and quality 2 收缩的力量Strength of contraction 3 肌肉组织的质感 质量Texture quality of muscle bulk Peripheral Joints subjective examination 特殊测试特殊测试 Special testsSpecial tests 不同关节 部位有不同的特殊测试For different joints regions there are different special tests 通常包括韧带的完整性 半月板损伤 关节畸形 等Usually involve ligamentous integrity meniscal defects joint deformity etc 发现关节不稳或过度活动的征象To detect signs of joint instability or hypermobility 神经张力测试Neural tension tests Peripheral Joints subjective examination 触诊触诊 PalpationPalpation 温度Temperature 循环Circulation 肿胀 质量 大小 活动性 颜色Swelling quality size mobil