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  • Musculoskeletal Physical Examination

    Hi guys,

    I am a physiotherapist and this is somewhat of a general question: I am interested to know what your physical exam looks like in someone presenting with pain?

    Given that in many cases we cannot definitively identify the "source" of pain, I wondered how much time you spend on specific ROM, pain provocation, neural testing etc. and how much value can we place on such tests in terms of diagnosis? I understand that these tests give us other helpful information for e.g. what movements/positions are sensitive etc.

    A specific example would be that I am currently treating a client with LBP radiating down his L leg. He has a positive SLR test with no motor deficits. How valid is this test in identifying the disc as being the "source" of his pain? Does this change my treatment of him? No. Does it change his prognosis given he has some radicular symptoms? It think perhaps it may take a little longer to recover compared with someone without radicular symptoms.

    I guess I am trying to reconcile the utillity of tests that are aimed at identifying very specific structures as sources of pain and the benefit of this and how you approach your physical exam given so much of what we now know about pain.

  • #2
    This is an excellent question, I'll do my best to unpack, but there's a lot to cover here.

    The physical exam is an important, but often small, component of our assessment. I would advocate for assessing any specific or glaring range of motion impairments and evaluating if any specific portions of range of motion/activities provoke symptoms. I would argue that much of this information can also be gained through a thorough subjective by simply having a conversation with the person in front of you and hearing their concerns and understanding what provokes their symptoms.

    If we are going to identify something as “abnormal,” we must first define what “normal” is. Turns out significant variability and individual differences exist in range of motion, joint structure/adaptations, and strength based on individualistic demands. To address a few of the items you mentioned specifically:
    1. Range of motion- There is variability in what constitutes “normal” range of motion at many joints; stated another way, there is likely more a spectrum of “normal” versus just one discrete number. We don’t spend too much time worrying about this barring significant deviations from “normal” especially in non-surgical or non-traumatic cases.
    2. Strength- overall we, as physical therapists, suck at assessing strength. Manual muscle tests have basically no utility besides determine if a patient can move against gravity as the test is predicated on the amount of resistance that the tester is providing. Your resistance, versus my resistance, versus my grandmas resistance is highly variable- making it a test with poor inter-rater reliability. The validity of MMT is also not great….can we really detect if a powerlifter who squats 405 is “weak” by pushing force down through their knee extensors? Do we really think that we can measure this difference with our hands? The answer is no, we really cannot. Thus, further reducing the overall utility of MMT outside of significant muscular weakness (i.e. can I move against gravity).
    3. Special tests- as a very broad and general statement, most special tests have a very low specificity and/or sensitivity. Most provocative tests will be positive in the acute phase for most individuals because they place your in uncomfortable positions intentionally, eliciting pain regardless of the "pathology" that may be present. Even if these tests were highly specific and sensitive, the question remains, how would these results change your treatment? What do you different for someone with medial knee pain vs. PFPS vs. OA? I would argue that our starting point is typically similar, we find an entry point into activity to allow the person to get back to doing the things that they want to do by manipulating intensity, volume, and frequency of exercise.
    To answer your question specifically about radicular pain, I do not think that that treatment would differ substantially for an individual with low back pain versus low back pain with radicular symptoms; however, there is some evidence to suggest that low back pain with radicular symptoms may take longer to resolve. Either way, I would advocate for exposure to activity and allowing the individuals to get back to doing the things that they would like to do.

    I hope this is helpful.
    Last edited by Hannah Mora; 12-22-2021, 02:19 AM.

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    • #3

      Thank you Hannah,

      You reply is really helpful, especially regarding special tests.

      SO much of what I learnt at university and in practice is in actual fact bunk! Haha. Funnily I have often felt inferior to other therapists that were so confident in what they 'felt' on the P.E or in making a 'diagnosis.' I often felt doubtful about exactly what I was feeling and what it meant. As it turns out my doubt and skepticism were warranted, and the over-confidence of some therapists is not.

      The last few years have been a big learning curve for me (and BBM has been a big part of that) and I have to say it feels a relief. Such a relief to let go of all the BS that never felt true.

      Thanks again Hannah and keep up the good work!

      Alicia

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      • #4
        Alicia,

        How you’re feeling is extremely common; I felt this way too when I first started learning manual therapy and special tests in school. Whether they are aware of it or not, clinicians like to feel like they are noticing or feeling something specific with special tests or manual therapy. This validates their thoughts and beliefs that we can identify pathological tissues and structures and provide specific intervention and structural changes to tissue with our hands, and makes them feel like they are providing something specific to a patient. Don’t let anyone make you feel inferior because you don’t feel what they think they are feeling with their hands. Often times these interventions by clinicians make them feel good because they are “doing something special.” Turns out, it’s way more complex than that.

        You aren’t alone in feeling this way. Glad you have found our content helpful and I hope you continue to meet like-minded clinicians!

        Hannah

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        • #5
          Thanks again Hannah,

          Merry Christmas!!

          A
          ​​​​​​​

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