Our joints are extremely important for our functional activities, from the temporomandibular joint for eating and talking to the major weight bearing joints such as the hips and knees. Our joints are designed to allow us to move about, to accomplish tasks and to bear weight, a job they do superbly well. However, with injury, illness or disease our joints can be affected in various ways, limiting our abilities and causing stiffness and pain. Physiotherapists are trained to examine joints logically, determine the limiting factors and construct a treatment plan accordingly, with many techniques at their disposal.
Joints, the junctions between two bones, can have weight carrying, force transmission or movement properties depending on their design and position in the body. An example of a movement joint is the shoulder with its great range, the acromio-clavicular joint is a force transmission joint allowing arm function and the back and hips are weight bearing joints with some movement function. The most obvious of our joints are all synovial joints, a particular and very important joint type. The bone ends are coated with articular cartilage which reduces friction, the joint fluid is secreted by the synovial joint lining membrane and the joint capsule, formed by the ligaments, holds the joint protected against mechanical forces.
Observing the patient as they walk into the examination room and sit down can give the physiotherapist valuable information about the state of their joint. Slow and guarded movement is common, along with splinting of the joint and carrying it in a close and protected position to minimise joint stresses. Once the physio has taken a history they will check out the joint visually, looking for swelling, effusion, warmth or a joint deformity. If there is no obvious problem in a cool, settled joint the physiotherapist will need to stress the joint more thoroughly to find the restriction. However, a swollen, inflamed joint should be treated acutely as soon as possible.
Moving on from the relatively quick visual joint assessment the physiotherapist will start to palpate round the joint structures. This systematic manual examination allows the physiotherapist to clarify which parts of the anatomy are involved in the problem. The typical areas tested will be the ligaments, the areas where the tendons and ligaments insert to the bone, the joint line itself and around the margins of the joint. Any fluid in the knee, called an effusion, can be identified as it moves about if it is thin, it is very firm if the swelling is tight and it is thick and deformable if the swelling is older and stickier.
Active joint range of motion is then assessed and this is the joint movement the patient can do for themselves. Depending on the joint, this is expressed in degrees or as a proportion of the tested normal range on the other side, with limitation of range noted and the reason. Passive range is then tested and the physiotherapist moves the joint for the patient to see if any more movement is possible within the limits of discomfort. If the active range is poor and the passive range full, i.e. the joint can move where it should, then weakness or pain may be the limiting factors. If the passive and active ranges are both restricted then joint stiffness may be the problem.
The physiotherapist will assess the active range of the joint movement which is what the patient can manage independently, noting the ranges as a proportion of normal and why the joint could not achieve full range, e.g. pain or muscle weakness. The physio will then move the patients joint passively without the patients effort to see if the joint ranges are different. If the physio can move the joint through its full normal range but the patient cannot do this, then either pain or muscle weakness is the likely cause. If neither the physio nor the patient can get the joint to full range, pain or joint stiffness may be the problem.
The last part of the examination is to test the joint in functional activities or positions, especially if there is little to find on the more detailed examination. The physiotherapist can see how the patient is willing to use the joint and this may reveal difficulties with joint function which until then have not been clear.
Joints, the junctions between two bones, can have weight carrying, force transmission or movement properties depending on their design and position in the body. An example of a movement joint is the shoulder with its great range, the acromio-clavicular joint is a force transmission joint allowing arm function and the back and hips are weight bearing joints with some movement function. The most obvious of our joints are all synovial joints, a particular and very important joint type. The bone ends are coated with articular cartilage which reduces friction, the joint fluid is secreted by the synovial joint lining membrane and the joint capsule, formed by the ligaments, holds the joint protected against mechanical forces.
Observing the patient as they walk into the examination room and sit down can give the physiotherapist valuable information about the state of their joint. Slow and guarded movement is common, along with splinting of the joint and carrying it in a close and protected position to minimise joint stresses. Once the physio has taken a history they will check out the joint visually, looking for swelling, effusion, warmth or a joint deformity. If there is no obvious problem in a cool, settled joint the physiotherapist will need to stress the joint more thoroughly to find the restriction. However, a swollen, inflamed joint should be treated acutely as soon as possible.
Moving on from the relatively quick visual joint assessment the physiotherapist will start to palpate round the joint structures. This systematic manual examination allows the physiotherapist to clarify which parts of the anatomy are involved in the problem. The typical areas tested will be the ligaments, the areas where the tendons and ligaments insert to the bone, the joint line itself and around the margins of the joint. Any fluid in the knee, called an effusion, can be identified as it moves about if it is thin, it is very firm if the swelling is tight and it is thick and deformable if the swelling is older and stickier.
Active joint range of motion is then assessed and this is the joint movement the patient can do for themselves. Depending on the joint, this is expressed in degrees or as a proportion of the tested normal range on the other side, with limitation of range noted and the reason. Passive range is then tested and the physiotherapist moves the joint for the patient to see if any more movement is possible within the limits of discomfort. If the active range is poor and the passive range full, i.e. the joint can move where it should, then weakness or pain may be the limiting factors. If the passive and active ranges are both restricted then joint stiffness may be the problem.
The physiotherapist will assess the active range of the joint movement which is what the patient can manage independently, noting the ranges as a proportion of normal and why the joint could not achieve full range, e.g. pain or muscle weakness. The physio will then move the patients joint passively without the patients effort to see if the joint ranges are different. If the physio can move the joint through its full normal range but the patient cannot do this, then either pain or muscle weakness is the likely cause. If neither the physio nor the patient can get the joint to full range, pain or joint stiffness may be the problem.
The last part of the examination is to test the joint in functional activities or positions, especially if there is little to find on the more detailed examination. The physiotherapist can see how the patient is willing to use the joint and this may reveal difficulties with joint function which until then have not been clear.
About the Author:
Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Cambridge or elsewhere in the UK.
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