When assessing muscle strength it is important to note any changes in the patient’s facial expression, which may be a reproduction of the presented pain. Resisted Isometric tests examine the contractile unit for pain and strength. Though there is no joint movement, isometric muscle contraction will cause compression and joint shearing and muscle atrophy will be observed (Petty 2001). Resisted muscle tests could also be used to test myotomes, if a neurological problem was suspected. This will be discussed in more detail later.
NEUROLOGICAL TESTING
Neurological examination involves carrying out specific diagnostic tests to examine the integrity of the nervous system and rule out any neurological causes. The physiotherapist would test myotomes, dermatomes, reflexes. A myotome being a group of skeletal muscles innervated by a particular spinal nerve and a dermatome being an area of skin that is supplied by a particular spinal nerve (Crossman & Neary 2000).
The shoulder joint and structures around it are derived from the C5 segment. Lesions of any of these structures will cause pain to be referred into the C5 dermatome which extends into the anterolateral aspect of the arm and forearm. This patient does not suffer from pins and needles or numbness but complains of a burning sensation down his arm which could suggest some form of neurological involvement (Gelb 2005).
For this patient, only upper myotomal tests are needed to be carried out. It involves testing the conduction of the nerve fibers by resisted isometric muscle tests, checking for a neuromuscular involvement. Nerve roots C5-T1 are tested for the cervical region. Light touch test is performed on the dermatomes to test for loss of skin sensation. A positive test would give an indication of nerve impingement (Gelb 2005).
Reflexes must also be tested if nerve involvement is suspected. Reflexes test the efficiency of the spinal reflex arc. If there is a certain amount of compression on the nerve, the reflex will be reduced or even absent (Atkins & Kesson 2005). Nerves are also palpated. Neurodynamic testing may be preformed in order to stimulate and move neural tissue in order to clinically evaluate mobility to find the neural tissue that is responsible for the production of the patient’s symptoms, and examine the mobility of the nervous system. The physiotherapist could carry out upper limb tension tests (1, 2a or 2b.) The aim is to stimulate and move neural tissue in order to clinically evaluate mobility and sensitivity to stress (Shacklock 1995).
Palpation Palpation is used by the Physiotherapist to assess prominence of bone, soft tissue, skin texture, temperature, muscle spasm and tenderness (Petty 2001). In this particular case the cervical spine and upper shoulder would be examined. The patient complains of stiffness in the morning, suggesting inflammation in the shoulder region. Palpation would allow the physiotherapist to check for problematic muscles. Torn fibers in the trapezius may be considered, which in turn is compressing on a nerve and pain is getting referred down the lateral aspect of the arm (Atkins & Kesson 2005).
Accessory joint movements It is important to examine accessory joint movements as they occur during all physiological movements. There is a restriction of the accessory range of movement then this can affect the physiological movements (Petty 2001). The physiotherapist would carry out accessory joint movements of the spine once neurological testing ruled out, as this type of movement could put pressure on the nerve and increase patient’ symptoms. The quality and range of movement, behavior of pain are noted.
For this particular patient accessory joint movements would be tested on the glenohumeral joint and cervical spine, as musculoskeletal involvement is suspected in the upper shoulder region Contraindications and precautions When carrying out any of the above techniques it is important that the physiotherapist considers the patient’s safety as their main priority. Precautions and contraindications should be considered initially, in order for the physiotherapist to perform an appropriate and safe treatment.