In an assessment for proper body alignment of a standing client, which finding is normal?

Ching-Chuen Feng

At the end of the chapter, the learner will:

1. Obtain a health history related to the musculoskeletal system.
2. Perform physical examination of the musculoskeletal system using correct examination techniques.
3. Assess the ability to perform activities of daily living.
4. Discuss screening tools for falls risk assessment.
5. Document the findings from the musculoskeletal assessment.

I. Overview: Focused Musculoskeletal System Assessment

A focused musculoskeletal assessment includes collecting subjective data about the patient’s mobility and exercise level, collecting the patient’s and the patient’s family’s history of musculoskeletal conditions, and asking the patient about any signs and symptoms of musculoskeletal injury or conditions. Objective data will include assessment of range of motion and muscle strength. If the patient is at risk for falls will also be assessed.

II. Anatomy and Physiology Review:

III. Medical Terminology

Important Terms to know:

The normal spine should be straight with expected curvatures, and the body is symmetrical compared one side with the other.

ROM Terms:

Three types of ROM:

Active Range of Motion: Patient performs the exercise independently without any assistance.

Active Assisted Range of Motion: Patient moves the joints with some effort and requires some assistance from someone or equipment.

Passive Range of Motion: Patient does not perform any movement and depends totally on someone (therapist) or equipment to perform ROM.

IV. Step-by-step Assessment of the Musculoskeletal System

Safety considerations:

• Perform hand hygiene.
• Check room for contact precautions.
• Introduce yourself to patient.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain process to patient.
• Be organized and systematic in your assessment.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure patient’s privacy and dignity.
• Assess ABCCS/suction/oxygen/safety.
• Apply principles of asepsis and safety.
• Check vital signs.

Steps	Additional Information
1. Check patient information prior to assessment: Activity order Mobility status Falls risk (see Fall Risk Assessment below) Need for assistive devices 2. Check alertness, medications, pain. 3. Ask if patient uses walker/cane/wheelchair/crutches. 4. Conduct a focused interview related to mobility and musculoskeletal system.	Determine patient’s activity as tolerated (AAT)/bed rest requirements. Determine if patient has non-weight-bearing, partial, or full weight-bearing status. Determine if patient ambulates independently, with one-person assist (PA), two-person assist (2PA), standby, or lift transfer. Consider non-slip socks/hip protectors/bed-chair alarm. Ask relevant questions related to the musculoskeletal system, including pain, function, mobility, and activity level (e.g., arthritis, joint problems, medications, etc.).
5. Inspect, palpate, and test muscle strength and range of motion: Observe general appearance, body symmetry, gait, and posture. Normal appearance should be erect posture, smooth, and coordinated movement. Stand behind the patient to inspect the straightness of the spine. Assess gross motor skills: have the patient perform range of motion exercises on neck, shoulders, elbows, wrists, hip, knees, and ankles. Palpate the muscle to assess muscle tone. Normal muscle tone helps to maintain normal postures. Assess muscle strength and ROM of the joints on upper and lower extremities. Have the patient perform active ROM while the examiner applies resistance using 0-5 scale (Naqvi & Sherman, 2020). Score Criteria of muscle strength 5 Full range of motion with full resistance 4 Full range of motion with some resistance 3 Full range of motion against gravity 2 Achieving full range of motion with gravity eliminated 1 No range of motion, evidence of muscle contractility such as a twitch 0 No muscle contractility Assess for bilateral handgrip strength and dorsi/plantar flexion strength.	If the patient states pain or tenderness in an area, further assessment should be done. Normal or abnormal findings should be elicited by observation and palpation of the surrounding area for symmetry/asymmetry, skin appearance/discoloration, warmth/heat, erythema, ulcers, hair distribution, muscle tone, crepitus of joint, and ROM (Vilella & Reddivari, 2020). The Adams Forward Bend Test is used to screen for scoliosis. Ask the patient to bend forward with feet together, knees straight, and arms dangling at sides. The back should be completely straight. If the back shows that one side is higher than the other, this indicates a sign of scoliosis. Adams Forward Bend Test Note patient’s gait, balance, and presence of pain. Assess grip strength Note strength of handgrip and foot strength for equality bilaterally. Assess strength on plantar flexion Assess strength on dorsiflexion
6. Evaluate patient’s ability to sit up before standing, and to stand before walking, and then assess walking ability.	Patient position prior to standing
7. Report and document assessment findings and related health problems according to agency policy.	Accurate and timely documentation and reporting promote patient safety.

Fall Risk Assessment

Falls are a significant problem for hospitalized patients. There are some tools available for assessing and identifying falls in hospitalized patients (Aranda-Gallardo et al., 2013). Morse Fall Scale (Morse, Morse, & Tylko, 1989) is a valuable tool commonly used for hospitalized patients to identify risk factors for falls and to prevent potential falls. In Morse Fall Scale, the nurse gathers information on 6 categories reflecting falls risk including history of falls, secondary diagnosis, ambulatory aids, intravenous therapy, gait, and mental status.  The nurse will tally the score from the 6 categories, and base on the total score to evaluate objectively if the patient is at risk for falls, and then provide necessary interventions to prevent falls (AHRQ, n. d.).

Tally the patient score:

   0: No risk for falls

<25: Low risk

25-45: Moderate risk

>45: High risk

Falls are also a potential problem for older populations who live at home or long-term care facilities. Access additional health information to educate patients on how to prevent falls. Fall Risk Assessment: https://medlineplus.gov/lab-tests/fall-risk-assessment/

V. Documentation

Patient denies problems with muscle weakness or tremor, no history of falls. Performs ADL independently, denies problems with mobility. Steady coordinated gait with erect posture, full ROM, muscle strength (5/5) equal and strong bilaterally in all joints with smooth and nonpainful movements, muscle size symmetric bilaterally, shoulders aligned, spine straight and in midline. No pain or tenderness on palpation.

VI. Related Laboratory and Diagnostic Tests

Some blood tests will be used to diagnose musculoskeletal problems, such as:

• Serum calcium levels will be abnormal in patients with osteomalacia or parathyroid problems.
• Rheumatoid Factor will be checked to diagnose rheumatoid arthritis, an autoimmune disease.
• HLA-B27, a specific gene, will be used to diagnose ankylosing spondylitis, a disorder that may affect the spine, pelvic bones, and hip joints.
• White blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may be checked to diagnose an infection or inflammation.
• Creatine Kinase (CK) or Creatine Phosphokinase (CPK) can be checked to diagnose muscular injuries such as myopathy, muscular dystrophy, and or rhabdomyolysis. CK can be found in skeletal muscle, myocardium, and brain. When muscle is damaged, CK will be elevated in the blood.

Some diagnostic tests can be used to diagnose musculoskeletal problems.

• X-ray studies can be used to identify and evaluate bone density and structure.
• Computed tomography (CT) scan is performed to evaluate musculoskeletal trauma and bony abnormalities that are not able to be detected in X-rays.
• Magnetic resonance imaging (MRI) can evaluate problems in bones and soft tissues, which can be used to diagnose torn muscles, disk abnormalities, tears in ligament or cartilage, and other hip or pelvic conditions.
• Bone densitometry can be done with x-rays or ultrasound to evaluate bone density in the spine, hip, wrist, and the total body. It is also used to predict fracture risk and effectiveness of treatment for patients with osteoporosis.
• Bone scan examines the entire skeletal system to evaluate the cause of unexplained bone pain, to detect damage to bones initiated by infection or other disease, and to discover cancer in bones caused by metastasis.
• Arthroscopy is an examination that uses a fiber-optic endoscope inserting into the interior surface of a joint to perform surgery and/or diagnose diseases of the patella, meniscus, and synovial membranes.
• Electromyography (EMG) is to evaluate the electrical activity of muscles and nerves, which can diagnose neuromuscular diseases, motor and nerve problems (Hinkle & Cheever, 2018).

VII. Learning Activity

VIII. Citations and Attributions

• Agency for Healthcare Research and Quality (AHRQ). Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors.  https://www.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/morse-fall-scale.html. Accessed July 15, 2021
• Aranda-Gallardo, M., Morales-Asencio, J. M., Canca-Sanchez, J. C., Barrero-Sojo, S., Perez-Jimenez, C., Morales-Fernandez, A., de Luna-Rodriguez, M. E., Moya-Suarez, A. B., & Mora-Banderas, A. M. (2013). Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis. BMC health services research, 13, 122. https://doi.org/10.1186/1472-6963-13-122
• Doyle, G. R. & McCutchen, J. A. Clinical procedures for safer patient care. https://opentextbc.ca/clinicalskills/chapter/introduction/

• Hinkle, J. L. & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical Nursing. (14th ed.). Philadelphia, PA: Wolters Kluwer.

• MedlinePlus. Forward bend test. https://medlineplus.gov/ency/imagepages/19465.htm
• Morse, J. M., Morse, R.M., & Tylko, S.J. (1989). Development of a scale to identify the fall-prone patient. Canadian Journal on Aging, 8(4), 366-377.
• Naqvi, U. & Sherman, A. I. (2020). Muscle strength grading. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436008/  Accessed July 15, 2021
• Vilella, R.C. & Reddivari, A. (2020). Musculoskeletal examination. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing.  https://www.ncbi.nlm.nih.gov/books/NBK551505/ Accessed July 15, 2021.