Common Mistakes in Physiotherapy Evaluations and How to Avoid Them

How to Effectively Gather Patient History for a Comprehensive Evaluation

Approach to patient evaluation and program development

Patient care is a problem-solving process

It is a feedback loop.

It is compatible with the problem-oriented medical records approach.

It is a complete evaluation of the patient avoids some important contributing factor.

It is allow for defining the functional limitations of the patient

A Simplified feedback loop depicting a problem-solving approach to patient care

Assess Needs

The first step is to assess the patients needs by using an evaluation process that gathers:

A. subjective information

B. objective data about the patient and the problem

A. Subjective Information (Case History)

- Ask questions to get the patient to:

1. How he perceives his symptoms:

A. Establish the location, type and nature of the pain or symptoms.

B. Determine if the pain and symptoms fit into a pattern related to segmental reference zone, nerve root or extrasegmental patterns ( dural, myfascial pain and peripheral nerve patterns or circulatory pain).

2. Describe the behavior of symptoms through a 24-hour period:

A.Identify which motions or positions cause and influence the symptoms.

B.Determine how severe or how limiting the problem is.

C.Determine how irritable the problem is how by easily the symptoms are evoked and how long they last.

C. Briefly describe patient general health, medications being taken and weather any x-ray have been taken.

D. Describe any previous history of the condition such as previous treatment for the problem and what the results of the treatment were.

E. Describe related history, such as any medical or surgical intervention

F. Determine weather the problem affects the patients occupation, family, social life or other environmental situations

2. Objective data (The clinical evaluation)

- Systematically administer tests that will define the anatomic structures involved and the functional limitations of the patient:

1. Inspection

2. Function

3. Palpation

4.Neurologic tests

5. Additional tests

6. Cardiovascular status

7. Respiratory capacity and function

8. Cortical integration and control

9. Functional ability or capacity

10. Development level for children

1. Inspection

Make observations of activities and appearance of body parts to evaluate:

1. Activities of daily living such as gait, patient’s ability to sit, stand or dress himself and general ease of movement.

2. Use of any adaptive aids.

3. Posture

4. Shape of body parts such as contour changes, swelling, atrophy, hypertrophy and asymmetry

5. Appearance of skin, such as scars and discoloration

2. Function

1. Use the principle of selective tension by administering specific tests in a systematic manner to determine if the lesion is within an inert structure (Joint capsule, ligaments, bursae, fascia, durra mater and dural sheaths around nerve roots).

2. Additional joint integrity tests are used to verify problems within the joint.

3. Identify the anatomic structure involved and its state of pathology so that an appropriate TE program can be designed.

Functional tests

Active range of motion

Passive range of motion

Joint integrity tests

Resisted tests

Active range of motion

The patient is asked to move the body parts related to the symptoms through their range of motion

Determine if the patient is able and welling to move the part.

Anything abnormal in the movement

Any experience of pain

Any changes in sensation are noted

Passive range of motion

The same movements which the patient did actively are repeated passively.

When the end of the available range is reached, pressure is applied in order to get a feel of the resistance of the tissues

With the muscles relaxed, only inert structures are being stresses.

Passive range of motion

Measure the ROM and compare it with the active ROM.

Determine if the limitation follows a pattern of restriction typical for that joint when joint problems exist

Determine the stage of pathology by observing when pain is experienced relative to the ROM

Determine the stability and mobility of the joint

Note if there is a painful arc, which is pain experienced with either active or passive motion somewhere within the ROM.

Joint integrity tests

Joint integrity tests are passive tests, used to rule out or confirm joint or capsule lesions prior to testing for muscle lesions, these tests include:

A. Traction; separate the joint surfaces and note if the pain increases or decreases and how easily the bones move apart.

B. Joint integrity tests Compression; Approximate the joint surfaces and note if the pain increases or decreases. if the pain increases, the compressive force of muscle contraction may also cause increased pain. The source of the pain then is known to be some structure within the joint and not a muscle lesion.

C. Gliding; Glide one of the joint surfaces on other and note the quality and quantity of the joint play movement (how easily the bones move and whether or not the joint movement causes pain).

D. Restricted tests:

1. Resist the related muscles so that they contract isometrically in mid-range in order to determine if there is pain or decreased strength in the contractile units.

2. Mid-range isometric contractions are used so that there is minimal movement or stress to the noncontractile structures around the joint

3. Initially the tests are performed on groups of muscles.

4. Then if a problem is noted, each muscle potentially involved is isolated and tested.

Palpation

Palpate, if possible, structures that are incriminated as the source of the problems.

Usually palpation are best done after the functional tests in order not to increase the irritability of the structures prior to testing.

Palpation include:

1. Skin and subcutaneous tissue; note temperature, edema and texture.

2. Muscles, tendons and attachments; note tone, tenderness, trigger points and contractures.

3. Tendon sheaths and bursa; note tenderness, texture and crepitus.

4. Joints; note effusion, tenderness, changes in position or shape and associated areas such as ligaments

5. Nerves and blood vessels; note presence of neuroma and pulse

Neurological tests

Any indication of motor weakness or changes in sensation directs the evaluator to specific tests to determine nerve, nerve root or central nervous system.

Evaluation of neurological system

1. Key muscles; determine strength and reflexes of muscles related to specific spinal levels and nerve patterns.

2. Motor ability; determine central versus peripheral control of muscles.

3. Sensory testing; note changes in temperature, perception, superficial and deep pressure, pain patterns and proprioception.

4. Nerve trunk; determine if there is pain on pressure or stretching of the trunks.

5. Cranial nerve tests.

Cardiovascular status

Endurance testing such as determine a target heart rate and then monitoring the pulse before, during and after exercise.

Circulatory integrity such as monitoring a lower extremity pulse, color and edema.

Monitor symptoms such as syncope.

Respiratory capacity and function

Breathing patterns

Ability to cough effectively

Functional limitations or restrictions

Vital capacity and flow rates

Chest mobility

Rate and rhythm of breathing

Functional ability or capacity

Wheelchair assessment: kind, skills and care.

Dressing, personal hygiene, feeding and safety assessments.

3. Assessment

List the problem areas

Determine major versus minor problem that can be dealt with directly by using physiotherapy procedures versus those that should be referred to other specialist.

Develop Plan

Establish the goals of treatment based on:

a. The problems identified in the evaluation.

b. The physiological status, such as the patient’s adjustment to the problem, motivation and personality.

c. Socioeconomic and cultural reactions and expectations

d. Home or relative care, the physical and emotional environment, family reaction, cooperation and responsibilities

e. Vocational plans and goals

Implement Plan

Once the plan of care is established use procedures and techniques that would fulfill the plan and meet the goals

Evaluate Plan

Frequently evaluate and reassess the effectiveness of the procedures and techniques and modify them or the treatment plan whenever indicated:

1. Compare original data with current data at frequent intervals

2. Identify goals that have been met, those that need modification

3. Identify new goal according to changes in the patient or his life style.

Home Program

A home program should be viewed as an extension of the treatment plan of care.

1. Early identification of patient’s home or alternative care setting, family reactions, social

2. identification of patient’s economic capabilities,

3. identification of patient’s equipment needed

4. identification of patient’s vocational plans provide a foundation for anticipating adjustment to

5. identification of patient’s compliance with home exercise program

Goals of therapeutic exercises

The positive effects of therapeutic exercises include development, improvement, restoration or maintenance of normal:

1. Strength

2. Endurance

3. Mobility and flexibility

4. Coordination and skill