A Practical Guide on Physiotherapy Assessment for Physiotherapy Students Gopal Nambi S
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Introduction to AssessmentCHAPTER 1

There is No Short Road to Knowledge
“Diagnosis arises from the examination and evaluation and represents the outcome of a process of clinical reasoning. This may be expressed in term of movement dysfunction or may encompass categories of impairments, functional limitations, abilities/ disabilities or syndromes.”
WCPT (1999, P.7)
 
CLINICAL DECISION MAKING
A thorough understanding of the patient and his/her disorder is a complex process which involves a series of interrelated steps which help the physical therapist to plan an effective treatment compatible with the needs of the patient and the goals of the health care team. These steps include:
  1. Assessment of the patient.
  2. Identifying the problem.
  3. Determining the diagnosis.
  4. Determining the prognosis and plan of care.
  5. Implementing the plan of care.
  6. Reassessment of the patient and evaluating the treatment outcome.
Adequate knowledge and experience, cognition process strategies, communication and teaching skills are important components of skilled decision making. Also a good communication amongst the rehabilitation team members and effective documentation is a must for timely reimbursement of the services.
 
PROBLEM-ORIENTED MEDICAL RECORD (POMR)
Originally developed by Weed, which is used by many therapists and institutions. Divides the treatment process in four phases.
Phase-1: Includes a detailed physical examination, laboratory and other tests and their results.
Phase-2: Interpreting the database to identify the specific problem.
Phase-3: Choosing a treatment plan for each of the problem also includes making of an evaluative progress note for each problem.
Phase-4: Assessment of the effectiveness of each of the plan and making necessary changes as the treatment progress.2
 
SOAP Format
  • Subjective finding
  • Objective finding
  • Assessment
  • Planning of treatment.
Progress report is written in the subjective, objective, assessment and plan (SOAP) format. Subjective findings are what the patient or his/ her family report. Objective findings are what the therapist observes measures or tests. Assessment is correlating the subjective and objective findings to formulate long and short-term goals and plan is fixing the interventions.
The POMR highlights the relationship of the database to the treatment plan thus makes the specific problem of the patient to become the central focus of planning. To store the large amount of data computerized POMR is available.
 
ASSESSMENT AND EVALUATION
Assessment is the means of evaluating everything done during clinical decision making process (clinical reasoning). The effectiveness of a treatment is assessed by comparing the effects of the selected and processed techniques on the patient's signs and symptoms.
To complete proper assessment a thorough systemic examination is required. A correct diagnosis depends on knowledge of functional anatomy, accurate patient history, diligent observation and thorough examination.
 
ASSESSMENT OF THE PATIENT
It is believed that 80% of the information needed to identify the cause of the symptoms is given by the patient himself during history taking, thus making interviewing a very important skill for every physiotherapist to learn.
 
INTERVIEWING TECHNIQUES
  1. Open-ended questions: Answers to these are in more than one word.
  2. Closed-ended questions: Answer is either ‘yes’ or ‘No’
  3. Funnel technique or Funnel sequence: Starts with open-ended question and ends with close-ended questions.
  4. Paraphrasing technique: Synthesizing and integrating the information obtained during questioning.
This helps in identifying the patient's problems. The resources available for proper intervention consist of three components:
  1. Patient history
  2. System review
  3. Tests and measures.
    1. Patient history: History can be obtained from the patient, family or caregiver. Information obtained should contain the patient's primary complaint, history of present illness, significant medical condition that affected them in the past, lifestyle practices and habits.
      The therapist should listen carefully to the patient and observe for physical manifestations that reveal the emotional, state of the patient (e.g. Slumped body posture, poor eye contact, etc.).
      Interview is also an effective tool for establishing rapport for effective communication and mutual trust which in turn are vital for the success of the rehabilitation program.
    2. System review: It involves a brief examination of the entire body, followed by the detailed examination of the area of interest. This allows the therapist to decide if the patient's problems can be treated by him or if he should be referred to a specialist for significant medical condition.3
    3. Tests and measures: These are definitive assessment tools used to determine the degree of dysfunction (e.g. Range of motion, oxygen consumption, manual muscle test, etc.). Adequate training and skill are required to perform these tests to ensure the validity and reliability or it could result in inaccurate data leading to an inappropriate treatment plan. The therapist should review the patient's problem and choose for the appropriate test, also he/she should resist the tendency to gather extraneous data which might not only confuse the diagnosis but also increase the cost of care. Only in case where the initial data obtained are inconsistent should addition or specialized test be indicated.
 
PURPOSE OF ASSESSMENT
The purpose of assessment is to clearly understand the patient's problem. It serves several purposes.
  1. Physiotherapy diagnosis.
  2. Definition of physiotherapy objectives.
  3. Determining treatment intervention.
  4. Defining the parameters to monitor the effects of therapy.
  5. Better recognize common disorder.
  6. Impose overall health and functional outcomes.
  7. Reduce vulnerability to subsequent illness.
  8. Provide better quality of life.
 
FORMS OF ASSESSMENT
Different forms of assessment have described (Maitland et al 2001) and summarized as follows:
  1. Assessment during initial consultation includes the welcoming and information phase.
  2. Reassessment in various phases of each treatment session.
  3. Assessment during the application of treatment intervention.
  4. Retrospective assessment and prospective assessments to monitor the overall process.
  5. Final analytical assessment including the parting phases in which measures are undertaken to enhance long tem.
 
Assessment at Initial Examination
At the first session the therapist has to gather information about the patient and accordingly draft a treatment plan. This information includes the following data.
  • Biomedical
  • Psychological
  • Social
  • Cultural
The key is to develop a clear, disciplined procedure of examination and planning. Improvisations are made to adapt the procedures for special needs of patients.
The following algorithm of information, procedures, reflections and planning are suggested for the first session - Algorithm of first session.
Within the first session the physiotherapist should collect information regarding:
  • Causes and contributing factors for the condition.
  • Treatment goals and suitable interventions.
  • Activity involving the patient in the treatment process.
  • Any precautions or contraindications in regards to examination or treatment procedure.4
 
Reassessment
The term reassessment was first described in 1968 and now has become a part of the declarative knowledge of the profession (WCPT, 1999). The effect of any treatment needs to be continuously monitored and the treatment should be adapted as per the needs of the patient. Reassessment plays a key role in this process and it should be done during each treatment session.
  • At the initial examination of the patient and after the examination of various active and passive movement tests.
  • At the beginning of each subsequent sessions (pre-treatment assessment) to check for the effects of the last treatment session.
  • Immediately after the application of treatment interventions. At the end of treatment session.
Purpose of reassessment: Allows the therapist to compare results proving the effectiveness of the treatment intervention selected.
Aids in differential diagnosis: Enables the physiotherapist to reflect on the decision made during diagnostic and therapeutic processes.
Reassessment helps the therapist to recognize patterns of clinical presentations with reactions to the interventions selected.
Reassessment supports in the learning process of the patient.
 
Assessment during Treatment
The following factors are monitored during the treatment.
  • Are the treatment objectives being achieved?
  • Are there any undesirable side effects?
The physiotherapist needs to be alert for both the beneficial effects as well as side effects during intervention. As long as the changes are favorable, the technique may be continued. When changes cease to take place it is useful to perform a reassessment to evaluate the effect of the technique applied to the patient's condition.
 
Retrospective and Prospective Assessment
 
Retrospective Assessment
  • This should include information from both the patient as well as the therapist.
  • First information from the patient should be collected. Seek spontaneous information from the patient, as compared to 3 weeks ago how do you feel now?
  • Effects of the treatment interventions: All the things done during therapy, do you think have been most helpful? Was any technique not helpful?
  • What were the effects of the exercises recommendations and instructions given? Are there any difficulties in any of the self-management methods? Do they reach the expected goals?
  • What have you learned from therapy so far?
  • The symptoms and the level of activities have to be put in perspective to the period before the disorder had worsened.
  • The therapist should check the treatment records for changes in the subjective and physical parameters after intervention.
 
Prospective Assessment
  • After reviewing the therapeutic process, the treatment objectives for the next period of therapy should be decided.
  • The following questions will help in planning.
    • On which aspects should we work together?5
    • Which activities need to get better? Are there any activities in your work or hobbies which you do not have the confidence to do or need to be very careful while performing? Which activities still need to get better you?
    • If new treatment objectives have been defined (e.g. Pain during bending) then these activities are used as physical parameters during reassessment.
 
Final Analytical Assessment
  • At the end of the therapeutic process a final assessment may be made. The process of this assessment is done over the last 2–3 sessions.
  • The following information should be analyzed:
    • First examination.
    • Behavior of the disorder throughout treatment (Details derived from the retrospective assessment).
  • State of affairs at the end of the treatment arises, taking into account the changes in subjective and physical parameters.
The patient and therapist together analyze:
  • Overall therapeutic process: Which intervention brought which result?
  • The learning process: What was especially important for the patient and has been learned?
  • The effectiveness of any prophylactic measures and self-management interventions.
  • Suggestions of any medical or other measures that can be carried out?
For the successful outcome the participation of the patient in planning is very essential. The timely reimbursement of the service can be provided. Patient participation in planning is essential in ensuring successful outcomes. Documentation is also an essential requirement for effective communication among the rehabilitation team members and for timely reimbursement of services.