When should physiotherapists assess patients?
• On first patient contact, it is
essential to perform an initial assessment to determine the patient’s problems
and to establish a treatment plan.
• During the treatment,
assessment is particularly appropriate while performing treatments such as mobilisations
and exercises when the patient’s signs and symptoms may vary quite rapidly. Be
aware of any improvement or deterioration in the patient’s condition as and
when it occurs.
• Following each treatment, the
patient should be reassessed using subjective and objective markers in order to
judge the efficacy of the physiotherapy intervention. Assessment is the
keystone of effective treatment without which successes and failures lose all
of their value as learning experiences.
• At the beginning of each new
treatment, assessment should determine the lasting effects of treatment or the
effects that other activities may have had on the patient’s signs and symptoms.
In reassessing the effect of a treatment, it is essential to evaluate progress
from the perspective of the patient, as well as from the physical findings.
Aims of the subjective assessment
The
aims of subjective assessment are to gather all relevant information about the
site, nature, behaviour and onset of symptoms, and past treatments. Review the
patient’s general health, any past investigations, medication and social
history. This should lead to a formulation of the
next
step of physical tests.
Aims of the objective assessment
The
objective assessment aims to seek abnormalities of function, using active, passive,
resisted, neurological and special tests of all the tissues involved. This may
be guided by the history. However, it is important to conduct all tests objectively and equally, and not attempt to bias the
findings
in an attempt to make the hypothesis fit. Objective examination is
concerned with performing and recording objective signs. It aims to:
• reproduce all or parts of the
patient’s symptoms;
• determine the pattern, quality,
range, resistance and pain response for each movement;
• identify factors that have
predisposed or arisen from the disorder;
• obtain signs on which to
reassess the effectiveness of treatment by producing reassessment ‘asterisks’
or ‘markers’ (Jull, 1994)
SUBJECTIVE ASSESSMENT
Initial questioning
Subjective
assessment needs to include the name, address and telephone number of the
patient, and the patient’s hospital number, if appropriate. Both the age and
the date of birth of the patient should be recorded. The medical referrer’s
name and practice should also be recorded for correspondence, discharge
letters, etc. Present condition
Area of the symptoms
It is useful to record the area of the pain by using a body chart,
because this affords a quick visual reference (Maitland 2001). The patient may complain of
more than one symptom, so the symptoms may be
recorded or referred
to
individually as P1 and P2 and so on. Areas of anaesthesia or paraesthesia may
be recorded differently on the pain chart – they may be represented as areas of
dots in order to distinguish them from areas of pain
Severity of the symptoms
The severity of the pain may be measured on a visual analogue
scale (VAS) or on a numerical scale of 0–10 to quantify the pain, where 0
stands for no pain at all and 10 is perceived by the patient as the worst pain imaginable.
The mark on a VAS can then be measured and recorded for future comparisons
using a ruler. Although these measures are not wholly objective, they do allow changes
to be monitored as the treatment progresses.
Duration of the symptoms
Establish
whether the pain and symptoms are intermittentor constant. Is the pain present
all of the time or does it come and go depending on activities or time of day? Aggravating and easing factors
Positional factors
Most
musculoskeletal pain is mechanical in origin and is therefore made better or
worse by adopting particular positions or postures that either stretch or
compress the structure that is giving rise to the pain. Moreover, aggravating and
easing movements may provide the physiotherapist with a clue as to the
structure that is causing the pain.
Time factors
It
is useful to record the behaviour of signs and symptoms over a 24-hour period –
the diurnal pattern. Do the symptoms keep the patient awake or awaken the
person regularly during the night? Is this because of a particular
sleeping
posture or to other, unrelated factors? On arising, how are the symptoms for the
first hour or so of the day and, moreover, do the symptoms vary from the
morning to the afternoon and into the evening? Does this follow a particular
pattern? This information can be included on
the
body chart. Determining the SIN factors Once the severity of the symptoms and the aggravating and easing factors have been noted, it is
then possible to
determine the SIN factor of the condition: severity/ irritability/nature. SIN factors are used
to guide the length and
firmness of the objective assessment and subsequent treatment.
Severity
This
can be quantified by the VAS, numerical scale or other valid pain
questionnaire. It can be recorded as high (pain score of around 7–10), moderate
(score around 4–6) low (score around 1–3).
Irritability
This
is the time that the person has to perform the activity to increase the pain
and, conversely, how long it takes before the pain settles to its former
intensity. It can be measured as either high (the aggravating factor causes the
pain to increase very quickly or instantly and then the pain takes a long time
to settle back), moderate (the aggravating factor takes longer to increase the
symptom) or low (the aggravating factor can be performed for a long time before
exacerbating the patient’s symptoms and then on stopping the activity the
symptoms subside rapidly). An example of low irritablity would be that the knee
pain is aggravated after jogging for one hour and then subsides after one minute
of rest.
Nature
It
is possible to hypothesise the nature of the condition following the subjective
history, i.e. whether the patient’s condition has a predominantly inflammatory,
traumatic, degenerative or mechanical cause.
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