When should physiotherapists assess patients?

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.