General Physiotherapy Assessment

Original Editor - Carin Hunter based on the course by Nick Rainey
Top Contributors - Carin Hunter, Jess Bell, Tarina van der Stockt and Kim Jackson

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (16/11/2022)

Introduction

It is recommended to develop standard practice protocols for each patient that comes into your treatment rooms with any complaint. If Your protocols are followed, they will provide the lowest chance possible for a poor outcome. Each area should be elaborated on in your own clinic to ensure it is specific for your demographic of patient.

Screen patient for

• Red Flags - Potential referral out
• Yellow Flags - Significant psychological and social recovery limiting factors
• Patient Expectations

The following are questions you should be able to answer after the initial examination:

The following questions are based on the book by Louis Gifford, Aches and Pains, and they illustrate the type of conversation expected to be initiated by the therapist in order to gain crucial information about the patient. This information will assist with rapport, discussing goals and the treatment plan.

The following questions, the therapist should be able to answer after the initial examination:

1. Basic information regarding who the patient is.
2. The main reason the patient has come to see you and what their goal is.
3. When the patient thinks of their worst case scenario, what does that look like?
4. When you think of their worst case scenario, what does that look like?
5. Could this be the worst case scenario? Why?

The following, is information the patient should be able to explain after the initial examination:

1. A diagnosis with an understandable explanation
2. Recovery timeframe
3. Things to do to help
4. Things to avoid
5. What the physical therapist can do to help?

Yellow Flags

It is also important to screen for what are called “yellow flags”. These are anything that can contribute to their pain from a psychological and social perspective. There are two different ways that you can address these.

1. Optimal Screening for Prediction of Referral and Outcome (OSPRO)

One tool that can be used in the assessment of yellow flags is the Optimal Screening for Prediction of Referral and Outcome (OSPRO) tool.

For more information, please click on this article link:

2. Functional Pain Management Society’s Intake questionnaire

A second tool that can be used is the Functional Pain Management Society’s Intake questionnaire: Intake questionnaire

Please see the video below on using the Intake questionnaire:

Psychosocial Exam Components Cheat Sheet: Psychosocial Exam Components Cheat Sheet

Please see the video below on how to use the Cheat Sheet

Body Chart

When conducting an assessment, a body chart is a good tool to use for an objective record of the location, symptoms and behaviour of the patients pain. On the body chart, make note of an asterisks sign.

An asterisks sign is also known as a comparable sign. It something that you can reproduce/retest. It can be functional or movement specific. This is used to measure the improvement or worsening of symptoms.

Basic Process for Evaluation

• Establish as precise of a diagnosis as possible
• Clear the spine for distal complaints
• Determine patient’s irritability
  • This will determine the intensity of testing. Don't aggravate your patients symptoms but we want to push them to the limit of what they can achieve.
• Perform aggressive myotome testing
  • This should include myotome fatigue testing
  • This should be conducted if:
    • the patient presents with a peripheral complaint without a clear mechanism of injury
    • There is a concern about imaging findings or potential findings in their spine
    • There is a concern about damage of their spine
• Perform a Sensation Exam
  • This should be conducted if the patient presents with:
    • Paresthesias in a pattern that is not obviously dermatomal or in a peripheral nerve field (we need to determine where the symptoms are)
    • Neuropathy and we need to determine if they have protective sensation
• Perform a Reflex Exam
  • This should be conducted if the patient presents with: (Kearns 2022, Heffetz 2007)
    • Widespread pain
    • Decreased balance
  • Reflexes include
    • Tendon reflexes
    • Hoffman’s Test
    • Ankle clonus
      • Ankle clonus is the only one indicated if there is central thoracic pain
• Upper cervical ligament testing
  • This should be conducted if the patient presents with: (Piekartz 2019)
    • Have a primary complaint of UQ issues and neck trauma
    • A complaint of their head being “unstable”
    • May require upper cervical manual therapy
• Perform a gait assessment
  • if the patient presents with
    • Any lower quarter complaints
    • Any balance complaints
• Expose the skin of the area you are examining
• Find objective measures that we can retest that represents their primary complaint. (We call this an * sign.)
• Provide an intervention to improve the * sign
• Provide a HEP that improves the * sign
• Agree with the patient on goals
• Educate the patient
  • Diagnosis
  • Prognosis
  • How likely it is they’ll achieve their goals
  • How long to reach their goals
  • Actions
    • What will happen when the patient is at the clinic
    • What the patient should do at home.
    • What the patient should not do at home.
• Determine pain mechanisms
  • Nociceptive,
  • neuropathic,
  • nociplastic (Nijs 2021)
• Rule out worst scenario
  • Consider the worst case and rule down as much as possible or refer

What do we do with exam findings?

Whenever we do tests we are looking for impairments. However, we do not just want to be impairment finding and treating PTs. We need to take into account the evidence and pathology to identify the best interventions and prognosis for those interventions. This is how we grade impairments. We don’t need an extensive algorithm, just a basis for decision making.

Here are a few principles.

• If someone has pain with a test we need to know if it is their familiar pain.
• If there is an impairment and it doesn’t recreate their familiar pain does it seem relevant either biomechanically or due to research?
• All impairments are not created equal. Grade how significant it is for their pain and functional limitation.  
• We don’t need to treat all found impairments. We need to assess their relevance. If we treat it, does it improve their functional asterisk? Make sure that you treat with enough dosage to assess that if there’s not improvement it’s due to a lack of relevance of the impairment and not a lack of dosage. This is where knowing irritability is vital. (If it takes 75# of a DB OH press to elicit pain sometimes and shoulder ER is slightly weak on that side and not painful then it will take a lot of rigorous shoulder ER training to identify if it is helpful for his asterisk sign.)

What do we do when we can’t recreate their familiar pain?

The easy answer is to increase the rigor of the exam. The challenge is when there are more than one problem areas. For instance, what if we easily recreate their spine pain, but do not replicate their neurogenic pain? We could do tests that replicate the neurogenic symptoms, but that doesn’t tell us if it is a neural dependent or container dependent (in this case the container would be the foramina of the spine). If we increase the intensity of the spine testing then we may aggravate the spine too much. In this case, we wait to see if the impairment in the spine is relevant to the neurogenic pain. We may be able to find out in session if they are a fast responder (what some call an “easily reducible derangement”) or we may need to wait to see if their functional subjective asterisk improved between session.

The same will go for a somatic referral, not just neurogenic symptoms. Sometimes there is a referral from the spine (or other structures). This may be our hypothesis, but the only way to prove it in the session is to flare-up their spine pain. Thus, we would just need to wait until we can more aggressively test or to find out if the subjective functional asterisk improved.

Historically, sometimes clinicians just performed tests to see if they hurt without seeing if they were relevant. We’ve done a much better job now of making sure that the pain that is created is relevant. It will make you a much better clinician if you can identify relevant impairments that aren’t painful.