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

Introduction

In clinical practice, it is beneficial to develop standard practice protocols. Following evidence-based protocols means that you reduce the chance of a poor outcome. You should make sure that these protocols are specific to your patient demographic.

General Assessment

Screen patient for:

• Red flags - potential referral out
• Yellow flags - significant psychological and social recovery limiting factors
• Patient expectations

You should know the following after the initial examination:

These questions / themes are based on those in Louis Gifford's book, Aches and Pains. The therapist should initiate a conversation which covers these areas in order to gain crucial information about the patient. This information will assist with developing rapport, discussing goals and planning the treatment.

You, the therapist, should know / be able to answer the following after the initial examination:

1. Basic information relating to who the patient is
2. The main reason the patient has come to see you and what their goal is
3. What is the most likely worst case scenario?
4. How confident are you that the patient is not presenting with the worst case scenario? Why?

The patient should understand / be able to explain the following after the initial examination:

1. A diagnosis - they should be able to give an explanation of this diagnosis
2. Recovery time frame
3. Things to do to help
4. Things to avoid
5. What the therapist can do to help

Yellow Flags

As mentioned above, it is important to screen for “yellow flags”. These are anything that can contribute to an individual's pain from a psychological and social perspective. There are different ways to assess for yellow flags, including the following screening tools:

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

• More information on the OSPRO is available in this article: Development of a Yellow Flag Assessment Tool for Orthopaedic Physical Therapists: Results From the Optimal Screening for Prediction of Referral and Outcome (OSPRO) Cohort

2. Functional Pain Management Society’s Intake questionnaire

• Please see the video below for more information on using this questionnaire and click on the link for a copy of the questionnaire: questionnaire

3. Psychosocial Exam Components Cheat Sheet

• This Psychosocial Exam Components Cheat Sheet can also be helpful. Please see the video below for more information:

Body Chart

When conducting an assessment, a body chart is useful as it provides an objective record of the location, symptoms and behaviour of a patient's pain. It should be filled out by the clinician. On the body chart, make note of any asterisk signs.

An asterisk sign is also known as a comparable sign. It is something that you can reproduce/retest that often reflects the primary complaint. It can be functional or movement specific. It is used to measure if symptoms are improving or worsening.

Basic Process for Evaluation

• Establish as precise a diagnosis as possible
• Clear the spine for distal complaints
• Determine the patient’s irritability
  • Irritability can be assessed by establishing the level of activity required to aggravate symptoms, how severe symptoms are and how long it takes for the symptoms to subside.
  • This will determine the intensity of testing. We don't want to aggravate a patient's symptoms, but we want to push them to the limit of what they can achieve.
• Perform myotome testing
  • 5-10 seconds of rigorous myotome testing should be performed for each myotome
  • 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 the patient's spine
    • There is a concern about damage of the patient's spine
• Perform a sensation examination
  • This should be conducted if the patient presents with:
    • Paraesthesia and you are unsure if symptoms are in a dermatomal pattern or in a peripheral nerve field
  • Neuropathy to determine if the patient has protective sensation

• Perform a reflex examination
  • This should be conducted if the patient presents with:
    • Widespread pain (central neurological disorder suspected)
    • Decreased balance (central neurological disorder suspected)
  • 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:
    • A primary complaint of upper extremity issues and neck trauma
    • A complaint of their head feeling “unstable”
  • This patient may require upper cervical manual therapy
• Gait assessment
  • This should be conducted if the patient presents with:
    • Any lower quarter complaints
    • Any balance complaints
• Expose the skin of the area you are examining
  • Look for any bruising, redness, swelling, skin changes, or muscle atrophy
• Find objective measures that relate to the patient's primary complaint that you can retest - i.e. the asterisk sign
• Provide an intervention to improve the asterisk sign
• Provide a home exercise programme that improves the asterisk sign
• Discuss and agree with the patient on goals
• Educate the patient on:
  • Diagnosis
  • Prognosis
  • How likely it is that they will achieve their goals
  • How long it will take 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
• Rule out the worst scenario
  • Consider the worst case and rule out as much as possible or refer on

What do we do with Examination Findings?

When we perform tests, we are looking for impairments. However, we cannot simply treat impairments in isolation. We need to apply clinical reasoning and consider how the impairments are affecting the individual. Thus we need to consider:

• The pathology
• Available evidence to identify the best interventions and likely prognosis
• The impact these impairments have on an individual's life

Testing considerations:

• If a patient has pain during a test, we need to know if it is their familiar pain.
• If testing identifies an impairment, but doesn’t recreate the patient's familiar pain, it is important to consider if this is relevant.
• Not all impairments are created equal. It is important to grade how significant each impairment is in relation to a patient's pain and functional limitations.  
• We don’t need to treat all impairments we find, but we need to assess their relevance. If we treat an impairment, does it improve the patient's functional asterisk sign? It is important to remember dosage when making this assessment. Dosage should be sufficient to affect a change. If it is, and there is no change, it may be that the impairment is not relevant to this patient's pain. It is also essential to understand irritability.

What if we can’t recreate a patient's familiar pain?

If you cannot illicit the patient's familiar pain, you could opt to increase the rigour of the examination.

Case Situation: A patient presents with lumbar pain with a neurogenic referral. On examination, the mechanical spinal pain is reproducible, but the technique does not reproduce their neurogenic pain.

Decisions to make as the therapist:

• We could do tests that replicate the neurogenic symptoms, but that doesn’t tell us if the pain is 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 the 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 sign improved between sessions.

This scenario can be applied to many different cases and is also applicable for a patient presenting with a somatic referral. For example, you might hypothesise that pain has a spinal origin, but the only way to prove this during the assessment is to flare-up the patient's spine pain. Thus, we would need to wait until we can test more aggressively or to find out if the subjective functional asterisk sign improved.

Historically, clinicians sometimes performed tests to see if it made patients hurt without considering if they were relevant. We are now able to do a much better job of making sure that the pain created during testing is relevant. You will become a much better clinician if you can identify relevant impairments that aren’t painful.