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! (1/11/2022)

Introduction

These standards are for each patient that comes into Rainey Pain & Performance with a pain or orthopaedic complaint. (Many items will be pertinent for other types of patients as well.) If followed, they will provide the lowest chance possible for a poor outcome. Each area has minimal explanation in order to keep this a concise document.

Screen patient for

• Potential referral out (Finucane 2020)
• Significant psychological and social recovery limiting factors (O’Sullivan 2018)
• What they expect from their experience

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

1. Who is the patient?
2. What is the primary goal the patient would like to achieve?
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 following are questions the patient should be able to answer after the initial examination.

1. What is wrong with me?
2. How long will it take for me to get better?
3. What can I (the patient) do for it?
4. Is there anything I (the patient) shouldn’t do?
5. What can you (the physical therapist/healthcare professional) do for it?

Questions by Louis Gifford, Aches and Pains

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 in the Optimal Screening for Prediction of Referral and Outcome (OSPRO) tool. OSPRO Yellow Flag (OSPRO-YF) Assessment Tool Scoring Portal

For more information, please click on the article below:

Lentz TA, Beneciuk JM, Bialosky JE, Zeppieri Jr G, Dai Y, Wu SS, George SZ. Development of a yellow flag assessment tool for orthopaedic physical therapists: results from the optimal screening for prediction of referral and outcome (OSPRO) cohort. journal of orthopaedic & sports physical therapy. 2016 May;46(5):327-43.

2. Functional Pain Management Society’s Intake questionnaire

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

Please click on the link below for access to this tool

Intake questionnaire

Video on using the Intake questionnaire

Psychosocial Exam Components Cheat Sheet: https://docs.google.com/document/d/1iwXOiuL4r1ggmro4B_GW2i2yfYNBUd-4q7qFkOHRbMg/edit Psychosocial Exam Components Cheat Sheet

Video on using the Cheat Sheet

Body Chart

This is the body chart words.....

Asterix Sign

Something that you can reproduce/retest. Can be functional or movement specific

Establish as precise of a diagnosis as possible

Clear the spine for distal complaints

Determine patient’s irritability (We need to know how intense to test the patient. Don’t do too little or too much!)

Perform aggressive myotome testing, including myotome fatigue testing, if the patient

• has a peripheral complaint without a clear MOI
• is concerned about imaging findings or potential findings in their spine
• is concerned about damage of their spine

Perform a sensation exam if the patient

• Has paresthesias in a pattern that is not obviously dermatomal or in a peripheral nerve field (we need to determine where the symptoms are)
• Has neuropathy and we need to determine if they have protective sensation

Perform a reflex exam if the patient presents with (Kearns 2022, Heffetz 2007)

• widespread pain
• decreased balance

Reflexes include (tendon reflexes, Hoffman’s and ankle clonus)

Ankle clonus is the only one indicated if there is central thoracic pain.

Upper cervical ligament testing should be performed on patients who (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
• 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.