Physiotherapy: Principles of Assessment

Chapter 5: Principles of Assessment

• Assessment is a cornerstone to physiotherapy
• Encompasses observation, judgement, and reflection
• The physio should explore with the individual to see how treatment goals are met
• Treatment should be adjusted to the patient
• Assessment and treatment cannot be divided

Analytical Assessment

• Goes a stage further than assessment
• Includes analysis of the patient's disorder, treatment, and interactions

Assessment

• Includes all procedures to monitor the therapeutic process throughout encounters
• Procedures do not stop after first examination
• Ongoing and analytical

Assessment During Treatment

• Determines if treatment objectives are being achieved in clinical reasoning

Final Analytical Assessment

• Undertaken towards the end of the treatment to reflect on the therapeutic process and outcomes

Initial Assessment

• Takes place in first session(s)
• Includes subjective and physical examinations
• Determines causes and factors to the movement disorder

Progressive Assessment

• Uses both retrospective and prospective data
• Determines the overall effects of the treatment

Retrospective Assessment

• Looks back at the person's history, and how they thought and felt
• Focuses on the prior level of function

Prospective Assessment

• Looks forward to see how the therapist could help the patient improve

Communication

• Continuous assessment requires some level of collaboration between parties
• Precise wording is critical, both with language and non-verbal
• Communication may encourage that the patient sees the issue in a different way

Psychosocial Assessment

• Integral part of the overall physiotherapy process
• Done through attentive listening, careful observation and deliberate questioning

Balance in Physiotherapy

• More experienced physiotherapists are more capable of interacting

Therapist-Centeredness

• Qualitative research says therapists may let their procedures prevail in the first session

Patient-Centeredness

• Empathy is shown more in later appointments
• Personal experiences happen more in second treatment sessions

Ethical Practice

• No therapeutic touch without examination
• Professional attitude is critical, must continuously assess findings
• Practitioners must evaluate treatment effects

Improvisation

• A core component to assessment, cannot be rigid to the approach

Improvisation with Skills

• Beginners can feel overwhelmed with all that is needed
• Experience is essential in applying intuition

Algorithm for First Session(s)

• Welcoming and information phase
• Subjective examination
• Plan and summarise for exam
• Physical exam with first treatment and reassessment
• Summarise first session
  • Reflect and Summarizing
  • Hypotheses
  • Planning next session

Purpose of Assessments

• Serves several purposes:
  • Diagnosis
  • Definition of Objectives
  • Determination of Intervention
  • Monitoring the effects of interventions

Assessment at Initial Examination

• Sort out complex data about the patient and shape a treatment plan

Data Includes

• Biomedical
• Psychological
• Social
• Cultural

Objectives of First Session(s) Search for Data Including

• Causes and contributing factors
• Treatment goals and suitable interventions
• Active integration of the patient in the treatment process
• Any precautions and contraindications

Biomedical Model

• When considering the causes of a problem, seeking information on pathobiological processes

Neurophysiological Model

• Used in assessments of pain during movement, acknowledges pain may exist due to processes in neuronal networks

Treatment

• Goals should be defined in terms impairments/functions, activity and participation
• Emotional factors should also be defined

Factors (aka "yellow flags") To Ongoing Disability Due to Pain:

• Emotional
• Cognitive
• Aspects of Belief

First Session Aims

• Information gathering
• Developing relationship

Early Intervention Aims

• To gain patient trust and belief in therapist

Contraindications

• Assessment may reveal indications that preclude treatment

Red Flags

• Risk factors for serious disease that need referral to other clinicians, including:
  • Cauda equina
  • Significant trauma
  • Unexplained weight loss
  • History of cancer
  • Fever
  • IV drug use
  • Steroid use
  • Patient age > 50 with first episode of pain

More Red Flags

• Severe, unremitting nighttime pain
• Marked morning stiffness
• ESR > 25
• Vertebral collapse or bone destruction

Precautions - What to Screen for

• The following body systems can reveal if treatments are contraindicated:
  • Cardiovascular
  • Pulmonary
  • Gastrointestinal
  • Urogenital
  • Endocrine
  • Nervous
  • Musculoskeletal
  • Rheumatic
  • Psychiatric
  • Skin

Considerations

• In physical examination, be mindful of:
  • Irritability
  • Severity
  • Stage and stability
  • General health

Pre-Intervention Questions

• Always ask:
  • What do I want to happen with the session?
  • What do I want to avoid?

Treatment

• Be thorough to ensure no adverse effects, and that progress has been made

During Treatment Steps Includes

• Monitor signs and nerve conduction
• Assess for pain with movement
• Watch for inflammation

End of Treatment Goal

• Assess cognitive information to ensure the patient is aware of next steps and education

End of a Session

• It often indicates if the patients symptoms are better or worse

Reassessment During Each Treatment Session Should Occur...

• During initial phase and exam after tests of movement
• After that and at start of a session to reflect on reactions to session before
• Immediately after interventions in tx
• At the end of the treatment session

Reassessment Aims includes

• Compare treatment results
• Aid differntial diagnosis
• Enable therapist to reflect on the processes

For Reassessment to be useful therapist need to be aware of

• Clinical presentation of symptoms
• Signs may change as a result of the interventions or not
• Make a proper adjustments

Communication Quality During Procedure Should

• Include education with the patient to observe
• Make a choice with the words used
• Avoid asking directly, allow the patient to reflect on their feelings
• Find the right word to engage and inform about the session

Patient's Statements and Therapist's Reassessments

• If the patient states a negative about pain, determine if the patients overall sensation of wellbeing has been modified by it
• Ensure the patient does not associate the symptoms with the process

Essential Step

• It is essential that a physiotherapist asks the patient to describe the pain, then tell them how it is affecting their ability to actually move

Metaphors

• Used for many, to encourage more patient-friendly dialogue

Treatment Team

• Care is a shared responsibility
• If additional care is required from another practitioner, it should be arranged

Conclusion

• Therapy is to help reduce pain and increase function
• It has to be clear the interventions used