“If you’re not assessing, you’re just guessing.”
Physiotherapists always need some form of assessment in order to design an appropriate, individualized treatment program.
The assessment and re-assessment are critical elements in determining the correct physiotherapy treatment. They also determine whether the client requires further medical evaluation from a physician (e.g. for a non-musculoskeletal problem or for a musculoskeletal problem that requires immediate medical attention).
Why the assessment is so important
There are a number of reasons for performing an initial physiotherapy assessment, including:
At the end of the assessment, the following information should be identified:
- The client goals
- A problem list (pain, difficulty with activities, etc).
- A clinical diagnosis as well as possible differential diagnoses
- Contributing factors to the problem. This would include:
- internal factors
- motor control, mobility (including flexibility) , stability (including strength)
- external factors
- training regimen, footwear, equipment, surface, etc
Why is medical screening important?
Additionally, in some cases, your physiotherapist may be the first one to recognize signs and/or symptoms of a non-musculoskeletal problem. While a physiotherapist is not able to diagnose a non-musculoskeletal condition, they should recognize when a collection of signs and symptoms do not present as a musculoskeletal condition. It should not be taken for granted that all non-skeletal causes are excluded by the referring doctor.
Possible reasons why these non-musculoskeletal conditions may not have been picked up by another health care provider include:
- Medical specialization: Medical specialists may fail to recognize underlying systemic disease.
- Disease progression: Early signs and symptoms are difficult to recognize, or symptoms may not be present at the time of medical examination.
- A client may not report symptoms or concerns to the physician because of forgetfulness, fear, or embarrassment.
The process of screening for medical disease includes the following steps:
- Reviewing the client history
- Pain patterns and pain types
- Associated signs and symptoms of systemic diseases
- Systems review
Why is accuracy IMPORTANT?
A lack of accuracy may lead to inappropriate treatment. Inappropriate physiotherapy treatment is usually ineffective, with no change in pain and/or functional levels. In some cases, inappropriate treatment may result in aggravation (worsening) of the condition.
A lack of accuracy may also result in failure to recognize conditions that could benefit from other interventions, such as surgery to correct a torn anterior cruciate ligament or a torn muscle/tendon. In some cases, it is essential to recognize these conditions as early as possible to ensure the best possible outcome (e.g. in the case of a ruptured Achilles tendon).
We want to be as accurate as we can in order to create an environment of success for our clients.
However, we also have to realize that there are limitations in how accurately we can identify the tissue/structure that is causing the pain. There are some clinical tests and/or clusters of tests that can increase or decrease the probability of identifying a particular tissue (muscle, joint, ligament) as the pain generating structure. There are very few tests that have a high degree of accuracy in identifying the tissue source of pain.
Here is an example to illustrate what I mean. Current medical research looking at low back pain has concluded that the tissue source of low back pain cannot be specified in the majority of patients. Diagnostic tests (including MRI) are also much less accurate than we would like them to be. The usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear (Hancock et al, 2007). This research also concluded that there is no current literature indicating that knowledge of the tissue source of low back pain leads to improved outcomes.
As a result of some of the limitations of both clinical and diagnostic tests, it is important that clinicians focus more on what we can do to help with the problem, since we can’t always be accurate in identifying the problem.
This DOES NOT mean that we should stop trying to accurately identify the problem, rather, it means that we should be more aware of instances where source identification is unlikely, and/or situations where source identification is not necessary for treatment to begin.
Evaluation of progress/response to treatment will guide further decisions regarding future diagnostic testing necessity.
Hancock MJ, Maher CG, Latimer J, et al. Systematic review of tests to identify the disc, SIJ or facet joint as the source of low back pain. Eur Spine J. 2007 Oct;16(10):1539-50.
Identifying the causes of the problem and/or pain is usually done with a functional assessment approach (as opposed to an anatomical/structural assessment approach in the accuracy phase of the assessment).
Investigating and indentifying the causes of the problem is probably the most significant aspect of the assessment that separates one clinician from another. It may not be difficult to identify the area of the pain/complaint. For example, the client may present with anterior (front) knee pain, and a referring diagnosis of patellofemoral pain syndrome. The key to improving the condition is to determine the factors which led to the injury and/or complaint.As mentioned above, this step is critical in determining the appropriate treatment plan. Some clinicians will spend too much time and energy debating which specific anatomical structure is responsible for the pain. This aspect of the assessment should focus on identifying dysfunctions in the movement patterns of the individual and examining how the movement problem is associated with their pain pattern. This is different than examining the isolated movement of one particular joint. Movement problems/dysfunctions can be classified according to deviations in their movement behavior.
There are internal and external factors that influence movement problems. External factors may include a running surface, equipment (including footwear), temperature, ergonomics, physical activities, occupational factors, posture, and training factors (frequency, intensity, and duration). Internal factors include tissue integrity/quality (age, previous injury, health conditions), overall mobility, stability, and motor control of the individual (including joint range of motion, flexibility, stability, strength, proprioception, agility, power), and the training level and cardiovascular fitness level of the individual.
Generally, the more complex and chronic the condition, the more variable the assessment will be among different health care practitioners.
My assessments are unique because of my extensive knowledge and clinical experience. While there are many similarities among the core competencies learned while completing a physical therapy degree, the knowledge pursued by physiotherapists once they graduate is dramatically different. This knowledge is gained through a variety of avenues, including post-graduate courses, conferences, seminars, continued reading of recent, relevant text books and peer-reviewed journal articles, webinars or teleconferences, etc. Particular expertise in specific sport areas will also vary from one practitioner to another. For example, if your pain is related to playing hockey, golf, or baseball, it would be advantageous if your health care practitioner understands the specific movements and demands of that activity.
Client: A baseball pitcher with a sore shoulder.
Medical screening is always important as there are some non-musculoskeletal causes of shoulder pain.
Accuracy is important to identify probable and potential tissue damage. Common tissues affected in the shoulder include: rotator cuff (full tear, partial tear, tendinopathy, impingement); labrum (SLAP lesions); shoulder joint capsule/ligaments (sprain, impingement); long head of the biceps (tendinopathy, full or partial tear, impingement); brachial plexus or other peripheral nerves.
Determining the contributing factors to a sore shoulder in a baseball pitcher (often the result of rotator cuff tendinopathy or tear) is essential to successful management of these conditions. This is an area of tremendous variability in the assessment and treatment provided by the health care practitioner.
Possible contributing factors include internal and external factors.
External factors include:
- Overuse (related to throwing frequency, position (P, C, 1B, 2B, SS, 3B, OF), velocity, pitch count, etc)
Internal factors include:
- Rotator cuff weakness
- Poor scapular stability
- Poor/asymmetrical glenohumeral range of motion
- Poor thoracic spine mobility
- Soft tissue/flexibility limitations (pec minor, lats, external rotators, rhomboids)
- Poor exercise technique (further stress on the shoulder; eg. bench press, overhead press)
- Poor throwing mechanics (talk to pitching coach)
- Poor cervical spine posture/function (eg. FHP)
- Hip/ankle/lower extremity imbalances/ weakness/loss of mobility (eg. contralateral ankle or hip)
- Inappropriate structural balance in strength training program (eg. too many chest exercises, not enough back exercises)
As you can see from the above list, there are a many areas that may need to be assessed to analyze contributing factors to shoulder problems in baseball players.
In many cases, if throwers look after early symptoms with appropriate assessment and treatment, many problems can be addressed with as few as 4-5 extra drills in each shoulder rehab program plus a brief sit-down conversation with each client/patient on exercise program modifications. It really can be that simple! Unfortunately, it rarely happens - and that’s why problems become chronic and more complicated.
Similar group of health care providers:
(orthopaedic surgeons vs ER physicians vs family physicians vs physiotherapists vs chiropractors vs athletic therapists vs massage therapists, etc)
Different health care providers:
(physiotherapist A vs physiotherapist B vs physiotherapist C, etc)
The goal is to determine all of the causes that are related to the pain and/or problem.
The goal is to determine the anatomical structure that is causing pain, with the highest degree of accuracy.