PHYSIOTHERAPY

ASSESSMENT

Dr. N. Wanjiru
SOAP
 Subjective

 Objective

 Assessment

 Plan
SUBJECTIVE ASSESSMENT
 Name:

 Age:

 Sex:

 Occupation:

 Address:

 OPD NO / IPD NO:

 CHIEF COMPLAINT:

 HISTORY

 Present history

o Date of onset of injury:

o Mechanism of injury

o Direct injury

o Indirect injury

o Bending / twisting injury

o Rotational injury
 Mode of onset:
◦ Sudden
◦ Gradual
◦ Insidious
 Periodic
 Duration: that help to determine the condition
◦ Acute: present since 7 to 10 days
◦ Sub acute: present since 10 davs to 7 weeks
◦ Chronic: present for longer than 7 weeks

 Condition:
◦ Improved
◦ Stationary
◦ Worsen
 Current treatment:

 Pain assessment
– Site:
– Side;
– Type: nerve pain, muscle pain etc.

 Different type of pain and related structure

■ TYPES OF PAIN
– Cramping, dull aching
– Muscle
– Dull aching
– Ligament, joint capsule
– Sharp shooting
– Nerve root
– Sharp bright, lightening
■ Nerve like
– Burning pressure like
■ Sympathetic nerve
– stinging, aching
 Frequency:
– Nature: constant / periodic / episodic

 Pain aggravating factor & pain relieving factor:

 Intensity:
– Intensity of pain can be assessed with the help of VAS
(visualanalogue scale) or numerical rating scale

 Numerical rating scale: PAIN SCORE 0-I0 NUMERICAL

Past medical history

 Relevant previous medical problem to present condition

 History of other disease & injuries

 Operation & hospitalization

 Medication Frequency:

 Nature: constant / periodic / episodic

 Pain aggravating factor & pain relieving factor

 Personal history
 Personal habits:

 Sleeping habits

 Tobacco: duration, frequency, amount

 Cigarette smoking: duration, frequency,

amount

 Alcohol: duration, frequency, amount

 Family history
 Similar problem in relatives
 Hereditary diseases
 Consanguinity
 Social history
 Social status:
 Educational status:

 Environmental history
– Environment of home
– Environment of work place
 FUNCTIONAL HISTORY

 Previous

 Current
 OBSERVATION
◦ Perform a general overview of patients
posture
◦ Observe walking at normal speed ,then
slow and fast speed
◦ The examiner must watch the lumbar
spine , pelvis ,hips , knees ,feet and ankle
during walking
◦ Patient should walk bare foot.

 Also examine the pt. Walking with and

without aids.
 TROPHYC CHANGES / SURGICAL SCAR

– Trophical or skin changes like texture, bruising , color

– presence of scar, wounds or pressuresores etc.

 Deformity
◦ Congenital anomalies - such as CTEV
◦ Acquired deformity - fixed flexion deformity,
knock knes, bow leg etc

 External appliances functional aids including

walking aids, catheters etc
Investigations
 X-ray

 MRI

 CT Scan

 Full haemogram

 ESR
Medication
Objective assessment

EXAMINATION:
 Vital signs

 Heart rate: 60 - 100 b/m

 Blood pressure: 120 / 70 mmhg

 Temperature : 36.5-37.5'c

 Respiratory rate : 12 -16 c/m

PALPATION:

■ Tenderness: A state in which pain is felt on the release of

pressure over a
part

– Grading tenderness when palpating

– Grade 1 - patient complains of pain

– Grade 2 - patient complains of pain and winces

– Grade 3 - patient winces and withdraws the joint

– Grade 4 - patient will not allow palpation of the joint

NEURO ASSESSMENT

 Level of Consciousness: (GCS, Coma recovery scale)

 Alert: awake and attentive to normal stimulation

 Lethargic: drowsy, may fall asleep if not stimulated

 Stupor: responds only to strong, noxious stimuli,

returns to unconscious state

 Coma: can not be aroused

 Memory:

 Communication:

 Cognition:

 Attention

 Perception:

 Special Senses: (Cranial Nerves)

 Sensation (Deep, Superficial & Cortical)

 Muscle tone (Muscle groups)

 Muscle power (muscle group)

 Reflexes

 Coordination: (Non-Equilibrium test & Equilibrium test)

 Balance

 Posture

 Function activities
 Assistive devices (fitting)

 Muscle Girth:

 Voluntary Control

 Range of Motion

 Limb Length
 Rt Lt
Muscles
SHOULDER
4 4
Flexor
4 4
Extensor
4 4
Abductors
4 4
Adductors
4 4
External rotators
4 4 MUSCLE POWER
Internal rotators
ELBOW
5 5
Flexor
5 5
Extensor
FOREARM
5 5
Pronator
5 5
Supinator
Wrist
5 4
Flexor
5 4
Extensor
5 4
Radial deviation
5 4
Ulnar deviation
HAND
5 4
Intrinsic
5 4
Extrinsic
 Rt Lt
Muscle
HIP
5 4
Flexor
5 4
Extensor
5 4
Abductor
5 4
Adductor
5 4
Internal rotator
5 4
External rotator
KNEE
5 4
Flexor
5 4
Extensor
ANKLE
5 4
Dorsiflexors
5 4
Planter flexors
5 4
Evertors
5 4
Invertors
5 4
Intrinsic
5 4
Extrinsic
TRUNK
4 4
Trunk flexors
4 4
Trunk extensors
4 4
Trunk side flexors
3 3
Trunk rotators
COORDINATION

 Non-Equilibrium test
 Finger to nose
 Finger opposition
 Mass grasp
 Pronation/ supination
 Rebound test
 Tapping (hand)
 Heel to knee
 Grading scale
– Grade 4: Normal performance is demonstrated

– Grade 3: Movement is accomplished only w/ slight difficulty

– Grade 2: Movement is accomplished w/ moderate difficulty

(movements are arrhythmic; exhibit unsteadiness, oscillations
are evident, extraneous movements are evident)

– Grade 1: Movement is accomplished with severe difficulty

(movements are arrhythmic; very unsteady, large oscillations,
large extraneous movements are evident)

– Grade 0: Client unable to accomplish task

 Equilibrium test
 Standing: normal posture
 Standing: normal posture with vision occluded
 Standing: feet together
 Standing: lateral trunk flexion
 Tandem walking
 Walk: sideways
 Walk: backwards
GAIT EXAMINATION:
Assess for:
 Weight shift and acceptance during;
 Left limb advancement,
 Limb clearance
 Single limb support
 Single limb advancement

■ Check the course

 ? trunk, hip, knee muscles & balance & coordination
PATHOLOGICAL GAIT

 Antalgic Gait
 Ataxic Gait
 Calcaneal Gait
 Circumdactory Gait
 Hand To Knee Gait
 High Stepping Gait
 Lordotic Gait
 Scissoring Gait
 Trendlenburd Gait
 Valgus Gait
 Waddling Gait
■ AMBULATORY STATUS:
– Note patient's mode of locomotion such as
on wheel chair, ambulatory with or without
assistive device, bedridden, etc.

■ Posture (Attitude of limbs) :

 Standing, sitting, lateral views
 Anterior, posterior and lateral view
 The posture should be taken from
maximum possible position

■ Deviations at diff region should be checked

BALANCE ASSESSMENT
■ Berg Balance Scale
■ ITEM DESCRIPTION SCORE
(0-4)
■
1. Sitting to standing 3
2. Standing unsupported 2
3. Sitting unsupported 4
4. Standing to sitting 4
5. Transfers
1
6. Standing with eyes closed 2
7. Standing with feet together 1
1. Reaching forward with outstretched arm 2
2. Retrieving object from floor 1
3. Turning to look behind 1
4. Turning 360 degrees 2
5. Placing alternate foot on stool 2
6. Standing with one foot in front 0
7. Standing on one foot 0

■ Total 25 (Walk with assistance, risk of fall)

DISABILITY ASSESSMENT
EXPANDED DISABILITY STATUS SCALE
 Scores: 6.0 (Intermittent or unilateral constant assistance (cane,
crutch or brace) required to walk 100 meters with or without
resting)