“I was so disappointed today. I went to see the physiotherapist and he spent a third of the session talking to me, a third of it looking at me do different movements, and only spent 5 minutes on actual treatment.” We often hear this type of complaint when the client doesn’t properly understand how physiotherapy works. Some expect us to completely understand the issues when we physically assess their body somewhat like a mechanical engineer examining a car, and that we’d know what the issue is from how the body deviates from normal.
Musculoskeletal (MSK) issues happen below the surface, not at the superficial skin level, so unlike a car where we can easily “pop the bonnet”, MSK issues require much detective work to figure out where the issue lies. And although MSK issues often stem from mechanical issues, they are far more complex than just being mechanical as humans have other organ systems working, and above that, they have a mind with psychosocial factors playing into how they function. So, when someone sees me for the first time, unless they request for just treatment (some do if they already understand what their issue is), I don’t dive straight into the treatment. I do a thorough examination to understand the patient’s issue and how best to treat them. Let me guide you through what this entails.
Subjective and Objective Assessment
In medical care, we divide assessment into two parts: subjective and objective assessment.
1. Subjective assessment looks into all that is subjective in the case study. This would be the subject’s personal experience, feelings, and opinions. For the clinician to understand this, it involves talking with the client and listening to them to understand.
2. Objective assessment looks into all objective findings. Opposed to subjectivity which is opinionated, this is looking into the actual facts. What are factual things in our assessment? Things we as clinicians can observe, that we can feel, that we can accurately record down.
Example of Physiotherapy Clinical Assessment
To further understand subjective and objective assessment, let’s put on our clinical detective hats and look at an example I might face. A client limps down the hallway as she guides me to her living room. I notice immediately that she is reducing her weight-bear through the left leg and she has taping across that left knee in an unusual manner. We take a seat in her living room and I ask her what her main issue is. She replies by telling me about how she twisted her knee playing a game of rugby. I press into the detective work, asking her to grade her pain out of 10. “1 out of 10 when I’m at rest, but 4 out of 10 when I’m walking flat ground”, she replies. Let’s stop here and ask ourselves what is subjective and what is objective here.
I’ve created a table here with a possible way of dividing the two:
So why has it been divided like this? Are the subjective findings truly based on subjectivity and the objective findings based on objectivity? We as the clinician cannot fully say with objective certainty whether something is true from the client’s perspective as that is something they experienced in their own shoes. Could they have not remembered correctly what happened, could they be exaggerating or underplaying their pain levels? It is impossible to tell, so anything the client tells us and, in this example, pain levels, how they injured themselves, is considered subjective. You can see then that the objective findings are all based on what we as clinicians see and detect. Any third person entering into that room would be able to gather the exact same information, and so therefore are all objective findings.
Subjective Findings Are Just as Important
It may be tempting then for one to think that subjective findings don’t matter as much as they can have a falsity about it due to the subjective manner. This is not true for three main reasons.
1. Subjective findings give light to history
2. Subjective findings give light to behavior of symptoms
*Both 1 and 2 can’t be easily known, or ever known, from objective findings.
3. It is not feasible to do all objective testing such as imaging, blood testing, nerve conduction testing
1. Importance of History
The history of the condition gives us understanding on what structures may be impacted. If we know the mechanism of injury, we can more easily figure out what kind of injury it is. For example, the client twisted their knee a specific manner, we know what structures we would have to focus our attention on. Or say the client has severe knee pain but never had any trauma or overtraining which could explain the pain, then it would be very important to do further testing/referral to explain the severe pain.
2. Importance of Behavior of Symptoms
Behavior of symptoms allows us to understand how to properly manage the problem. Take for example someone gets pain in their thumb but we never ask to find out what tasks might be involved in causing this pain. Perhaps the thumb pain will never resolve as our treatment will reduce the pain short term but their lifestyle uses the thumb in a particular manner which again brings on the issue. This area of understanding becomes more complex and important with chronic issues, and where there are multiple symptoms affecting multiple areas.
3. Avoiding Costly Investigations
It can be very costly to do imaging such as MRIs, CT scans, X-rays; along with all other investigations like blood testing, nerve conduction testing. Not only costly in monetary expense but also time required on waiting lists for the specialized testing and time for the examiner such as a radiologist to examine the findings and produce a final report. Therefore, clinical assessment and processing is needed to build a reasonable case for further investigation. Clinical assessment allows the client to narrow down which further investigation to take, if required – for example a nerve conduction test may be reasonable if clinically we found weakness/sensory deficit in a specific nerve distribution. As mentioned, time is costly and so even if an investigation is required, the clinician can provide treatment along with management advice for the patient while they wait for the conclusive findings of the final report.
Objective Findings Provide Objectivity
Objective assessment compliments the subjective assessment. Rarely do we ever do a blanket assessment for clients, assessing every and all joints. It is based on the knowledge we receive in the subjective assessment that we have a few hypotheses, and working with this, we use our objective assessment to further narrow this down obtaining a more confident final diagnosis. This objective assessment also allows us to determine the severity of the issue and gives us a baseline to compare against. For example, you could have someone with a sprained ankle and the objective assessment will allow you to determine what extent the ankle range of motion is affected or the extent the calf muscle has been depleted. Once you have recorded a baseline objective assessment, you always return to this to evaluate how it changes with treatment, activity and time.
Subjectivity within Objective Assessment
There is a subjectivity that comes from the clinical detective in their objective examination. We call this inter-rater reliability. Let’s come back to the clinical example mentioned above: under the objective examination we have recorded there “limping with reduced weight-bearing left leg”. Could it be possible that if another clinician had been there, they’d see it differently? Perhaps they’d seen them prior to the injury and know it’s a long-standing limp so don’t record it as relevant. Maybe they think the limp is minimal so it isn’t worth noting, or it could be that the client hops and so it is recorded as “hopping with non-weight-bear left leg”. Even though there is this subjectivity on the part of the clinician, it is still considered objective in this assessment as it is someone other than the client’s own opinion and feelings on it. This clinician subjectivity is further reduced as the clinician becomes more specific and precise with their recording – the limping could be qualitatively described in more detail with the movement of the joints being recorded, the client’s facial expressions; or perhaps quantitative measures can be recorded, using a scale to measure the weight the client puts through her leg so that there is a number recorded.
Objective Recording Must be Objective
What about this other objective finding “unusual taping across left knee”? Is that objective? What we see here is the clinician inserting their own assessment into the objective observational finding. The “unusual” description is not considered objective, as it is only unusual for this clinician - perhaps another clinician would find this completely normal. What can be written as objective is “taping across left knee”, but as this is quite vague, it should have a qualitative description – what type of tape, what part of the knee is it wrapped around, how taut or loose is the taping?
Never Too Much Assessment
Better More Assessment than More Treatment
Robust reasoning tells us it is better to spend one session on a lengthier assessment with little treatment than it is to spend three sessions on lengthy treatment with poor assessment, only to find later that something was not picked up earlier on the treatment. It would be equivalent to getting in your car to drive, only to figure out hours into the journey that the destination is opposite where you are traveling. This is not to say that there is no place for trial therapy as sometimes that must happen even after all appropriate investigations have occurred, however this is only last resort and for specific cases of chronic pain conditions.
Assessment Within Treatment
Hands-on therapy is central to my practice in physiotherapy. Although there are many new gadgets out there, some of which I do believe there is a time and place for, hands-on treatment is essential as so much information is gathered through the sensory input of our hands while we treat. We can feel the specific way the tissues feel as we massage through soft tissue, we can feel the type of resistance as we mobilize joints or stretch muscles, we can take note of how a client reacts for any hands-on treatment, and with all that input we can make swift and sound judgements on the treatment. Even though another area which I largely specialize in is western acupuncture, unless if it is specifically requested by the client or their condition would benefit from it over hands-on treatment, I will prioritize hands-on treatment at least for my first session for the reason that I can gather more information with this.
Subjective Assessment within Treatment
It is vital to receive feedback on the pain levels or any other symptoms (such as numbness, pins and needles, heaviness, dizziness) during treatment itself. I’ve had clients just let me continue through treatment while in pain, only to tell me at the end that it was very painful. Sometimes there is a feeling of repetition on the therapist’s part, having to constantly ask how the client is feeling every few minutes. Unless the client is of the understanding that any change of symptoms must be relayed back to the therapist, this repetition must continue to happen – much better to bother the client and provide excellent treatment than to be polite and exacerbate their condition. Anyhow, usually if the client is encouraged from the outset to be expressive of their symptoms, they will immediately update the therapist and won’t find it a bother to hear the therapist ask for the feedback.
Assessment After Treatment
As if it is not enough to assess prior to treatment, and assess during treatment; it’s important also to assess after treatment. The reason is because it is a more comprehensive assessment than the assessment during treatment. The assessment during treatment occurs briefly with observing a single movement, feedback received while touching, or a short question that is asked. Only enough information is received back to ensure the treatment isn’t exacerbating and that the treatment is effective. The more thorough assessment performed at the end includes reassessing certain movements assessed at the beginning to compare how it has changed, and includes a deeper conversation with the client to understand how/if their symptoms have changed. This ensures the treatment falls within expectations of how the treatment should have acted on the client, and if not, then the additional information provides insight into how to further manage the client.
Knowing now the importance of assessment within physiotherapy sessions and how it conclusively benefits the client the most, next time you are in a session and there is much time spent in question asking or in assessment of movement, posture and structure, have an open mind as to what the physiotherapist is looking for and if in doubt, ask questions to understand more about what the physiotherapist is getting at. Obviously here at Abbey Mobile Physio we value accurate assessment, hence this blog post, however we also understand that clients often don’t understand what we are getting at. We endeavor to explain ourselves as clearly as possible and perform assessments as subtle and quickly as able, however as there is much depth in MSK assessment, we will have further blog posts going into more detail about this.
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