4 Evaluation and Assessment

The means by which one seeks information on severity, irritability, nature, and stage of injury Evaluation Subjective elements Objective elements

History of the injury Subjective Evaluation Past medical history Special questions Additional information Pain profile

Observation and visual inspection Objective Evaluation Range of motion Accessory joint mobility Muscle performance Special tests Palpation Functional testing

comparable sign: a sign produced by active or passive movement or test that reproduces the patient’s symptom, such as pain or protective muscle spasm

Start when patient enters room. Observation and Visual Inspection Note gait, stance, posture, guarding, use of the injured segment. Note swelling, discoloration, scars.

Active range of motion Range of Motion Passive range of motion End-feel

Cannot be produced actively by patient but is necessary for full, normal motion of joint Accessory Joint Mobility Evaluated with joint mobilization techniques Look for stiffness, amplitude of available mobility, end-feel, pain Compare bilaterally

Evaluation of muscle strength and endurance Muscle Performance Manual isometric tests, isotonic evaluation, isokinetic machines

Are used to determine aggressiveness of treatment Special Tests Are specific to body segment and tissue

Sensory, motor, reflex testing Neurological Testing Signs and symptoms distal to acromion process in upper extremity and distal to gluteal fold in lower extremity

Performed after other tests Palpation Temperature, tone, edema, mobility of skin and subcutaneous tissue Crepitus, nodules, spasm, scar-tissue mobility, tissue consistency From superficial to deep Only as deep as necessary

Irritability and severity of injury dictate if and when tests are performed. Functional Testing Agility, coordination, proprioception are key. Evaluate for smoothness of movement, fullness of motion, quality of performance.

Assessment Conclusions based on results of evaluation Used to determine problems and goals When is it done? After initial evaluation Continually during program Prior to return to participation

Identifying Problems and Goals Problems Goals Goal for every problem No goal without problem General and specific Based on subjective and objective findings Form basis for setting goals Long term and short term

Includes plan of action to achieve goals Plan for Treatment Includes frequency, duration, components of treatment Changes as goals change

Necessary throughout treatment program to determine effectiveness of treatment Continual Assessment Before treatment, after treatment, throughout treatment Advances in program based on results

Done prior to return to sport participation Functional Assessment Determines readiness to return to full participation Must be individualized based on sport, position in sport, and level of competition

Record keeping is essential for judging the treatment’s effectiveness, for communicating with other care givers, as a reference in the event of reinjury, insurance claims, and as a legal document. Rehabilitation Records

S = Subjective SOAP Format O = Objective A = Assessment P = Plan

Initial evaluation record Types of Records Each treatment record Progress note Discharge summary Diploma