The Art of the Patient Assessment Explained

A good friend and colleague of mine recently asked me how I balance being efficient while also being thorough in the patient assessment process. As I alluded to in my series “Biopsychosocial rehab: Mistakes I’ve made – Part 1 and Part 2”, this is no easy task. During an assessment you have to:

• Listen to the patient
• Read the patient
• Build rapport
• Rule out red flags and serious tissue pathology
• Map out a treatment plan
• Get some hands-on treatment in (for most cases)

Things can get interesting in a hurry when you mix the above with situations where there may be psychosocial factors, language barriers, multiple pain sites, multiple physical comorbidities, and other preconceived notions and expectations. So the question is – how does one balance being systematic and efficient while also being thorough? While there is no one answer to this question, I think it is important to establish two things: expectations and priorities.

Establishing expectations

This applies to both the clinician and the patient. It’s important for the clinician or reception services to communicate basic expectations such as:

• Location of the appointment (especially if you work in a business with multiple locations)
• Appointment length
• What an appointment consists of (roughly)
• Clothing and/or paperwork requirements
• Cost
• Any other special considerations (e.g. parking, accessibility)

Mike Studer mentions this at great length in his Masterclass on behavioural economics – establishing expectations goes a long way to setting the stage for an effective assessment. Two recent Physio Network Research Reviews also discussed patient expectations:

1. Ben Cormack’s Review highlighted important expectations of patients with musculoskeletal pain, including knowledge on what’s wrong, how long it will take to resolve, what they can do for themselves and what can you (the therapist) do to help them.
2. Sarah Haag’s Review outlined factors which make exercise more beneficial such as trust, confidence, motivation and connection.

With respect to the patient’s expectations, I simply like to ask “what are your expectations of me?” Or, “what are you hoping to get out of this appointment?”. Obviously there are certain expectations that are not achievable, for example – you do legally and ethically need to do an assessment in that first session, the patient can’t just come in and expect to be on the treatment table within the first few minutes (this is where an intro email/word from reception can be useful). Additionally, it is likely unrealistic for a patient to expect their issue can be fixed in that first session. That being said – make sure to look after more reasonable expectations such as:

• Getting some hands-on treatment in
• Specific treatment requests. Some may hate me, but is it really that big of a deal to do five minutes of ultrasound if it gets the patient to do everything else they need?
• Answering questions. I’ve had many patients with lots of questions during the first appointment. However, at least 9.5/10 of them are pretty okay with not having a lot of hands on treatment if they have a lot of questions.

If you’re not able to cover all of the patient’s questions or assess everything in that first session then it’s important to tell the patient right away. Also, make sure to write the assessments down in a “to-do list” and plan them out in your future reviews.

Establishing priorities

Priorities can be established through a general flow I’ve outlined below.

1- Ruling out red flags and serious tissue pathology

The biggest priority of a physiotherapy assessment is to rule out red flags (e.g. cancer, infection) and serious tissue pathology (e.g. fracture, dislocation, ACL rupture or lumbar radiculopathy requiring surgery). No amount of pain science education or therapeutic exercise is going to fix someone’s bone cancer. Nothing else really matters until you have ruled out red flags.

1- Patient goals

If we’re dealing with multiple goals and/or body parts, I ask what the patient’s priorities are to help inform my assessment structure. This can be helpful in the event of dealing with multi-site pain cases, as well as patients with busy lifestyles who may not be able to commit to rehabbing five areas at once. As a reminder from Ben Cormack’s Review – people want to know what’s going on and how long it’ll take. Make sure to hit those on the head first!

2- Determining what tests need to be done

Once you’ve ruled out red flags and serious tissue pathology then the value of special tests goes downhill. Research has really dispelled the value of special tests in musculoskeletal rehabilitation – although there is more value in test clusters (1,2). Ultimately you have to ask yourself – does this change things from a rehab or a medical perspective? For example:

• A Lachman’s or Anterior Drawer test of the knee would have great value in the event of an Anterior Cruciate Ligament (ACL) rupture with laxity and instability
• In contrast, a Clarke’s sign to diagnose patellofemoral pain is not really a great use of time. Does it really change your treatment if it’s positive or negative?

Special tests I use often include:

• Neurological scan (dermatomes, myotomes, reflexes, cord signs) in the event of suspected radiculopathy
• Ligament testing in event of suspected ligament sprain or rupture
• Position-based testing (e.g. Empty can test for shoulders) to help with education on what movements I would encourage more/less of

I believe it’s important to be sparing with special tests, as doing too many can lead to issues such as patient flare up, multiple positives convoluting your management plan, and reduced time for treatment. If there’s an assessment tool you want to use yet isn’t urgent you can leave it for another day. Examples of these can include questionnaires, more fancy strength tests (e.g. max repetition single-leg calf raises) and activity specific tolerance tests (e.g. six-minute walk test).

SIDE NOTE: While I am a fan of screening questionnaires, it seems as though if you listen to enough podcasts, we should be screening for everything ranging from psychosocial factors to diet and sleep. Don’t get me wrong, those aren’t bad ideas, however it can be very time consuming and overwhelming for both the patient and the clinician; you also run the risk of getting too far away from the concerns that the patient has actually come to see you for (keep in mind the four main points above mentioned from Ben Cormack’s Research Review!). Once red flags and serious pathologies are ruled out, some of these “icing on the cake” measures can be done later on. In the rare instances where I do use more detailed questionnaires, I often just send them home with the patient to do at their own pace.

Wrapping up

Obviously there is a lot of clinical judgement involved here, and there isn’t an exact formula for every assessment (even though we wish there were!). Nonetheless, it’s important to prioritise assessments based on clinical reasoning, as well as what’s important to the patient in front of you. I hope that this article has given you some guidance on the balancing act between being both efficient and thorough during your assessments. As always – thanks for reading!

If you’d like an easy way to keep up to date with the latest research then look no further than Physio Network’s Research Reviews. Check out summaries of all the latest research HERE.