The Subjective Examination

The subjective examination is an important component of the patient assessment process. It lays the foundation for clinical reasoning, which is essential for developing an accurate diagnosis and an effective plan of care.

Conducting an effective patient interview requires skill and practice, particularly in knowing where, when, and how to begin. A good starting point is using open-ended questions with a funnel-down approach, which allows the clinician to guide the conversation and collect comprehensive information efficiently.

Key areas to cover during the subjective examination include:

• Chief Complaints: Understanding the primary reason(s) the patient is seeking therapy.
• Previous Level of Function: Documenting the patient’s baseline function before the onset of their current condition.
• Mechanism of Injury: Identifying how the injury or condition occurred, which can provide insights into potential contributing factors.
• Behavior of Symptoms – SINSS Model: This acronym stands for Severity, Irritability, Nature, Stage, and Stability. It provides a structured framework for understanding the patient’s condition, guiding the evaluation process, and informing treatment decisions. Utilizing the SINSS model can help clinicians paint a detailed picture of the patient’s condition, allowing for a more tailored approach to treatment planning.
• Medical and Surgical History: Reviewing past medical conditions or surgeries that may influence the patient’s current presentation.
• Employment and Work History: Gaining insight into the patient’s daily activities and potential occupational hazards or demands.
• Psychosocial Factors: Incorporating an assessment of psychosocial factors, such as fear-avoidance beliefs, catastrophizing, and depression, can provide a more holistic understanding of the patient’s condition and guide treatment planning.

The Objective Examination 

After gathering comprehensive subjective data, the next step involves the objective examination, where the clinician uses various physical assessment techniques to gather quantifiable data. This part of the evaluation focuses on identifying physical deficits and impairments related to the patient’s primary complaint.

Key components of the objective examination include:

• Screening of Neighboring Joints and Systems: Assessing areas adjacent to the primary site of complaint to rule out referred pain or secondary dysfunctions.
• Active and Passive Range of Motion (ROM) Testing: Measuring the movement capabilities of the affected joints, both when the patient moves them actively and when the clinician moves them passively.
• Muscle Length Testing: Determining the flexibility and length of muscles that might be contributing to the patient’s condition.
• Manual Muscle Testing (MMT): Evaluating the strength of specific muscle groups to identify weaknesses or imbalances.
• Neurodynamic Testing: Assessing nerve mobility and detecting neural tension or irritation.
• Palpation and Joint Accessory Motion Testing: Using hands-on techniques to evaluate tissue texture, tenderness, and joint integrity.
• Standardized Outcome Measures: Utilizing standardized tests to assess functional capacity and monitor progress over time.
• Special Clinical Tests: Performing specific clinical tests designed to confirm or rule out suspected diagnoses. These should be used selectively and only after other data have been collected, as over-reliance on special tests can lead to misdiagnosis. These special tests are typically performed later in the assessment process to confirm hypotheses generated from the initial findings. Clinicians should prioritize their clinical reasoning skills and use special tests judiciously to support, not replace, the diagnostic process.

Diagnosis

The next step involves integrating both subjective and objective data to formulate a comprehensive understanding of the patient’s needs for treatment through a formal diagnosis.

In some cases, the diagnosis might be provided by a referring physician; however, the medical diagnosis on a prescription may not always align perfectly with the functional deficits that need addressing through physical therapy. For patients accessing therapy through direct access, there may be no initial diagnosis. Regardless, the focus should be on the treatment diagnosis, which reflects the specific impairments or functional limitations that the clinician intends to address.

Prognosis

A thorough assessment should also include a well-defined prognosis, which goes beyond simply labeling the outlook as excellent, good, fair, or poor.

Providing a rationale for the assigned prognosis is critical, and should be based on factors such as:

• Patient Motivation: The individual’s willingness and ability to engage in the therapeutic process.
• Comorbidities and Past Medical History: Existing health conditions that may affect recovery.
• Acuity of Injury or Primary Complaint: The stage and severity of the patient’s current condition.
• Nature of the Dysfunction or Related Disease Processes: Understanding the underlying pathology to predict recovery timelines and potential challenges.

Goals

Setting specific, measurable, attainable, realistic, and time-bound (SMART) goals is a vital component of the assessment process. These goals should be collaboratively developed with the patient to ensure they are aligned with their personal therapy journey and realistic within the context of their daily life.

Effective goal-setting involves:

• Specific: Clearly defining what is to be achieved.
• Measurable: Establishing criteria to track progress.
• Achievable: Ensuring goals are feasible within the patient’s abilities and timeframe.
• Realistic: Setting goals that are achievable and meaningful to the patient.
• Time-Bound: Providing clear deadlines to foster accountability and motivation.

Plan of Care

The plan of care is an important part of the assessment that outlines how the treatment will address the patient’s functional impairments. The plan of care should detail the patient education strategies, the proposed frequency, intensity, type, and duration of treatment and outline the specific interventions planned to achieve the established goals.

Ultimately, the plan of care translates the assessment findings into a structured plan that guides the therapeutic process, ensuring that interventions are targeted, evidence-based, and patient-centered.

Reference:

O’Sullivan, S. B., Schmitz, T. J., & Fulk, G. D. (2019). Physical Rehabilitation (7th ed.). F.A. Davis Company.

Cameron, M. H., & Monroe, L. G. (2021). Physical Rehabilitation: Evidence-Based Examination, Evaluation, and Intervention (1st ed.). McGraw Hill.

McCulloch, K. L., Buxton, E., Hackney, J., & Lowers, S. (2010). The Use of Standardized Outcome Measures in Physical Therapy in the United States and Canada. Physiotherapy Theory and Practice, 26(8), 490-504.