4

Evaluation and Assessment

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

EvaluationEvaluation

Subjective elements

Objective elements

History of the injury

Subjective EvaluationSubjective Evaluation

Past medical history

Special questions

Additional information

Pain profile

Observation and visual inspection

Objective EvaluationObjective 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 Observation and Visual Inspectionand Visual Inspection

Note gait, stance, posture, guarding, use of the injured segment.

Note swelling, discoloration, scars.

Active range of motion

Range of MotionRange 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 MobilityAccessory 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 PerformanceMuscle Performance

Manual isometric tests, isotonic evaluation, isokinetic machines

Are used to determine aggressiveness of treatment

Special TestsSpecial Tests

Are specific to body segment and tissue

Sensory, motor, reflex testing

Neurological TestingNeurological Testing

Signs and symptoms distal to acromion process in upper extremity and distal to gluteal fold in lower extremity

Performed after other tests

PalpationPalpation

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 TestingFunctional Testing

Agility, coordination, proprioception are key.

Evaluate for smoothness of movement, fullness of motion, quality of performance.

AssessmentAssessment

Conclusions based on results of evaluation

Used to determine problems and goals

When is it done?

After initial evaluationContinually during programPrior to return to participation

Identifying Problems Identifying Problems and Goalsand Goals

Problems

Goals

Goal for every problemNo goal without problemGeneral and specific

Based on subjective and objective findingsForm basis for setting goals

Long term and short term

Includes plan of action to achieve goals

Plan for TreatmentPlan for Treatment

Includes frequency, duration, components of treatment

Changes as goals change

Necessary throughout treatment program to determine effectiveness of treatment

Continual AssessmentContinual Assessment

Before treatment, after treatment, throughout treatment

Advances in program based on results

Done prior to return to sport participation

Functional AssessmentFunctional 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 RecordsRehabilitation Records

S = Subjective

SOAP FormatSOAP Format

O = Objective

A = Assessment

P = Plan

Initial evaluation record

Types of RecordsTypes of Records

Each treatment record

Progress note

Discharge summary

Diploma