The first physical therapy appointment is a comprehensive evaluation designed to establish a precise understanding of the patient’s functional limitations and the underlying cause of their impairment. This session is primarily diagnostic, serving as a dialogue to gather the necessary information to create a strategic treatment approach. The goal is to identify the specific biomechanical or neurological dysfunction driving the problem, moving beyond simply treating symptoms. This initial meeting acts as the foundational blueprint for the entire course of therapy.
Preparing for the Evaluation
Before arriving, patients should gather logistical and medical items to streamline the administrative process. This includes photo identification, the current health insurance card, and any required physician referral or prescription. Patients should also prepare a comprehensive list of all current medications (prescription and over-the-counter), supplements, a summary of past surgeries, existing chronic medical conditions, and any previous imaging results, such as X-rays or MRIs.
Physical preparation is equally important, as the therapist will need to observe movement and access the affected body area. Patients should wear loose-fitting, comfortable clothing that allows for a full range of motion, similar to workout attire. For instance, shorts are advisable for a knee issue, while a tank top or loose t-shirt is appropriate for shoulder or neck problems.
The Subjective Examination (Patient History and Interview)
The subjective examination is the initial verbal interaction where the physical therapist obtains the patient’s detailed medical narrative and forms a working hypothesis about the condition. The therapist begins by asking about the “chief complaint,” focusing on the onset of symptoms (traumatic or insidious) and the mechanism of injury.
The patient characterizes their pain using a quantifiable measure, such as a 0-to-10 scale, and describes the nature of the discomfort (e.g., sharp, dull, aching). The therapist explores aggravating and alleviating factors, identifying specific positions or activities that worsen or lessen the symptoms. The discussion also covers past medical history, lifestyle factors like work and hobbies, and specific functional limitations, such as difficulty lifting or climbing stairs.
The Objective Physical Assessment
Following the detailed verbal history, the therapist conducts the objective physical assessment to confirm the initial hypothesis and gather measurable data. This hands-on portion involves a series of tests to evaluate the physical impairments contributing to the patient’s issue.
The assessment typically includes:
- Range of Motion (ROM) measurement, often using a goniometer, to quantify the degree of movement and identify stiffness or hypomobility.
- Strength testing through Manual Muscle Testing (MMT), where the therapist applies resistance to specific muscle groups and grades their force on a scale, typically from 0 to 5.
- Palpation, which involves physically feeling the affected area to check for tenderness, swelling, muscle tension, or tissue abnormalities.
- Postural analysis and movement screening, observing standing posture, gait, and functional movements like a squat or lunge to reveal compensatory patterns.
- Specific “special tests,” such as ligament stability tests for a joint injury or neurological screening, to confirm or rule out particular diagnoses.
Setting Expectations and the Plan of Care
The conclusion of the first appointment involves the therapist synthesizing all gathered data to form a clinical impression and collaboratively establishing the Plan of Care (POC). The POC is the structured roadmap for the entire treatment process, outlining the necessity and direction of the therapy. The therapist discusses the findings, explaining what structures are likely involved and how they relate to the patient’s symptoms and functional limitations.
The POC must contain measurable short-term and long-term treatment goals that are directly tied to improving the patient’s functional abilities (e.g., walking pain-free for 30 minutes). The therapist specifies the recommended type, frequency, and duration of therapy services. This concluding phase often includes instruction on a simple Home Exercise Program (HEP), empowering the patient to begin recovery immediately and bridging the gap between clinical sessions.