It is common to feel a degree of uncertainty before a first physical therapy session, especially when recovering from an injury or dealing with chronic discomfort. This initial appointment, known as the evaluation, is a comprehensive process designed to identify the root cause of your physical limitation, not just treat the symptoms. The goal of this first visit is to establish a clear, personalized path toward regaining function and reducing pain. By understanding the distinct phases of the evaluation—from the subjective interview to the objective assessment and treatment planning—you can approach your first session with confidence and a clear expectation of the process.
Preparing for the Session and Initial Intake
The preparation for your first physical therapy session begins with logistical considerations to ensure a smooth start to your care. You should wear loose-fitting, comfortable clothing that allows the physical therapist easy access to the area being examined, such as shorts for a knee issue or a tank top for a shoulder problem. Bringing the correct documents is also important, including your health insurance card, photo identification, any physician referrals or prescriptions for therapy, and a list of all current medications, including over-the-counter supplements.
Once the initial paperwork is complete, the session begins with the subjective interview, which is your opportunity to communicate your personal experience to the therapist. This detailed conversation focuses on your patient history and the nature of your complaint, including when the symptoms began and how they have progressed over time. The therapist will ask specific questions about your pain, such as its intensity on a scale of zero to ten, its quality (sharp, dull, or burning), and whether it is intermittent or constant.
You will also discuss factors that make your symptoms better or worse (relieving and aggravating factors), which helps the therapist understand the mechanics of your problem. The interview explores how your condition affects your daily life, work, and recreational activities, establishing your functional limitations and providing context for treatment goals. The therapist will also review your past medical history, including any previous surgeries, injuries, or treatments you have received for the current issue.
The Comprehensive Physical Assessment
Following the subjective history, the physical therapist proceeds to the objective, hands-on examination, which is a detailed assessment of your body’s mechanics and function. This assessment begins with observation, where the therapist watches you move, noting your posture, how you walk (gait analysis), and how you perform functional tasks like sitting down or reaching overhead. This visual analysis helps identify any compensations or imbalances that may be contributing to your problem.
A systematic evaluation of joint mobility is then performed, starting with range of motion (ROM) measurements. The therapist assesses active ROM (how far you move the joint yourself) and passive ROM (where they gently move the joint for you). This comparison helps determine if the restriction is muscular or structural, identifying limitations caused by joint structures or muscle weakness.
Strength testing is performed using manual muscle testing (MMT), where the therapist applies resistance to a muscle group and assesses its power. This process isolates specific muscles to pinpoint weaknesses requiring strengthening. The therapist will also use palpation, which involves touching the affected area to locate specific points of tenderness, muscle tension, swelling, or structural anomalies. This tactile examination confirms the specific tissues involved in your discomfort.
The assessment concludes with specialized tests, which are specific maneuvers performed to confirm or rule out a suspected diagnosis, such as testing the integrity of ligaments or nerves. For example, a therapist might perform a specific orthopedic test on the shoulder to check for rotator cuff involvement or a neurological screening to assess reflexes and sensation.
Understanding Your Treatment Plan and Next Steps
Once the comprehensive assessment is complete, the physical therapist will discuss their initial findings and provide you with a working diagnosis and prognosis, which is an estimated timeline for recovery. This discussion synthesizes the subjective information you provided with the objective data collected during the physical examination. You will then work together to establish collaborative goals, ensuring the treatment plan aligns with your personal aspirations, whether they involve returning to a specific sport or simply being able to walk without pain.
The therapist will clearly define the expected frequency and duration of your treatment, often recommending an initial schedule of two to three sessions per week for a period of several weeks, depending on the severity of your condition. This plan is dynamic, meaning the frequency may be reduced as you show measurable improvement and progress toward your goals. The session will also include the first round of active treatment, which might involve initial therapeutic exercises, manual therapy techniques, or modalities like heat or ice.
Finally, you will receive your first home exercise program (HEP), a customized set of activities to perform between sessions. This program is fundamental to recovery, reinforcing clinic work and accelerating healing. The therapist will demonstrate the exercises to ensure correct form, and you will receive written or digital instructions detailing the frequency, sets, and repetitions. The session concludes with scheduling follow-up appointments, providing a clear path for ongoing rehabilitation.