Physical therapy is a healthcare discipline focused on restoring movement and function in individuals affected by injury, illness, or disability. It uses specialized exercises and physical techniques to help patients regain strength, mobility, and independence. Before any therapeutic intervention can begin, a comprehensive initial evaluation must be performed by a licensed physical therapist. This first appointment is a structured, systematic process required to determine the nature of the patient’s condition and the proper path forward.
Defining the Initial Assessment
The initial assessment serves as the foundation for the entire rehabilitation process. This session allows the physical therapist to gather both subjective and objective data about the patient’s current health status and functional abilities. Subjective data collection begins with a thorough review of the patient’s medical history, including past surgeries, chronic conditions, and any relevant imaging results.
The therapist asks detailed questions about the current complaint, such as the location, intensity, and behavior of symptoms, and what activities aggravate or ease the discomfort. This interview helps the clinician form an initial hypothesis regarding the source of the patient’s movement impairment and sets a baseline for pain levels. The assessment also fulfills a professional responsibility to screen for conditions that fall outside the scope of physical therapy practice, often referred to as “red flags.”
If the therapist suspects a serious underlying pathology, they are obligated to refer the patient back to a physician for further diagnostic testing before initiating treatment. Establishing baseline data is necessary to determine the appropriateness of physical therapy services. This comprehensive intake ensures that the subsequent physical examination is focused and relevant to the patient’s specific functional limitations.
Key Steps During the Hands-On Examination
After the subjective interview concludes, the evaluation transitions into the hands-on, objective data collection phase. This segment begins with an observational assessment, where the therapist visually analyzes the patient’s posture, gait pattern, and overall movement quality. The clinician looks for asymmetries, guarding behaviors, or visible signs of swelling or muscle atrophy that might indicate a chronic issue.
A brief systems review follows, which is a rapid check of the cardiovascular, neurological, and integumentary (skin) systems to ensure safety and identify potential non-musculoskeletal factors contributing to the problem. This typically involves checking sensation, reflexes, and balance to screen for broader systemic involvement.
The core of the objective examination involves specific tests and measures, starting with assessing the active and passive Range of Motion (ROM) of the affected joints. Active ROM is measured when the patient moves the joint themselves, providing insight into muscle control and willingness to move. Passive ROM, where the therapist moves the joint, helps differentiate between joint capsule restrictions and muscle tightness as the limiting factor.
Next, the therapist performs Manual Muscle Testing (MMT) to grade the strength of specific muscle groups, usually on a standardized scale of 0 to 5. This procedure helps quantify muscular deficits and isolates weakness contributing to functional loss, with a grade of 3 indicating movement through the full range against gravity. Palpation, or touching the tissues, is also used to identify areas of tenderness, muscle spasm, or temperature changes in the affected region.
The therapist then performs specialized clinical tests designed to identify specific tissue involvement, such as ligamentous stability tests or nerve compression tests. These maneuvers apply controlled stress to a structure to reproduce symptoms and confirm or reject the working hypothesis. Finally, a functional assessment observes the patient performing tasks related to their goals, such as the Timed Up and Go (TUG) test or climbing stairs, providing a real-world measure of their current abilities.
Translating Results into a Treatment Plan
Once all the subjective and objective data has been collected, the physical therapist synthesizes these findings to formulate clinical judgments. This synthesis results in the establishment of a Physical Therapy Diagnosis, which is a classification of the patient’s condition based on their movement impairments, distinct from a medical diagnosis. For instance, a patient with a medical diagnosis of “shoulder pain” might receive a PT diagnosis of “rotator cuff tendinopathy with associated scapular dyskinesis.”
Following this classification, the therapist determines the Prognosis, which is the predicted level of improvement and the anticipated timeframe required to achieve it. This prediction considers factors like the severity of the injury, the patient’s overall health status, and their motivation to comply with the treatment program. The prognosis helps manage patient expectations and guides the subsequent planning process.
The next step involves setting measurable, functional goals that the patient and therapist agree upon. These goals are explicitly tied to the patient’s desired activities and must be specific, such as “to walk one mile without pain” or “to return to overhead lifting without restriction.” Goals are typically categorized as short-term objectives and long-term outcomes to track progress effectively.
The final product is the Plan of Care, which outlines the specific interventions—including therapeutic exercises, manual techniques, and patient education—necessary to meet the established goals. This plan also specifies the frequency of visits, such as two times per week, and the total duration of the rehabilitation episode.