A physical therapy evaluation is the mandatory first visit with a licensed physical therapist, serving as a comprehensive assessment of your physical state, capabilities, and limitations. This initial, hands-on meeting must be completed before any restorative treatment can begin. It gathers necessary information to understand your condition and its impact on daily life, establishing the foundation for all subsequent therapy sessions.
Defining the Role of the Evaluation
The primary purpose of the initial evaluation is to establish a precise baseline against which future progress will be measured. The therapist identifies specific impairments, such as muscle weakness or joint stiffness, that contribute to your functional limitations. This process determines if your condition requires the skilled intervention of a Doctor of Physical Therapy (DPT) rather than self-management techniques.
Synthesizing this data allows the therapist to formulate a physical therapy diagnosis, which is distinct from a medical diagnosis provided by a physician. While a medical doctor might diagnose “osteoarthritis,” the physical therapy diagnosis focuses on movement system impairment, such as “impaired joint mobility” or “decreased muscle performance.” This clinical analysis determines the root cause of the movement problem, guiding the treatment plan.
Step-by-Step Components of the Assessment
The evaluation is systematically divided into two key phases: the subjective and the objective examination.
Subjective Examination
The subjective examination begins with a detailed patient interview to understand your medical history, including past surgeries, illnesses, and existing health conditions. You will be asked about the severity and nature of your current symptoms, describing your pain levels and how your condition affects activities like walking, lifting, or sleeping. This interview captures your self-reported functional limitations, ensuring the therapist understands what you are having difficulty with. The information gathered focuses the remainder of the examination, ensuring objective tests are directly related to your primary complaints.
Objective Examination
The objective examination is the hands-on, physical testing phase where the therapist collects quantifiable findings. This includes specific, standardized measurements:
- Active and passive range of motion (ROM) to assess joint flexibility.
- Manual muscle testing (MMT) to grade muscle strength on a numerical scale.
- Specialized orthopedic tests designed to identify or rule out tissue injuries, such as a ligament tear or nerve compression.
Observation of functional movements is another component, where the therapist may analyze your posture, gait pattern, or how you perform tasks like squatting or balancing. Neurological screening assesses sensation, reflexes, and muscle control to ensure the central nervous system is functioning correctly. This objective data establishes the measurable baseline used to track your progress.
Developing the Treatment Strategy
Immediately following data gathering, the therapist synthesizes the subjective and objective information into a formal clinical judgment and treatment strategy. This assessment phase includes determining a prognosis, which is the predicted level of improvement you can attain and the estimated time required to reach that level. The prognosis is a professional forecast based on the severity of your condition, medical history, and other factors like lifestyle and nutritional status.
The next step involves establishing clear, measurable, and objective goals that align with your functional needs and desires, often using the SMART criteria (Specific, Measurable, Achievable, Relevant, Time-Bound). These goals serve as concrete targets for your recovery journey, proving the treatment is effective and medically necessary. A goal might be to “walk 500 feet without resting within six weeks” or “lift a 20-pound object from the floor.”
This strategy is formalized in the Plan of Care (POC), which serves as the clinical roadmap for your entire episode of physical therapy. The POC defines the specific interventions—such as therapeutic exercise, manual therapy, or modalities—and states the proposed frequency and duration of future treatment sessions. This document is required for regulatory and insurance purposes to ensure compliance and proper reimbursement.
The creation of the Plan of Care marks the transition from the evaluation phase to the intervention phase, providing a structured framework for all subsequent sessions. It ensures that all stakeholders, including the patient, the therapist, and any referring providers, are aligned on the strategy and expected outcomes.