If you’re not assessing, you’re just guessing.
Assessment is a delicate step-by-step process to interview and examine a patient to come to a provisional diagnosis. Simply put, assessment is the foundation of a therapist’s treatment and clinical decision-making. It is a skillful series of steps used to understand the current physical state of an individual. Assessment can also be defined as the synthesis of clinical findings into a clear understanding of presenting conditions that in turn facilitate the construction of a treatment protocol.
The importance of assessment and evaluation is very well established theoretically but often diminished in practical clinical practice. For a patient to achieve health optimization, therapists should be able to independently evaluate, diagnose, and treat clients effectively. For this to happen, it is important to understand that assessment is both a facilitator and catalyst to positive and healthy outcomes.
When we talk about assessment, what are the actual goals? There are three main purposes of assessment, namely, diagnosis, treatment planning, and prognosis. Unfortunately, to quantify all three of these purposes, a therapist is required to put in a large amount of time and effort. Given the expertise in movement science, the therapist identifies key factors that underlie movement and movement dysfunction, which are most often separate from the medical condition. The focus of a physical therapist is differential evaluation and the treatment of dysfunction rather than differential diagnosis and treatment of disease as in the case of a physician. This is often the reason why physiotherapy assessment takes time. It is also important to understand that a physical therapist needs to be specific when it comes to which anatomical structure is affected. Simple low back pain is not a diagnosis, but rather a symptom. It is the job of the therapist to identify what structure is responsible for that pain so that he/she can formulate a treatment protocol and achieve a positive patient prognosis.
It is common knowledge that an accurate assessment is beneficial to the patient. Assessment is arguably the most important step in the rehabilitation process, as our clinical reasoning is based on the information it provides and provides the basis for our decision-making throughout the rehabilitation process. Many conditions are complex, which requires the ability to analyze all the relevant information such as client history, signs and symptoms, aggravating factors, client goals, past medical history, clinical assessment/examination findings, and diagnostic imaging. A genuine and thorough assessment reduces a patient’s pain and discomfort. Let us try to understand the importance of assessment through a few examples.
Around four in five individuals experience low back pain at some point in their lives and 23% of adults suffer from chronic low back pain. It is the fifth most common reason for visiting a clinician. With such a large number of individuals experiencing low back pain, it is not surprising that 20% of all individuals suffering from the condition are misdiagnosed. One of the reasons for misdiagnosis is improper assessment taking. Research claims that an estimated 15 to 30 percent of lower back cases result from SI Joint Dysfunction. However, due to various inaccuracies in diagnostic testing, the condition goes unrecognized and leaves a majority of patients perplexed. Flat-footed people are 50% more likely to suffer from low back pain, but it is not even considered during assessment.
These are just a few of the many examples where a proper assessment can help a patient and clinician alike. The use of advanced assessment tools adds value and credibility to the evaluation process. Questionnaires and specific screening tools are often used to get an idea of what the client’s condition may be. Along with diagnostic tools, outcome scores must be used for measuring the prognosis of the client as well.
With assessment being such an important diagnostic tool, how does a therapist use it to their advantage? Unique assessment methods and accurate screening tools always benefit a hospital or a clinic that practices physiotherapy. Not only does assessment guide clinicians toward a diagnosis, but also sets guidelines for discharge criteria and sets prognostic goals.
Overall, with the help of an accurate assessment, the clinician can –
– Come up with a provisional diagnosis, and support subsequent interpretation and clinical decision-making.
– Set goals
– Come up with treatment protocols suited to meet those goals
– Measure or quantify prognosis
– Facilitates organized documentation and a good reporting system
– Enhance patient-therapist trust/bond through patient education to help them understand their condition
– Counsel patients on their current condition and help them achieve health optimization
– Identify the unique needs or requirements of clients
– Eliminate barriers to care
– Dig deeper into the concerns of a patient when a new symptom arises
– Set individualized discharge criteria
Now, how can my assessment contribute to making a clinic better?
If a therapist can perform a reliable and credible assessment, he/she can achieve all that is stated above and also be the direct beneficiary as it helps his/her clinic both financially and morally. If the head therapist can perform a near-perfect assessment, he/she is perfectly capable of transferring that skill to the remaining members of the staff. The quality of the work ethic of the staff is directly proportional to giving quality health care. Various aspects of assessment need to be reflected on each day. Are we getting enough information and organizing it effectively to allow for appropriate interpretation? Do we obtain a chronological story and useful background information to support our assessments of all situations and symptoms?
A clinic needs to make sure that unnecessary hospitalization due to inaccuracy or incorrect diagnosis must be avoided at all costs. Having adverse consequences is a definite way to destroy a clinic’s reputation and ruin all monetary benefits. Finally, the assessment and evaluation should be an integrated part of the treatment process. It verifies that the treatment is in line with the needs and priorities of the patients; the documentation of changes might motivate both patients and health professionals and it might increase adherence to the recommended treatments.
Now that we understand how important assessment is, let us try to dig deep into the importance of assessing Gait. A gait is a pattern of limb movements made during locomotion. Human gaits are the various ways humans can move, either naturally or as a result of specialized training. When we study how a person walks or runs, we can identify individuals’ unique movements, determine normal gait patterns, diagnose issues causing pain, and implement and evaluate treatments to correct abnormalities. Gait problems can occur with or without injury and it is the job of the therapist to find out what the problem of the client is.
So, what are the parameters of gait? What are we measuring? There are two main phases of gait, the Stance phase, and the Swing phase.
– The stance phase is subdivided into –
Initial contact (heel strike)
Loading response (foot flat)
Terminal stance (heel off)
Pre-swing (toe off)
– The swing phase is subdivided into –
Let us try to understand this a little better with the help of a diagram.
Initial contact: The moment the foot touches the ground and begins the first phase of double support. Its function is to establish contact with the ground surface and initiate weight acceptance.
Loading response: Begins with the initial contact and continues until the contralateral foot leaves the ground. The foot continues to accept the weight and absorb shock by rolling into pronation.
Mid-stance: Begins when the contralateral foot leaves the ground and continues until the ipsilateral heel lifts off the ground. The body is supported by a single leg and begins to move from force absorption at impact to force propulsion forward.
Terminal stance: Begins when the heel leaves the floor and continues until the contralateral foot contacts the ground. In addition to single limb support and stability, this event serves to propel the body forward. Bodyweight is divided over the metatarsal heads.
Pre-swing: Begins when the contralateral foot contacts the ground and continues until the ipsilateral foot leaves the ground. It provides the final burst of propulsion as the toes leave the ground.
Early swing: Begins when the foot leaves the ground until it is aligned with the contralateral ankle. This event functions to advance the limb and shorten the limb for foot clearance.
Mid-swing: Begins from the ankle and foot alignment and continues until the swing leg tibia is vertical. As in early swing, it functions to advance the limb and shorten the limb for foot clearance.
Late swing: Begins when the swing leg tibia is vertical and ends with initial contact. Limb advancement slows in preparation.
Understanding the gait cycle allows for effective gait analysis. When analyzing gait, it should be done systematically, looking at each joint separately throughout the entire gait cycle and detecting deviations from normal. Each joint has a specific function during each phase and subphase of the gait cycle. The ankle, knee, and hip are to have a certain range of mobility during gait, and deviations from these normative values indicate a pathological or musculoskeletal impairment.
On what basis does one assess gait? Well, various studies have been conducted to quantify the normative values of all the parameters of gait. The normative values of the gait cycle are as follows –
Any deviation above the standard deviation can be considered significant and needs to be addressed. A study conducted by The clinician’s experience also comes into play here as the gait cycle of an individual may be deviated, but also may not be the root cause for the client’s pain.
It is important to remember that abnormal gait patterns can be caused due to musculoskeletal impairments and that abnormal gait patterns in turn cause musculoskeletal impairments. Let us look at an example that explains both scenarios.
Gait that aggravates pain –
1. A study conducted by Wataru Kuwaharu et al, published in the Journal of Orthopedic Science, reported that In lumbar spinal stenosis patients, smaller anterior lumbar tilt and larger anterior pelvic tilt during gait loading may affect the aggravation of low back pain by gait loading. Increasing lumbar lordosis during gait might be one of the factors leading to low back pain in lumbar spinal stenosis patients.
2. Podiatric biomechanics states that when a person’s posture is altered, this changes how they place their foot when walking, and which muscles have to stretch and flex unnaturally to compensate for these changes and maintain balance. This in turn leads to low back pain.
3. Trochanteric bursitis, which is an inflammation of the tissues around the side of the hip, is often triggered by poor balance and abnormal gait patterns.
Pain causing gait deviation –
Patients with OA hip often have pain which makes them walk with excessive erector spine activity which later causes more pain
In lumbar spinal stenosis patients, smaller anterior lumbar tilt and larger anterior pelvic tilt during gait loading may affect the aggravation of low back pain by gait loading. Increasing lumbar lordosis during gait might be one of the factors leading to low back pain in lumbar spinal stenosis patients
Patients with lumbar disc herniation experience severe pain that alters gait mechanics
There exist several abnormal or pathological gait patterns that are caused due to pain or disease. If a therapist knows the reason/cause of a specific gait pattern, he/she can focus on the root cause of the pain and overall make the patient healthy. A few abnormal gait patterns are as follows – MUSCULOSKELETAL:
Antalgic gait – Antalgic gait is due to pain in the lower extremities that results in a limp that is associated with a shortened stance phase relative to the swing phase. This gait deviation, asymmetry, can be caused by issues that originate in the trunk, hip, knee, or ankle.
Leg length discrepancies – Leg length discrepancies can either be structural or functional. This can cause a pelvic drop and decreased hip, knee, and ankle plantarflexion. To compensate, the patient may use vaulting or toe-walking.
Trendelenberg Gait – Trendelenburg gait occurs when the gluteus medius is weak. Gluteus medius weakness can be the result of dysfunctions or diagnoses related to back pain or lumbopelvic pain, chronic hip dysfunctions, or lumbopelvic surgery.
Posterior Lurch Gait – Posterior lurch gait is when the trunk leans posteriorly with a hyperextended hip, especially during the loading response due to a weak gluteus maximus.
Circumduction of Hip Gait – Circumduction of the hip during the swing phase occurs for several reasons including weak hip flexors, contralateral hip dysfunction, or leg length discrepancy. This is a combination of hip hiking, forward rotation of the pelvis, and abduction of the hip. Hip flexor weakness is caused by L2-L3 nerve compression or possibly upper motor neuron lesions.
Spastic hemiparetic gait is characterized by unilateral leg extension and circumduction, in which the paretic leg performs a lateral motion (circumduction ) during the swing phase. This is also known as circumduction gait.
Spastic diplegic gait (scissors gait) – It is characterized by bilateral leg extension and adduction, and the legs appear to be stiff. When spasticity in the adductors is marked it results in a scissoring gait where the legs cross in a scissors-like pattern.
Steppage gait. In this gait, the patient must lift the leg higher than usual and the patient is unable to stand or walk on their heel. It is caused by weakness in the ankle dorsiflexors. This gait is also known as a slapping gait.
Waddling gait (myopathic gait) – In waddling gait weakness in the gluteus medius muscles leads the hip on the swinging side to drop during gait, in an attempt to counteract, the patient bends the trunk towards the other side, resulting in the gait to appear waddling.
Parkinsonism gait – The gait is slow with a short step length and a narrow base. The feet are lifted less high than normal resulting in shuffling. Patients with parkinsonism can develop a Freezing gait in which there is blockage of movement during turning or when approaching obstacles or narrow passages such as doors. This gait is also known as festinating gait.
Cerebellar ataxic gait – The gait is broad-based, insecure, and lacks coordination. Leg movements and step lengths are irregular and variable.
Senosory Ataxic gait. In this gait, the patient’s proprioception is disturbed resulting in the gait appearing broad-based and insecure. The patient uses visual control to compensate for the disturbed proprioception.
Now, let us focus on how to evaluate and analyze gait. Clinical gait analysis uses several different methods including Computerized video cameras to show movement in slow motion.
Markers are placed on the skin to monitor motion on camera. Sensors on a platform to measure footstep pressure and stride length.
An objective approach is quantitative and parameters like time, distance, and muscle activity will be measured. Other objective methods to assess the gait cycle that uses equipment include:
•Video Analysis and Treadmill
•Electronic and Computerized Apparatus
•Satellite Positioning System
Qualitative methods to assess and analyze gait include:
•Rancho Los Amigos Hospital Rating List
•Ten-Meter Walking Test
•6-Minute Walk Test
•2-Minute Walk Test
•Dynamic Gait Index
•Emory Functional Ambulation Profile
•Timed Up and Go Test. This test is statistically associated with falling in men, but not in women.
•Functional Ambulation Categories
All these methods are valid and reliable ways to objectively analyze the gait cycle. We must add objectivity to the gait assessment. Otherwise, the analysis becomes vague and precise goals and treatment protocols cannot be followed.
Now, what in the world is evidence-based practice? Evidence-based practice in physiotherapy (EBP) is an emerging and increasing theme in rehabilitation and physiotherapy. Although it is increasingly used worldwide, a precise and appropriate definition has not been agreed on by clinicians and researchers. The World Confederation for Physical Therapy (European region) has defined EBP as “a commitment to use the best available evidence to inform decision-making about the care of individuals that involves integrating physiotherapist practitioners and individual professional judgment with evidence gained through systematic research. Another definition according to Mirella et al is an area of study, research, and practice in which clinical decisions are based on the best available evidence, integrating professional practice and expertise with ethical principles.
With ethics and precision being key in physical therapy practice, it is extremely important that evidence-based practice is to be followed. Without evidence, how does one provide treatment? How would one know what is right from what is wrong when it comes to clinical relevance? Evidence-based practice is important for both physiotherapists and patients alike. It allows clinicians to develop the best practices in treating musculoskeletal and neurological conditions and reduce variation in treatment among other therapists. It also does the job of increasing positive outcomes and recovery. It helps progress the profession’s approach to developing, using, and promoting research and its contribution to generating new evidence, knowledge transfer, and service improvement.
All healthcare professionals alike should incorporate evidence-based practice, be updated with current research and studies to stay in the loop, and always have a solid basis for our treatment protocol. You never want to be outdated in the field of healthcare, because not only is that harmful to patients, but also the clinician’s reputation and credibility, and ruins the overall reputation of the profession itself.
One of the most important aspects of Evidence-Based Practice in Physiotherapy is the fact that it keeps physios accountable for what they are doing with every patient. By adhering to recommendations, or guidelines as directed by research, patients can know that they are getting the most up-to-date and highly recommended treatments.
Research and evidence have real-time effects on the way physiotherapists structure their rehabilitation plans. This helps to maintain objectivity, structure, and organization.
Now that the importance of EBP is established, let us dig deep into what the steps are to bring about EBP –
1. Formulate an answerable question – One of the fundamental skills required for EBP is the asking of well-built clinical questions. By formulating an answerable question you can focus your efforts specifically on what matters. These questions are usually triggered by patient encounters which generate questions about the diagnosis, therapy, prognosis, or etiology.
2. Find the best available evidence – The second step is to find the relevant evidence. This step involves identifying search terms that will be found in your carefully constructed question from step one. Select resources that perform your searches such as PubMed and Google scholar. Formulate an effective search strategy using a combination of keywords.
3. Appraise the evidence – It is important to be skilled in critical appraisal so that you can further filter out studies that may seem interesting but are weak
4. Implement the evidence – Individual clinical decisions can now be made by combining the best available evidence with your clinical expertise and your patient’s values. These clinical decisions should then be implemented into your practice which can then be justified as evidence-based.
5. Evaluate the outcome – The final step in the process is to evaluate the effectiveness and efficacy of your decision in direct relation to your patient. Was the application of the new information effective? Should this further information continue to be applied to practice?
With the help of these steps, clinicians can follow EBP in their clinics or hospitals and improve the quality of their care. It is always crucial to remember that the process is nowhere near easy, but worth all the effort in the end. The reason therapists should take the time to follow these steps are –
– It allows for better therapist-patient communication
– It builds a platform for physiotherapists and surgeons to communicate
– It helps the field of physiotherapy to become a better place in terms of validity and reliability
Since healthcare is meant to be holistic, there must exist constant communication between therapists and surgeons. But unfortunately, this does not happen as frequently as it should. With the help of Evidence-Based Practice, therapists attain competence which in turn is a strong facilitator of communication. One of the few reasons why surgeons and physiotherapists usually don’t communicate is because of the lack of competence of physios. As harsh as it may sound, without evidence-based practice, a therapist has no backing or reasoning for anything he does, and that results in low competence, which in turn results in reduced inter-professional communication.
Since every client requires time to take an evidence-based assessment, sometimes it affects a physio’s time management and may also affect the time of other clients who patiently wait for their turn. This is not to say that there should be any compromise with the quality of assessment, but it is a point to be noted as it genuinely can become an issue. Though evidence-based practice requires a lot of effort, it is definitely worth the effort as you get fantastic results.