Step one: assessing impairments, activity limitations and participation restrictions

Assessment is the first step in devising an appropriate physiotherapy programme. The assessment forms the basis of the goal-setting process. It identifies participation restrictions, activity limitations, and impairments.

Initially, various sources need to be used to extract details such as age, cause of injury, time since injury, neurological status, orthopaedic status, other injuries and complications, socio-economic background, medical and surgical management since injury, prior medical history, family support, employment status and living arrangements. These provide key insights into patients’ problems, and help direct the subsequent physical assessment.

Goal setting is an important aspect of a comprehensive physiotherapy and rehabilitation programme.17−28 The process needs to be patient-centred. Initially, a few key goals of rehabilitation are articulated by the patient and negotiated with the multi-disciplinary team.^{17, 19, 22, 23, 25, 29−33} These goals should be expressed in terms of participation restrictions.^{20, 25} For example, a key goal of rehabilitation might be to return to work or school. Physiotherapy-specific goals then need to be identified and linked to each participation restriction goal. The physiotherapy-specific goals should be functional and purposeful activities as defined within the activity limitation and participation restriction domains of ICF and, specifically, within the ICF sub-domains of mobility, self-care and domestic life. These sub-domains include tasks such as pushing a manual wheelchair, rolling in bed, moving from lying to sitting, eating, drinking, looking after one’s health, and pursuing recreation and leisure interests (see Ref. 34 for examples of ways to articulate functional goals appropriate for patients with spinal cord injury). Physiotherapy-specific goals are formulated in conjunction with the patient and other team members who share responsibility for their attainment. Both short- and long-term goals need to be set.^{24, 25} These may include goals to be achieved within a week or goals to be achieved over 6 months. In addition, specific goals (or targets) should be set as part of each treatment session²⁵ (see Chapter 7).

Goals are important for several reasons.²⁴ They ensure that the expectations of patients and staff are similar and realistic, and provide clear indications of what everyone is expected to achieve.²⁶ If compiled in an appropriate way, they actively engage patients in their own rehabilitation plan, empowering them and ensuring that their wishes and expectations are met.²⁶ Without goals, rehabilitation programmes can lack direction, and patients can feel like the passive recipients of mystical interventions.^{19, 22, 23, 30, 35} Goals also help focus the rehabilitation team on the individual needs of patients, and provide team members with common objectives.²⁴ Perhaps most importantly, goals provide a source of motivation and enhance adherence.

Goals are also used to monitor the success of therapy and to identify problems. Goals achieved indicate success and goals not achieved indicate failure. Failure may be due to any number of reasons which need exploring. For example, a patient may fail to achieve a goal because of medical complications or because equipment fails to arrive, factors which may be difficult to avoid. Failure to achieve goals may reflect poor therapy attendance. Alternatively, failure may indicate unrealistic goals which need revising. A risk of excessive reliance on goals to measure success is that it encourages the selection of non-challenging goals which have a high likelihood of success.²⁷

Guidelines to setting goals

Goals should be SMART. That is, they should be: Specific, Measurable, Attainable, Realistic and Timebound.³⁶ Physiotherapy-related goals need to be based on predictions of future independence, taking into account contextual factors such as patients’ and families’ perspectives, priorities and personal ambitions.^{19, 35, 37} Other factors which influence outcome include access to products, technology and support, and personal attributes such as age, personality and anthropometrical characteristics.³⁷⁻⁴³ Clearly, however, the strongest predictor of future independence is neurological status.^{32, 44, 45} Neurological status determines the strength of muscles which in turn largely determines patients’ ability to move.

A simplistic summary of levels of innervation for key upper and lower limb muscles is provided in Table 2.2 (for more details see Tables A1 and A2 in the Appendix). The summary is simplistic because muscles have been grouped together even though different muscles and parts of the same muscle often receive innervation from different spinal nerve roots. For example, the pectoralis muscles consist of pectoralis minor and the sternocostal and clavicular parts of pectoralis major. These muscles receive innervation from C5 to T1.⁴⁶

Table 2.2

The levels at which muscles receive sufficient innervation to enable reasonable movement⁴⁶

C4		Diaphragm
C5	Shoulder	Flexors
		Abductors
	Elbow	Flexors*
C6	Shoulder	Extensors
		Adductors
	Wrist	Extensors*
C7	Elbow	Extensors*
	Wrist	Flexors
	Finger	Extensors
	Thumb	Abductors and adductors
C8	Finger	Flexors*
	Thumb	Flexors and extensors
T1	Finger	Abductors*
		Adductors
T1–T12		Intercostals, abdominals and trunk
L2	Hip	Flexors*
		Adductors
L3	Knee	Extensors*
L4	Hip	Abductors
	Ankle	Dorsiflexors*
L5	Hip	Extensors
	Toe	Extensors*
S1	Knee	Flexors
	Ankle	Plantarflexors*
S2	Toe	Flexors

^*The ASIA muscles are asterisked (see Appendix for more details).

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