The history involves gathering information about the current and past health status of the patient related to why the patient/client is seeking the services of a PT.² The information may be obtained by interviewing the patient or the patient’s family, by accessing the patient’s medical record, and by consulting with other members of the patient’s health care team. The history is qualitative information based on the patient’s perception of the problem and is therefore included in the “S” portion of the “SOAP” note (see Chapter 2).

The role of the therapist during the interview is to guide the patient through pertinent questions about the patient’s musculoskeletal condition. This interaction allows the therapist to develop a rapport with the patient and to understand the patient’s insight into and opinion of the problem. The interview also assists the therapist in appropriately directing the remainder of the examination. Often, the patient interview will give the therapist ample information to make a preliminary physical therapy diagnosis. Questions asked during the interview include information about the onset of the condition, current symptoms, previous physical therapy treatments, past medical history, and lifestyle and health habits pertaining to work and recreation. Box 8-1 lists typical questions asked during the patient interview.

BOX 8-1 Questions Typically Asked during the Patient History Component of an Initial Physical Therapy Examination

1. What brings you to physical therapy today?

2. What do you feel is your primary problem? Is it stiffness? Pain? Weakness? Instability?

3. Was the onset of the problem slow or sudden? Was the problem caused by a specific incident or mechanism of injury?

4. Have you ever had this problem before? If so, were you treated for it? How long did it take to recover?

5. What provokes your symptoms? What relieves your symptoms?

6. Are your symptoms worsening or improving?

7. Are your symptoms constant or intermittent?

8. Can you describe your pain? Does your pain spread to other parts of your body?

9. What is your occupation?

10. What activities are you unable to do because of your symptoms?

11. Have you had any radiographs (“x-rays”) taken or diagnostic tests performed?

12. Are you currently taking any medication for this problem?

13. How is your general health?

14. Is there anything else you would like to tell me that I have not asked and that would be pertinent to your problem?

In addition to these questions specific to the patient’s reason for seeking physical therapy, the therapist should perform a review of symptoms (ROS) in order to identify symptoms that may have been overlooked in the history and to screen for medical conditions that may require referral to other health care providers.³ The ROS is usually performed by using checklists of common symptoms typically associated with various systems of the body (e.g., cardiovascular system, gastrointestinal system).

For more specific information about the location of symptoms, the patient is often asked to draw the location of the symptoms on a body chart (Figure 8-1). Pain scales may also be used to gauge the amount of pain the patient is experiencing (Figure 8-2). On completion of the history taking, the therapist should have gained information regarding the description and location of symptoms, nature of the disorder (acute versus chronic condition), behavior of the symptoms (what activities make the symptoms either better or worse), health risk factors that may be present, and limitations in activities the patient may be experiencing.

Figure 8-1 Body chart to indicate areas of pain. The patient is asked to indicate areas of pain with Xs, areas of numbness with slashes, and areas of tingling with plus signs.

Systems Review

The objective portion of the examination refers to quantitative or qualitative measurements that are taken by the PT. This portion of the examination begins with a systems review and is included in the “O” section of the SOAP note (see Chapter 2). The systems review includes a brief examination of the other systems of the body related to physical therapy (e.g., cardiovascular, neuromuscular, integumentary) and information about the patient’s cognition, communication, and preferred learning style.² The information gathered during the systems review assists the therapist in developing an appropriate, individualized plan of care and may further identify health problems that may require consultation with or referral to another health care provider. In a patient with a musculoskeletal condition, common systems reviews may include monitoring of heart rate and blood pressure, assessment of skin integrity, and a gross assessment of joint ROM, strength, and coordinated movements.

Tests and Measures

During the tests and measures portion of the examination, specific numbers or grades may be assigned (quantitative measurement), as is the case with ROM or strength measurements. At other times, parts of the examination are performed by observing and describing patterns of movement, deformities, or both (qualitative measurement). The purpose of the tests and measures is to establish baseline values and observations that can be used for comparison after a single treatment or a series of treatments. The PT can then make appropriate changes in the plan of care based on the amount of progress or lack of progress found with repeated tests and measures.

This section briefly describes some of the tests and measures performed in an orthopaedic physical therapy setting. The purpose is to familiarize introductory level students with common terms used when working with a patient who has a musculoskeletal problem.

Observation

Observation is the “looking” phase of the examination. It may begin in the waiting room, where the therapist can observe the patient’s general attitude, posture, and willingness to move. A perfunctory gait assessment may be made as the patient enters the examination area. Once the patient is appropriately undressed, a more detailed inspection can be made, including observation of obvious deformities such as an abnormal curvature of the spine, joint subluxations (a condition in which a joint partially dislocates), asymmetrical body contours, swelling, and color and texture of the skin. Many musculoskeletal injuries are a result of or are exacerbated by poor sitting and standing postures. Therefore particular attention is paid to the standing and sitting postures of the patient.

Active Range of Motion

Active range of motion (AROM) refers to the ability of the patient to voluntarily move a limb through an arc of movement. AROM provides the therapist with information regarding the quality of the movement (smooth versus rigid movement), the willingness of the patient to move the limb, any pain produced during movement, and whether the patient has any limitations in the motion as compared with the unaffected side. An example of AROM of the shoulder in multiple planes is provided in Figure 8-3.

Passive Range of Motion

Passive range of motion (PROM) refers to the amount of movement at a joint that is obtained by the therapist moving the segment without assistance from the patient. In some instances, because of injury or prolonged immobilization, a joint may have less motion than is considered functional. A joint in this condition is referred to as a hypomobile joint. In other cases, such as a joint subluxation, the joint may have excessive motion and is referred to as a hypermobile joint. PROM also gives the therapist an indication of the degree and pattern of pain, as well as the “feel” of the movement.

Many methods may be used to measure and document AROM and PROM. The most common measurement technique, goniometry, is performed with a goniometer and measures joint angles. Examples of goniometers are shown in Figure 8-4. The amount of motion available at any joint depends on the structure of the joint. In addition, norm values for joint ROM depend on several factors, including the patient’s age and gender.² Typically the therapist compares ROM values of the affected joint with those on the unaffected side. Figure 8-5 shows a PT conducting a PROM measurement of a patient’s knee flexion.

Figure 8-4 Variety of goniometers to measure joint angles. The size and type vary to measure long and short limb segments and the cervical region. (Courtesy Mark Hine.)

Strength

Strength can be defined as the amount of force produced during a voluntary muscular contraction. This contraction may be performed statically (no motion) or dynamically (through an assessment of ROM). When one is assessing the status of the muscles and tendons, a quick resisted test is used. This test allows the therapist to determine the general strength of a muscle group and assess whether the muscle contraction produces pain. If the resisted test shows that a muscle or muscle group is weak or painful, further testing may be performed to isolate the specific muscle. To isolate and test specific muscles, manual muscle testing (MMT) is performed (Figure 8-6). MMT allows the therapist to assign a specific grade to a muscle. This grade is based on whether the patient can hold the limb against gravity, how much manual resistance can be tolerated, and whether the joint has full ROM. Several systems of grading are widely used. One of the most common grading systems was initially described by Robert Lovett, MD, and later modified by Henry Kendall, PT, and Florence Kendall, PT.⁴ This key to muscle grading is outlined in Table 8-1.

Table 8-1

Key to Manual Muscle Testing Grades

	Function of the Muscle	Grade	Symbols	Symbols
No movement	No contraction felt or seen in the muscle	Zero	0	0
No movement	Tendon becomes prominent or feeble; visible movement of the part	Trace	T	1
Supported in horizontal plane	Moves through partial range of motion	Poor −	P −	2 −
	Moves through complete range of motion	Poor	P	2
	Holds against slight pressure in test position Moves through partial range of motion against gravity	Poor +	P +	2 +
	Gradual release from test position	Fair −	F −	3 −
	Holds test position (no added pressure)	Fair	F	3
	Hold test position against slight pressure	Fair +	F +	3 +
Tests in the antigravity position	Holds test position against slight to moderate pressure	Good −	G −	4 −
	Holds test position against moderate pressure	Good	G	4
	Holds test position against moderate to strong pressure	Good +	G +	4 +
	Holds test position against strong pressure	Normal	N	5