Approach to Assessment
AHS2050H
J Jelsma
Clinical Physiotherapy I - AHS2050H
Module on Assessment
Jennifer Jelsma
2010
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Approach to Assessment
AHS2050H
J Jelsma
Contents:
Contents: ............................................................................................................... 2
Programme: ............................................................. Error! Bookmark not defined.
Objectives: ............................................................................................................ 3
Introduction: .......................................................................................................... 3
ICF Model .............................................................................................................. 5
Details of components ....................................................................................... 6
Impairments of body functions and structures ............................................. 6
Activity limitations and participation restrictions ......................................... 6
Environmental factors .................................................................................... 6
Personal factors ............................................................................................. 7
Outline of approach to assessment ...................................................................... 7
Demographic and medical history..................................................................... 7
Interview (subjective)........................................................................................ 7
Objective (examination) .................................................................................... 8
Analysis .............................................................................................................. 8
Examples of how the framework can be used: ................................................ 9
Problem List..................................................................................................... 12
Short term aims ............................................................................................... 12
Long term aim .................................................................................................. 12
SOAP Notes ..................................................................................................... 12
Task..................................................................................................................... 13
Case study; ...................................................................................................... 13
Guidelines for assessment of children with neurological damage or
developmental delay ........................................................................................... 14
1. Demographic details .................................................................................... 14
From folder: .................................................................................................. 14
2. Subjective assessment ................................................................................ 15
Impairments (only describe impairments relevant to the individual child) 15
Activities ....................................................................................................... 15
Participation .................................................................................................. 15
Environment .................................................................................................. 15
3. General Observation.................................................................................... 15
How did child get to physiotherapy department? ....................................... 15
4. Objective Assessment ................................................................................. 16
a. Activity ...................................................................................................... 16
b. Impairments ................................................. Error! Bookmark not defined.
5. Problem List ................................................................................................ 17
6. Short term aims ........................................................................................... 18
7. Long term aim.............................................................................................. 18
8. SOAP Notes ................................................................................................. 18
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Approach to Assessment
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J Jelsma
Objectives:
At the conclusion of the module, the student should be able to:
 Describe the rehabilitation cycle
 Describe the components of the International
Functioning, Disability and Health. (ICF)
Classification
of
 Describe the process of patient assessment
 Explain how the ICF philosophy can be used as a framework to collect
and analyse patient data and to decide on treatment priorities.
Introduction:
One of the most difficult skills that a physiotherapy student has to learn is
clinical reasoning. In order to meet the needs of a patient, the student needs
to know what the needs are, analyse these needs and the problems that are
causing them, choose and apply suitable techniques and then assess whether
the intervention has been effective. There have been several models of the
clinical process that have been developed, but the most common model is a
cyclical model in which assessment leads to appropriate treatment which then
leads to changes in the condition of the patient. These changes need to be
assessed and the cycle begins once more. An example of the rehabilitation
cycle is given below1
1
Steiner WA, Ryser L, Huber E, et al. Use of the ICF Model as a clinical problem-solving tool in physical therapy
and rehabilitation medicine. Phys Ther 2002; 82: 1098-1107
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AHS2050H
J Jelsma
Figure 1. The Rehab-Cycle is a modified version of the Rehabilitation Cycle developed by Stucki and Sangha.14 It
guides the health care professional with a logical sequence of activities. Endpoints of this rehabilitation
management system are successful problem solving or individual goals achieved. The Rehab-CYCLE involves
identifying the patient’s problems and needs, relating the problems to relevant factors of the person and the
environment, defining therapy goals, planning and implementing the interventions, and assessing the effects.
(Reprinted with permission of the American Physical Therapy Association. Figures may be used for educational
purposes, research purposes, or personal use. Commercial use is prohibited.)
The problem is that there is so much information that must be gathered. Some
of it is not important and some ends up by being essential. The inexperienced
clinician needs to learn how to gather all relevant data, but also not to waste
time by gathering information that has no bearing on the planning of the
patient’s management.
How do we go about gathering this information and how do we go about
analysing the information to decide on treatment goals and intervention?
A useful framework to manage the information gained during patient
assessment is the ICF (International Classification of Functioning, Disability
and Health)2. This is a system of classification which helps users to identify
the different aspects of a person’s condition that can impact on health and
2
World Health Organization. International Classification of Functioning,
Disability and Health. Geneva: World Health Organization; 2001.
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Approach to Assessment
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J Jelsma
functioning. It can be used to gather information in a standardised manner
through the use of codes. It is also possible to use the philosophical
framework to gather information and plan treatment.
The ICF has different components:
 Impairments of body structure (eye) and function (seeing)
 Activity limitations (rolling, walking, dressing)
 Participation restrictions (limited access to education, transport)
 Environmental factors: (policies such as education policy for disabled
children, physical environment, availability of aids, appliances)
ICF Model
The first models of disability were linear. In other words, the problem with
the person (handicap) was a direct result of the injury.
Disease or disorder
Impairments
Disabilities
Handicaps
As time went on, it became clear that disability was far more complex and the
ICF presented the following model:
Interaction of Concepts
ICF 2001
Health Condition
(disorder/disease)
Body
Function & structure
(Impairment)
Environmental
Factors
Activities
(Limitation)
Participation
(Restriction)
Personal
Factors
Based on World Health Organization (2001) International classification of
functioning, disability and health: ICF. Geneva: World Health Organization, pg.
18. Accessed online: http://www.disabilitaincifre.it/documenti/ICF_18.pdf
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Details of components
Impairments of body functions and structures
Functions
Mental functions
Sensory functions (including pain)
Voice and speech functions
Functions of the cardiovascular,
haematological, immunological and
respiratory systems
Functions of the digestive,
metabolic and endocrine systems
Genitourinary and reproductive
functions
Neuromusculoskeletal and
movement related functions
Functions of the skin and related
structures
Structures
Structures of the nervous system
Eye, ear, related structures
Structures involved in voice and
speech
Structures of the cardiovascular,
haematological, immunological and
respiratory systems
Structures related to the digestive,
metabolic and endocrine systems
Structures related to the
genitourinary and reproductive
systems
Structures related to movement
Skin and related structures
Activity limitations and participation restrictions








Learning &Applying Knowledge
General Tasks and Demands
Communication Movement
Self Care
Domestic Life Areas
Interpersonal Interactions
Major Life Areas
Community, Social & Civic Life
Environmental factors





Products and technology
Natural environment and human-made changes to the environment
Support and relationships
Attitudes
Services, systems and policies
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Personal factors
These are not coded by the ICF but include behaviours specific to the
individual, such as smoking or enthusiasm about the treatment programme.
Outline of approach to assessment
Demographic and medical history
Interview (subjective)




Impairments - only ask about impairments relevant to the individual and
his/her condition
o Mental, function
o Communication
o Sensory (sight, pain, sensation)
o Cardiovascular
o Digestive, feeding, continence, sexual function
o Neuromuscular
o Skin condition
Activity limitations:
o Learning and applying knowledge
o Communication
o Mobility:
o Hand use and lifting and carrying objects
o In bed: rolling, bed pan use, reaching locker, shifting in bed
o Sitting
o Standing
o Walking
o Self-care:
o Washing, toileting, dressing, eating
o Physical activity (highest level of activity, duration or distance?)
Participation
o Interpersonal relationships: strangers, family and friends
o Play, education, work,
o Recreation and leisure – community life sport, participation in
religion
Environmental factors:
o Aids, appliances, wheelchairs
o Support and attitudes of others
o Housing: Accessibility, adaptions
o Transport
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o Social services (e.g. grants)
Objective (examination)
 This is planned based on the subjective interview and only those
impairments and activities which have been identified as problems are
assessed.
 This part of the assessment is more specific to the health condition of
the patient. E.g. thorough examination of respiratory function is
essential in a patient with asthma, but not necessary in an NMS patient.
In addition, special measurements and tests must be included. E.g.
goniometry for impairments of the neuromuscular system or the AIMS
to determine the activity limitations of children.
 The order of assessment can be the same as the subjective, but not
always. For example, in a patient whose main problem is pain, it is
likely that the pain and the neuromuscular will be assessed first,
whereas in children with CP, the highest level of physical functioning is
usually assessed.
Analysis
Once the information has been gathered, the clinician needs to make sense of
what he/she has found.
 What are the patient’s main problems? (These are usually activity
limitations or participation restrictions, but not always. Pain or
productive coughing are examples of impairments that could be
the main problems)
 What are the underlying causes of these problems? (These are
usually impairments, e.g. weak muscles, soft tissue damage, pain
in the knee on walking)
 How can change in either impairments or activity limitations be
measured
The ICF can help to identify patterns and to analyse the relationships
between the different findings. In addition, it can help the clinician to
prioritise the problems that the patient needs to have addressed first.
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Examples of how the framework can be used:
Health Condition
Activities
Participation
Body Functions
and Structures
Home Environment
Personal
Figure. Relationships among components of functioning, environmental, and personal factors that were
important for Teresa at 17 months of age (represented by thick lines). Based on Physical Therapy, Volume
86, Number 9, September 2006. A collaborative model of service delivery for children with movement
disorders: a framework for evidence-based decision making, by RJ Palisano.
Health Condition
Body Functions
and Structures
Home Environment
Activities
Participation
Personal
Figure. Relationships among components of functioning, environmental, and personal factors that were
important for Teresa at 17 months of age (represented by thick lines). Based on From: Physical Therapy,
Volume 86, Number 9, September 2006. A collaborative model of service delivery for children with
movement disorders: a framework for evidence-based decision making, by RJ Palisano.
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Note how the same child’s problems change as she gets older.
View Stucki G, Ewert T, Cieza (A. Value and application of the ICF in
rehabilitation medicine. DisabilRehabil 2002; 24: 932-938, figure 2) for an
example of using the structure in a patient with back pathology. The
difference between the patients and the therapists perception and analysis of
the problems is highlighted.
See Steiner et al., Use of the ICF Model as a clinical problem-solving tool in
physical therapy and rehabilitation medicine, 2002; 82:1098-1107, figure 4,
available here:http://ptjournal.net/content/82/11/1098/F4.expansion.html) for an
example of using the ICF to analyse the problems of a patient with chronic
pain.
It does not matter exactly which schema is used for analysis, as long as all
components are considered. It is suggested that the original model be used,
as in the example below, applied to a patient with a fracture of the tibia/fibula
in the early stages of treatment.
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Approach to Assessment
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HEALTH CONDITION
Fractured tib/femur acute. Car
accident.External
fixation
IMPAIRMENTS
ACTIVITY
LIMITATION
PARTICIPATION
RESTRICTION
Pain in thigh
Soft tissue damage
Weak muscles quads and gluts
Limited RoM of knee
Swelling
Sore under heel
Bed rest
Unable to look after
infant at home
Lost domestic work job
due to accident
Productive cough
Anxious
Cannot bridge to use
bed pan
Cannot shift in bed
Cannot reach locker
Cannot come into
sitting
No balance in standing
ENVIRONMENTAL
FACTORS
PERSONAL FACTORS
Locker not close to
bed
No husband
Supportive mother
Ward has no parallel
bars
Home - one story
and accessible to
wheelchair and
crutch walking
Not yet applied to
Road Accident Fund
for compensation
Overweight
Depressed
Smoker
How would the priorities change if the patient were to be discharged in the
next day or so?
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Approach to Assessment
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J Jelsma
Problem List
Once the analysis has been done, the most important FUNCTIONAL problems
should be identified and documents
Prioritise the most important problems and analyse completely, using the
following table.
Functional
Problems
Usually activity
or participation
(but could be pain
or respiratory
function)
Missing
Components
If necessary for
movement
analysis
Underlying
reasons
Usually
impairments of
body function
Intervention
indicator
Either for
impairments (e.g.
pain VAS) or
activities (e.g.
AIMS)
Short term aims
Must be functional aims (likely to be achieved in the next few treatment
sessions)
Long term aim
Think of ONE function you would like to improve in 6 months’ time.
SOAP Notes
Includes daily updates on the Subjective, Objective, Analysis of Problems
(SOAP) and treatment plan.
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Approach to Assessment
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Task
Read through case study
 Identify what problems the patient has and what codes could be used to
describe his/her condition using ICF checklist
 Refer to ICF diagram and identify which domains are most problematic
for the patient
 Using the diagram, identify which domains are connected and in what
way.
 Finally write your problem list with underlying causes, based on the
interactions noted in the ICF Diagram.
Case study;
Sophie is a 2 year old child who has Tuberculosis. She started on treatment
two months ago. She is an in-patient at Brooklyn Chest Hospital because her
mother is very ill with HIV and her grandmother is caring for three other
children. Her father is in jail. It is therefore unlikely that she will receive her
medication regularly.
She is a withdrawn child who rarely smiles. She does not say very much and
does not seem to understand English at all. She does not play with toys and
generally is quite apathetic.. She has an itchy rash on her stomach which
irritates her and causes her to scratch. She has a productive cough and easily
gets short of breath. She has problems with keeping her medication down and
often vomits during treatment. She is kept in nappies by the nursing staff. She
is undernourished and small for her age. She has weak trunk muscles and her
muscle tone is decreased. She has no limitation of range of movement.
She is able to roll and come into sitting. She crawls a little and can pull up
into standing. However, she is unable to walk independently.
She is likely to stay in hospital for the next three months.
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Guidelines for assessment of children with neurological
damage or developmental delay
ICF FRAMEWORK
Health Condition
(disorder)
Body function &
structure
Activities
Participation
Environmental
Personal
Factors
Factors
Based on World Health Organization (2001) International classification of functioning, disability
and health: ICF. Geneva: World Health Organization, pg. 18. Accessed online:
http://www.disabilitaincifre.it/documenti/ICF_18.pdf
Note in which area the child is experiencing the most problems. What are the
connections between these elements?
1. Demographic details
NAME:
DATE OF BIRTH:
ASSESSMENT:
AGE:
DIAGNOSIS:
ASSESSED BY:
DATE OF
From folder:
BIRTH HISTORY
SUBSEQUENT HISTORY
MEDICATION – type and what it is for
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SURGERY – date and type
2. Subjective assessment
Impairments (only describe impairments relevant to the individual child)








Mental function
Sight, hearing
Speech
Feeding
Pain
Respiratory or cardiac function
Continence
Skin condition
Activities




Learning and applying knowledge
Communication
Self-care; dressing, bathing, brushing teeth
Physical activity (highest level of activity, duration or distance?)
Participation



Domestic life (how he spends his day?)
Interpersonal relationships
Community and social life
Environment





Appliances
Transport
Accessibility in home (type of house, no. of rooms, no. of people
sleeping per room, available amenities, space move around) and other
areas
Support of community and family involvement
Services (disability and child support grant)
3. General Observation
How did child get to physiotherapy department?
Is child walking, in a buggy or wheelchair, using appliances?
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Observe child undressing and comment
4. Objective Assessment
a. Activity
START AT HIGHEST FUNCTIONAL LEVEL!
If standing, assess POSTURE in standing, with appliances on.
If in a wheelchair, assess POSTURE in wheelchair (this is where he spends
most of his time)
Describe and analyse FUNCTION IN HIGHEST LEVEL.
If ambulant, describe walking
Running
Jumping
Hopping left and right
Stair climbing
Throwing and catching a ball
Assess BALANCE in highest functional level, both static and dynamic.
Observe and describe how child moves to a lower functional level, e.g.
Transitional movement from STANDING TO SITTING ON A CHAIR AND
STANDING TO SITTING ON THE FLOOR AND BACK UP AGAIN.
Observe and describe how child gets into and out of HALF KNEELING,
KNEELING and CRAWLING. Is child able to maintain these positions? Is he
able to play in these positions? Describe type of play.
If the highest functional position is SITTING SUPPORTED IN A
WHEELCHAIR, describe what child can do in this position. Can he reach and
grasp an object? Can he hold a pen and write? Does he need help in getting
out of wheelchair – how much assistance does he need?
Transfer child to the mat. Can he SIT UNSUPPORTED? If not, describe what
is preventing him from doing so. Try LONG SIT, CROSS LEG SITTING, SIDE
SITTING. What can he do in these positions, eg. maintain position with
bilateral arm support, free one hand to reach or play, move out of these
positions?
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If child is unable to sit, position him in SUPINE. Describe function in this
position. Can he reach symmetrically with both arms? Can he kick legs? Can
he roll to SIDE LYING or PRONE?
In PRONE describe what he can do. Describe how he gets into PUPPY
PRONE, can he maintain this? Can he lift his head? Can he free one arm and
reach forward without collapsing on opposite side? Can he creep in this
position, describe how. Can he move out of this position into SUPINE or
CRAWLING POSITION? Describe this movement.
b. Impairments
RESPIRATORY CONDITION
TONE
Describe tone in all affected muscle groups.
ROM
If full range of motion, document FROM.
If range is limited, you must measure limitation with goniometer and record
accurately.
MUSCLE LENGTH AND STRENGTH
Note when muscle is shortened.
4. Review ICF Framework before analysing problems
5. Problem List
Document FUNCTIONAL problems
Prioritise the most important problems and analyse completely, using the
following table.
Functional
Problems
Usually activity
or participation
(but could be pain
or respiratory
function)
Missing
Components
If necessary for
movement
analysis
Underlying
reasons
Usually
impairments of
body function
Intervention
indicator
Either for
impairments (e.g.
pain VAS) or
activities (e.g.
AIMS)
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6. Short term aims
Must be functional aims (likely to be achieved in the next few treatment
sessions)
7. Long term aim
Think of ONE function you would like to improve in 6 months time.
8. SOAP Notes
Including progress and any changes you need to make to your intervention
plan
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Approach to Assessment
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J Jelsma
Clinical Physiotherapy: Approach to Assessment (AH2050H)
by Jennifer Jelsma, Physiotherapy Division,
Department of Health and Rehabilitation Sciences, University of Cape Town
(2010) is licensed under a
Creative Commons Attribution-NonCommercial-ShareAlike 2.5
South Africa License.
Please see http://creativecommons.org/licenses/by-nc-sa/2.5/za/
for terms and conditions. All images created by external parties retain their
original licenses
Source work available at vula.uct.ac.za
Permissions beyond the scope of this license may be available at
www.healthedu.uct.ac.za or healthoer@uct.ac.za
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