Assessment In Clinic Assignment

Internship

Paul Hussey
821-718-087
Thursday November 6th,2014
Andrew Clapperton

Clinical Assignment 2 Outline

Evaluative Phase:
In order to complete a successful treatment there are various phases that need to be completed
before any progress can occur. These phases are important overall because it allows the patient to receive full practical care that will recover them to optimal health, and by hearing what
the patient has to say, will give the therapist a more direct idea of what might be the underlying
issue. The phase in which I will be taking a closer look at will be the Evaluative Phase.
The evaluative phase in my opinion is the most crucial phase. This phase allows the
therapist to dictate what is going on with the patient through subjective and objective information. By gathering this information, it allows the therapist to conduct a hypothesis to the potential impairments the patients may bring in, which in turn, allows the therapist to form and
compose a treatment plan. There are multiple steps to which the Evaluative Phase is completed. It follows a specific order so that all the necessary information is gathered before making
any progress.
Steps to the Evaluative Phase:
Client with problem> Conduct Subjective Information> Create a Hypothesis> Perform
Objective Examination> Confirm Hypothesis> Gather and view clinical findings> Determine appropriateness for treatment.(Andrade,2008,pg.49)
* This guideline is the outline to the Evaluative phase, the only difference is if the patient was
referred previously or not. If no referral diagnosis is present, then ask basic general information
for subjective gathering. If referral diagnosis is present, gather information to confirm or disregard the diagnosis. Once that has been clarified, I can move forward to make my hypothesis
based on my findings found from the subjective info gathered. (Andrade,2008,pg.49)

Steps in Evaluative Phase

What Happens in Step?

Conduct Subjective Information

In the step, the therapist collects basic information from

the patient about their daily living, and information about
their associated injury. Ask pain questions.

Generate Hypothesis
Conduct Objective Information

Confirm Clinical Hypothesis

Summarize Findings

Determine Appropriateness of Treatment

Create hypothesis to what I think might be the issue,

given the subjective information that I have collected.
Perform various tests to test certain muscles
strength,ROM,endurance as well as looking for postural
dysfunction,to narrow your location of treatment.
After the information has been collected confirm your
hypothesis from before, if the objective information
proves it true.Based on findings come to conclusion.
Gather all the information that has been given to you via
mouth, and assessments to see what you have to work
with. Create limitation and outcome lists.
Based on information I reviewed, I can determine what
type of treatment I will provide to my patient.

Rationale for Evaluative Phase Steps:

Conduct Subjective Examination:
Conducting subjective information from a patient is a crucial step to understand what is going on
with your patient. The way that you acquire this subjective information, is asking basic questions
about active lifestyle and even job and side hobbies. I would have to also ask for their reason
seeking treatment, and get answers to questions related to their injury. Asking multiple questions and getting answers really shapes the picture, and allows me to see what possible impairments this individual may have. Its important to conduct subjective examinations because it
allows the therapist to get an understanding of how this individual lives, and also is able to understand the injury more with questions related. By having the answers to what I need to find
out, I can then move to create a hypothesis to what I think may be the issue.

Create a Clinical Hypothesis:

The next step in the evaluative phase is coming up with possible impairments that my client may
have. Thats where I take the subjective analysis and come up with potential issues this individual has. By creating this hypothesis, it allows me to focus in on more specific areas on the patients body, as well as focus more attention on specific MMTs and SOTs to perform on the patient. I create this hypothesis by overviewing the information I have conducted subjectively and
see if it relates to the complaint of their injury. I base their ADL lifestyle, with the complaint information and see if there is any correlation between the two. Making this clinical decision also
helps me think critically about the situation, and allows for which may allow me to have different
approaches on how I could treat them.

Conduct Objective Examination:

After the hypothesis has been created, you can then focus in on specific assessments and tests
related to the problem the patient has. Objective assessments give you measurements and
physical feedback to see whats really dysfunctional. With the hypothesis that I created I can use
assessments that pertain to that area, and yes the affected and unaffected side and mark differences. Postural dysfunction,muscle weakness,muscular dysfunction,impingement,fascial restrictions and muscle tightness are all things to look for when looking at objective information.
Gathering objective information is important for a treatment plan because it gives you a visual
aid to what is going on, rather then from word of mouth. With objective information testing it allows me to specify even more specifically now that I can visually see what area is impaired. Its
more focused because word of mouth gives a general idea of what could be wrong, but with the
objective testing and physical assessment aspect, thats where I can visually and physically see
what is wrong with my patient.

Confirm Clinical Hypothesis:

Going through all the assessments and looking at the patient, I can now see if what I believed to
be true was actually proven to be true. Objective information gives me the visual validity I need
to see if my hypothesis was actually accurate based on the subjective information I was told.
Once I confirm that my hypothesis is true, I can then look at the treatment progress as a whole.
It is important to confirm my clinical hypothesis because,it gives me a sense of what needs to be
done during treatment. If the hypothesis was never resolved, then the treatment process would
be non specific and that wouldn't really be truly beneficial to the patient. Its also important to
confirm the hypothesis based on findings because, without confirming it, I would have to reassess and complete other tests and check for other issues in the impaired area.(Andrade,2008,pg.52)

Summarize Clinical Findings:

Once I have confirmed that the hypothesis I have created was true, I can then start summarizing
the information I have gathered, and start making functional limitation and functional outcomes
lists to further progress the patients treatment plan.(Andrade,2008,pg.53) These lists allow me
to achieve outcomes that the patient had difficulty doing, and improving their overall health,
once the outcome had been attended to. The way in which I can create these lists would to
overlook the objective assessments to look for dysfunction and impairment, and make a list of
things that need to be fixed such as; ROM,muscle strength,muscle tightness,fascial restriction
or even postural improvements. This is crucial for the treatment process because it allows me to
follow a guideline to help this individual get back to optimal strength and form, so that they can
do their ADL, or job more sufficiently.

Determine Appropriateness for Treatment:

The final step in the Evaluative phase is determine what the appropriate type of treatment would
be for the patient. As the therapist, I have to decide what type of techniques I would use on the
person, given their condition. I have to understand what type of modalities I may have to use
given if theres inflammation,pain,scar tissue,fascial restrictions etc. All of those things have to
be taken into consideration before the actual treatment. In retrospect, if the results of all the assessments prove to show that the patient doesn't need massage therapy, or another practitioner
might deem more valuable, then a referral might need to happen. Thats where I as the therapist
have to make a clinical decision using the best available evidence given to me to determine the
appropriateness for the treatment. This step is crucial in the treatment process because it is the
overall aspect of how this patient is going to get better. If the patient is in need of physiotherapy,
and we provide the services of massage, is acute injury or dysfunction wont be getting better
the way it should. Its important to determine the treatment before it begins, so I can classify if
massage is the proper way to this patient.

Evaluative Phase to a Patient:

ID Number: 101026

Description of Patient History:

The patient who I will use to describe this phase, is an individual who had a lot going on. He
was a fit varsity athlete,and had good muscle tone and good build. I was not his initial treatment
therapist, but I was working with an ongoing treatment plan. Based on the SOAP notes provided
by the therapists before me, I had realized that he had been in a car crash, he had an inguinal
surgery,as well as having IT/hip issues due to volleyball. He had also mentioned that there is
soreness in his shoulder due to volleyball as well as there was a lot to work on. As for pain assessment, I went through various ranges with this individual, to come to the conclusion that
there was no specific pain just feeling of tension and tightness at end range. This patient also
mentioned that his pain tolerance was very good, so pain scale readings were usually minimal
(0-3 on the pain scale). When asking the patient what were the goals that he wanted focus on
for the treatment I was about to provide, he mentioned his IT bands were causing discomfort on
both sides, trigger points in the calves as well as rotator cuff discomfort on the left shoulder. So
the outcomes I wanted to achieve for the treatment were to; reduce less restriction in the IT
band region potentially releasing triggers that may arise,relieve the triggers in his calves by performing muscle stripping, as well as lowering tension in the muscles of the rotator cuff.

Description of the Evaluative Phase:

Subjective Information Gathering:
The information that I gathered with my patient, was just information relating to previous treatments in the clinic that he had gone to. I asked him questions relating to the issues relieving
around his surgery, as well as his IT band tightness. He had also brought up that he had shoulder issues from playing volleyball, and it feels discomforting when he hits the ball. He had also
let me know that he has trigger points in the medial heads of both calves and that he wanted
those triggers gone. As for a pain assessment for my own purposes because I have never
treated this individual before, I did a pain assessment on his IT band issue. After the questions
asked and the information gathered, he had made it quite clear on where specifically the restrictions were in his IT(near the greater trochanter) as well as down the femur. He tried doing
self stretch to eliminate and reduce restriction but it didn't fully fix the problem.
Generate Clinical Hypothesis:
While listening to my patient tell me about his restrictions to ADL, I was thinking of possible factors about what could be going on. The patient may have just overused the IT band while being
an active athlete playing his sport could cause wear and tear. Also the fact that he had a inguinal surgery,near the hip resulting in a wrecked psoas muscle could result in a compensating IT.
As for the triggers in his calves it could be from improper stretching to having tightness in a
muscle. The shoulder led me to believe overuse of the shoulder muscles when producing the
range of hitting a volleyball, the muscles needed to be relaxed and rehabilitated. There was a
diagnosis from previous therapists so I was going to confirm or refute it with my own diagnosis.
Objective Information Gathering:
When doing the assessments and testing for my patient, I didn't really do to many tests because
things have already been tested in the past. I did however, complete an SOT of the IT tightness
(Obers Test), to see if it would come out positive or negative. I tested both legs, but both of

them turned out negative, as both legs returned to the table. I also did the Thomas Test to test
for contracture of the hip flexors. Once again I had tested both legs, but both were negative and
no pain was reported. The patient did however state that the side he had surgery on felt a little
bit of tension when the opposing leg was brought to chest, but no pain was reported. I decided
to perform these assessments because they were done in previous treatments, as well as it
would give me a better understanding of this patients actual ROM in the specific areas he wanted me to treat. By both tests being negative it also allowed me to know the severity of the restrictions and if they were positive, it would let me know that there may be further complications
that need evaluating.
Confirm Clinical Hypothesis:
Once I confirmed all my tests and subjective information was gathered, the outcomes still
prooved to show that the IT bands were still tight, and based on the subjective information from
earlier on in the treatment, his calves and shoulders were still in discomfort. I now knew that
what I had guessed was the issue from before was indeed correct, and I could now move onto
determining the treatment for this individual.It was important to confirm my clinical hypothesis
because if it wasn't confirmed, I would have to check a bunch of other tests to check for other
impairments. Now I am able to successfully check those specific areas and provide a treatment
plan that will help this patient have improvements to his injured tissues.
Determine Appropriateness for Treatment:
When determine the appropriateness for the treatment, I overlooked all of the assessment outcomes and looked at the clinical list of limitations and outcomes. I made note if these impairments are treated by massage therapy, or if another practitioner would be more suitable. Majority of the clinical list was treatable thus not needing to refer my patient. Once i knew that I was
able to treat him, I thought of the various techniques that I would use to optimize and create the
best possible outcome and results for my patient. I knew that I would need to do trigger point
techniques to get rid of the trigger points in the specific areas, as well as myofascial techniques
to loosen up the fascia in regards to the IT bands. With trigger points, I apply the heat to the areas after the work has been complete on it to keep blood flow going to the area and keep the
fascia loose to the IT bands as well as gastrocs. After the treatment was complete, I gave my
patient self stretches and exercise to do to keep the tissues worked and try and loosen it up for
a self help post treatment. This step was important because it allows for a treatment plan to be
followed and can happen weekly and, keep going until the patients overall function is returned
good enough to consider discharge from the clinic.

Analysis/Reflection on Performance:
Overall, I feel that I covered all of the steps of the evaluative phase for this patients treatment.
The subjective information, I got information from the patient regarding his injuries and, also got
information about his life and activities to help me paint my own picture. It allowed me to get a
good understanding of my patient despite having SOAP notes. I looked at the previous diagnosis of my clients previously and came up with one similar. It was similar because of the similar

results and the subjective information was practically the same as the previous therapists who
worked on this patient. For the objective assessment aspect, I took a couple of SOT that weren't
completed to test for anything that the other therapists might have missed. To my knowledge,
after completing these steps they were both negative so no new symptoms or impairments had
arose since the treatments previous to mine. Since the tests were negative I could then confirm
just like the other therapists that what I had originally thought was the issue was what indeed
needed work on. The next step in the process was looking at the impairments this individual had
and creating list of how to fix those impairments and improve them to optimize normal health
again to the tissue or joints. I had asked my patient what his highest concerns were at that moment and death with those first, since those were the things that were the most serious in terms
of his athletic schedule. For my treatment, I ensured that all of the areas that needed to be
treated were met, and followed up with my patient if everything felt better then at the beginning
of the treatment, and if everything felt fine, as I got the answer Yes. The stretches i provided
with home care essentially would strengthen the areas that were in need of assistance, and
would also help stretch out the tight areas where there were restrictions.
Things I would do differently was evaluate the patient with more tests then what I did,
incase i missed something that could of potentially meant there was another underlying issue
that might be more severe. Also if I had more experience with patients, I would of been able to
apply harder depth to my techniques right away to ensure that I was targeting the affected tissues, rather then potentially being superficial to the issue. I found it was more difficult treating
an athlete then any average joe, because they're more solid and muscular, thus having to go
deeper with my techniques. Lastly another aspect I wish I could improve on would be my RemEx or even the home care stretches, just so I could offer my patients more then what I give
them during treatment. I would like to give them more specific things they could do at home to
self help themselves, just so they can do their share so Im not doing all the work.

Application of Findings:
Looking over what other therapists have evaluated on this individual, I was seeing similar results
whilst talking to him getting subjective information. The MT diagnosis that I composed was that
he had major fascial restrictions on both IT bands, as well as having very tight quads and high
muscle tension in both legs. Both of these impairments could of very well been due to his hip
problems he had, including the surgery that he had done. Through the assessments and information I gathered, it helped me create my treatment plan because it gave me an area to focus
on rather then not being specific enough in my treatment. Also since the areas that were impaired were large surface areas (Quads and upper thigh), I was able to use more broad contact
surfaces, and I could apply a lot more depth in my technique because it wasn't in a sensitive,low
tissue area. By using the techniques the way I did, it would allow me to do a more sufficient and
successful treatment for my patient, whereas if I didn't do certain techniques, I may have not
gotten the same results.
Reference List:
Carla-Krystin Andrade, (2008). Outcome-Based Massage-From Evidence to Practice. 2nd ed.
Toronto: Paul Clifford.