Chapter 2



The Therapist as Clinical Decision-maker

When a patient comes to a therapist with a problem, that patient is expecting the therapist to help alleviate or resolve the problem. To do so, therapists must:

Understand and Clarify the Origin and the Extent of the Problem

Does the therapist know the origin of the problem? Determine the onset, including the mechanism of injury, acquire knowledge of circumstances surrounding the injury (or injuries), the behavior of the problem, the physician's intervention, including surgical procedures, etc. Isolate and determine as much as possible the cause of the problem, and whether other structures are involved.

Assess the Impact of the Problem on the Person's Life

Establish a baseline of the patientís functional ability by accurately measuring and recording significant data. This also allows the therapist measures against which to judge progress and assess effectiveness of the treatment.

Establish Patient-centered Treatment Strategies to restore premorbid function as much as possible: incorporating the therapist's knowledge of anatomy, physiology, and interventions into treatments focusing on the patientís desired outcome(s). The therapist assists with and guides the person's healing process.


To make sound clinical decisions regarding their patients, therapists must follow a structured approach. Part I of the Hypothesis Oriented Algorithm for Clinicians (HOAC) proposed by Ecthernach and Rothstein (1989) provides such a structure for the evaluation of a person with a musculoskeletal problem:

Part I

  1. Collect initial data (chart review, history, interview patient/family/others)

  2. Generate a problem statement.

      Establish goals with the patient (measurable and functional with time frames).

  3. Perform physical examination (collect data on origin and extent of problem and impact on patientís life).

  4. Generate a working hypothesis about the problem(s).

      Correlate and interpret findings of the P.E. to determine a P.T Diagnosis or Occupational Challenge

      Refer to other practitioner (if therapist cannot generate a hypothesis)

  5. Plan reevaluation methodology (schedule dates for reevaluations)

  6. Plan treatment strategy based on hypothesis (overall treatment approach)

      Obtain consultation, if needed.

  7. Plan tactics to implement strategy (specifics of treatment plan)

  8. Implement tactics (perform treatment)
Collecting Data: The Chart Review: * The physician's findings will provide valuable information regarding the diagnosis, past history, and current status of all major systems. Remember that the physician's diagnosis will be somewhat different from your own.

** Knowledge of the surgical intervention is crucial to the evaluation and selection of treatment strategies. Awareness of the anatomy that has been affected by the injury and by the surgery, as well as how the structures heal is central to effective and safe rehabilitation.

Collecting Data: The Patient Interview

The primary goals of acquiring a patient's history are to accurately determine the origin of the person's problem and its impact on the person's life.

Remember to LISTEN to your patient, and let those responses guide your interview. Maitlandís Philosophy of Interviewing Patients (1993): The questions that the therapist asks should be, for the most part, open-ended in that they require more than a yes or no response. This allows patients to describe their circumstances in their own words.

Acquiring information about the patientís problem: Questions about the patientís problem follow the LOCIDAA format (Hicks & Kelsey, 1997): If the person uses: Assess the Impact of the Problem on the Person's Life:

Questions about the person should focus on the activities that the person performs and the environments in which they perform them. The activities should address home, work, and leisure/play and should reflect a typical day for the patient. Additional Questions: During the interview and subsequent treatment, therapists continually seek to gather information from their patients. When talking with patients, consider Maitlandís "Keys to Successful Communication" (1993):

Paralleling: the process of following the personís line of thinking and following-up with related questions.

Keying: pay attention to "key" words that people may use to describe their condition, often without realizing its significance.


The goal of the physical examination is compare information from the interview with physical findings, ultimately to identify the origin of a personís problem and to establish a baseline of the person's functional ability.

The Scanning Examination / Quadrant Screening

Although patients may come to a therapist with what appears to be a joint-specific problem, it is very important that therapists do not develop "tunnel vision." Many patient problems can arise from a central pathology but present themselves with peripheral symptoms. Therapists must view the patient as an entire system, evaluating the patient from a larger, wholistic perspective first, then moving toward a more focused evaluation of what appears to be the problematic area.

The scanning examination should briefly but accurately assess each region of the quadrant.

For the Upper Quadrant / Upper Quarter: the TMJ, cervical spine, scapula, shoulder, elbow, wrist, and hand.

For the Lower Quadrant / Lower Quarter: the lumbar spine, the sacroiliac joint, hip, knee, ankle, and foot.

Beginning therapists should make it a habit to perform the scanning examination on most of the patients that they see. Some exceptions: patients whose surgical status would it inappropriate to perform a scanning evaluation.

Once the therapist has ruled out more central or proximal problems, the therapist can then perform an evaluation more specific to an area. This consists of: Observation and Preliminary Palpation: observe the patient's hygiene, emotional status, body build (slim, obese, cachectic, short stature, etc), vital signs if indicated, deformities, or abnormalities in positioning of body parts. Perform preliminary palpation of the area to evaluate tissue warmth and texture.

Range of Motion and Selective Tissue Tension Tests: consists of specific active, passive, and resisted movement tests that assess the status of each of the component tissues of the physiological joint. Assessing both noncontractile and contractile structures with ACTIVE MOVEMENTS: test the general willingness and ability of the person to move the part as well as overall quality of movement. Pain with active movements suggests an irritated structure is being stretched, being pinched between two structures, or an involved contractile tissue is being used. Note loss of full range of motion, crepitus, pain, movement pattern etc.

Assessing noncontractile structures with PASSIVE MOVEMENTS: tests the range of movement available at the joint, end-feels of the joint, and whether there is pain on movement. Emphasizes assessment of the non-contractile/inert structures at the joint, primarily joint capsule and ligament. A tear in a ligament is a sprain. "Normal" End-feels: "Abnormal" End-feels: Pain on movement of the joint: pain at the extremes of movement indicates that a painful structure is being stretched or a painful structure is being compressed.

Assessing contractile structures with RESISTIVE MOVEMENTS: these assess the status of musculotendinous tissue. Determines tears or inflammation of a muscle or tendon. A tear in a muscle is a strain.

It is critical that therapists stress the muscle and tendon that they wish to test without stressing non-contractile joint structures. Isolate the specific muscle, and place it in a resting position (usually a midposition). It is important to stabilize the part while stressing/applying resistance.

When performing resisted tests, determine whether the contraction is strong or weak, and whether it is painful or painless. Weakness may be due to a neurologic deficit or actual loss of continuity/tearing of the muscle or tendon; a painful contraction signifies the presence of some pathology involving the muscle or tendon.

Four possible findings on resisted tests: Strength Evaluation

Depending on the patient's problem, therapists may choose to evaluate the patient's strength via Manual Muscle Testing (MMT). Indications for performing a MMT to assess muscular strength include: Neurological Evaluation

When assessing neurologic function clinically, if you detect a deficit, you can estimate the approximate site of the pathology by correlating the extent of the deficit with peripheral nerve and segmental distributions. Postural Control / Balance:

Performance of Functional Activities

In addition to information provided by the person in regard to limitations as a result of an injury/pathology, the therapist should evaluate and measure the person's ability to perform functional tasks. The tasks evaluated should be those that the person has identified and prioritized. Measure limitations related to the patientís performance of specific activities that are related to the personís desired outcome(s).


The therapist will take the information that the patient has provided in the interview, and correlate it with the findings of the physical examination. Then the therapist determines a physical therapy diagnosis / occupational challenge, sets goals based on the patientís desired outcome, and devises and implements treatment strategies.

The Occupational Challenge and the Physical Therapy Diagnosis: Therapists determine the pathophysiology or impairment(s) by correlating information from the evaluation (in which they ruled-in or ruled-out certain structures) with knowledge of anatomy, physiology, kinesiology, and pathology. The pathophysiology and/or impairment name the origin and extent of the problem.

The functional limitation and/or disability describe the deficits occurring because of a pathophysiological problem or impairment that effect a person's ability to perform his or her usual activities. Therapists determine functional limitations and disabilities from the history provided by the patient or significant other, as well as by the findings from the physical examination. (Cech & Martin, 1995).

When to Refer the Patient to Another Practitioner

Magee (1997) identifies several "red flag" findings that indicate the need for the therapist to refer the patient to another, more appropriate practitioner: DOCUMENTATION

Documentation of the initial evaluation should be structured (and follow the systematic approach used in the evaluation), objective (with measurements that can be reproduced), and documented treatment should be such that it can be performed by another therapist.


The initial orthopedic evaluation, which consists of a thorough history and physical examination, is but the first step in the treatment process of people with musculoskeletal problems. A reevaluation of the patientís status should always precede subsequent treatments, addressing many, if not all, of the components addressed in the initial evaluation. Therapists are continuously making clinical decisions based on information they acquire from the evaluation, working to guide the body's healing abilities to help the person regain functional abilities that are important to them.

Table of Typical Findings Associated with Problems of Specific Tissues

Therapists should be alert to patterns of signs and symptoms, as well as key words that the patient may use, which can provide clues to the origin of the patient's problem.

Go To Chapter 3

Return to Table of Contents