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Subjective assessment

  • Used to gain information about a patient’s presentation to help determine symptom sources and mechanisms, goal setting and to determine that most appropriate intervention.

  • The success of an effective subjective assessment does not lie in asking every possible question. Rather, it rests on the clinician’s ability to clinically reason the most appropriate questions and to understand the reasoning behind asking each question (Ryder, 2013). 

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The main components of a subjective examination are:

Body chart

Body Chart

Allows the practitioner to differentiate pain mechanisms, symptom sources and to recognise relationships between symptoms (Ryder, 2013).

Whats on a body chart?

  1. Areas of current symptoms

  2. Symptom quality,

    • The quality of the symptoms marked on the body chart can help determine the anatomical structure at fault. However, pain quality can be ambiguous and clinical reasoning must be used with each presentation (Dalton & Jull, 1989).  

      • Magee (2006) presented potential descriptors for various structures:

        • Bone = Deep, nagging, dull

        • Muscle= Dull ache

        • Nerve root= sharp shooting, electric shock

        • Sympathetic= Burning, pressure, stinging

        • Vascular= Throbbing diffuse pain

  3. Symptom intensity, 

    • Usually measured through a numerical or visual analogue rating scale (VAS)

    • Allow for determining effectiveness of a management plan or treatment intervention.

  4. Abnormal sensations

  • Abnormal sensations are placed on the body chart to and may include paraesthesia, anaesthesia, hypoaesthesia, hyperaesthesia, allodynia, analgesia, hypoalgesia or hyperalgesia along a peripheral nerve or nerve root.

​5. A tick is marked on the body chart to represent any unaffected, related areas that have been ‘cleared’​​

Hx of presenting conditon

HOPC

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Clarifying the following questions for each symptom helps to identify the nature of the symptoms and can help with determining relationships between symptoms:

  • How long have symptoms been present? Helps to understand stages of tissue healing timeframes and if there is any relationship between other symptoms. Did the symptoms start around the same time?

  • Was it gradual or sudden onset? Was there a mechanism of injury or lifestyle change that provoked initial symptoms? Helps to understand symptom sources i.e. gradual onset vs trauma may differentiate between bony fracture or GHJ OA. It also helps to identify whether there was a change in activity that overloaded tissue.

  • Are symptoms improving, worsening or staying the same? Helps to determine the stage of the condition and to determine time for recovery. Symptoms that are deteriorating can take longer to resolve (Ryder, 2013).

  • Has the patient had previous treatment – what effect did it have? Helps to isolate symptom sources, devise treatment options on interventions that were effective/ineffective.

PMHx

PMHx

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Does the patient have any major illnesses, accidents or history of major operations? i.e OP, RA, CV disease etc.

Symptom behaviour

Symptom behaviour

Constant or intermittent symptoms

Any symptoms that are not present for 24hours of the day are considered intermittent symptoms.

Constant pain that does not fluctuate is indicative of serious pathology, whereas constant symptoms that vary in intensity can be indicative of inflammatory or infective causes (Ryder, 2013).

 

Behaviour of symptoms

Can provide information on functional impairments and allow decisions to be made regarding the severity, irritability and nature of the complaints.

Aggravating/easing factors:

Understand the specific movements or postures that increase/decrease each of the patient’s complaints, and the time required to be in the identified movement/posture before a change in symptoms is noted.

This information helps to understand any functional restrictions, symptom relationships and allows the clinician to gain an understanding of the patient’s level of irritability. This aids in creating an effective physical examination and ultimately, an effective management plan.

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Severity and irritability of symptoms:

Used to guide the physical examination to avoid unnecessary exacerbations of symptoms.

Severity is related to the intensity of symptoms and the degree that symptoms limit movement and/or function. A symptom that is classified as severe would present as an inability to maintain a movement secondary to the intensity of symptoms whereas if the patient can continue with a movement despite symptoms, this is considered not severe.

Irritability is the degree which symptoms increase and subsequently decrease with an aggravating movement/posture and is time-related. If symptoms cease immediately, then the symptom is deemed non-irritable.

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24hour behaviour of symptoms:

Helps to be specific to monitor treatment success and identify serious pathology, inflammatory conditions or mechanical behaviour.

Night symptoms –

  • trouble sleeping (helps to identify potential stress on structures),

  • positions of comfort/discomfort (helps to disseminate aggravating positions),

  • pillow use (if cervical symptoms are present),

  • mattress type,

  • woken by symptoms? (if so, how many times in one night? In a week? Can they get back to sleep? How long?)

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Morning symptoms –

  • What are symptoms immediately upon waking before getting out of bed?

  • What are symptoms like after getting out of bed?

    • Prolonged morning pain plus stiffness, can indicate inflammatory component (Magee, 2006).

    • Prolonged morning stiffness without pain can indicate presence of degenerative disease (Huskisson et al. 1979).

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Evening symptoms –

  • Usually dependent on patient activity levels. For example, days at work versus days not at work – are symptoms different?

Special questions
Sx & FHx

Specical questions

Special questions are used to identify red flags and differentiate conditions that are suitable for physiotherapy intervention or those that require further investigation outside of the scope of physiotherapy (Henschke et al., 2013).

For each patient, this includes (Butler; 2010; Ryder, 2013):

  • General health: Poor general health can be indicative of systemic disease processes. Ask about: fatigue, fever, nausea or vomiting, stress, anxiety or depression. Does the patient have any major illnesses or history of major operations? i.e thyroid, OP, RA, CV/resp. disease, DM. Understanding the potential relationship to their symptoms secondary to these is important.

  • Weight loss: Any recent weight loss? Unexplained weight loss can be secondary to malignancy or systemic disease.

  • Cancer: Both personal and family history of cancer is required to determine if physiotherapy intervention is appropriate or if there is potential contribution of red flags.

  • Neurological symptoms: are there signs of spinal cord compression? (bilateral pins and needles in hands and/or feet, or walking difficulty). Are there signs of cauda equina? (saddle paraesthesia/anaesthesia and bladder/bowel sphincter disturbances)

  • Drug use: has there been long-term use of medications/steroids that can cause OP? Is the patient taking anti-coagulants? Is there prescription medication for their condition or are they self-prescribing?

  • History of radiographs, medical imaging or tests

What to do with all this

SHx & FHx

Social history is concerned with patient perspectives and expectations, age, employment, home situation and leisure activities. This allows for managing the patient within the context of the WHO-ICF. Family history may help to understand a patient’s susceptibility to development of a condition or their perceptions.

What to do with all this information?

Once all of the above information has been gathered, it is now important to clarify anything that may not be understood of the patient symptoms. Then, identifying subjective asterisks such as a functional task restriction or specific patient complaint, so that it can be reassessed in later sessions.

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It is vital that the physiotherapist clinically reason what has been found within the subjective examination, noting relationships between symptoms, pain mechanisms, behaviour and patient history. This can help with a provisional diagnosis of the patient’s symptoms and direct an appropriate, effective and efficient physical examination and management plan.

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Using all this information to conduct a physical examination requires reasoning of precautions or contraindications, severity, irritability, degree to which pain will be reproduced, time between assessments to allow easing of symptoms or the nature of assessment.

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