Orthopedic Physical Therapy Evaluation

SOAP NOTES FOR PHYSICAL SOAP NOTES FOR PHYSICAL THERAPY WORKSHEET USED THERAPY WORKSHEET USED IN ORTHOPEDIC EVALUATIONIN ORTHOPEDIC EVALUATION

• Prepared byPrepared by• Mohamed Ahmed Ammar RPT ,DPTMohamed Ahmed Ammar RPT ,DPT

SOAP NOTESSOAP NOTES• DefinitionDefinition::• A SOAPA SOAP note is a documentation method

employed by health care providers to create a patient’s chart.

•  There are four parts of a SOAP note: ‘Subjective, Objective, Assessment, Subjective, Objective, Assessment, and Planand Plan

• Comprehensive ,accurate evaluation of patients with Comprehensive ,accurate evaluation of patients with musculoskeletal disorders is essential for effective musculoskeletal disorders is essential for effective clinical practice ,it answersclinical practice ,it answers

• Those questionsThose questions• 1. What is the source of the symptoms or dysfunctiondysfunction? 2. Are there other contributing factorscontributing factors? 3.What is the prognosisprognosis ? 4.What treatmenttreatment should be selectedselected? 5.How should it progressprogress ? 6.What are the precautionsprecautions and contra indicationscontra indications to

examinationexamination and treatmenttreatment?

These questions are the same regardless of the These questions are the same regardless of the patient’s complaints, treatment style, or the choice of patient’s complaints, treatment style, or the choice of therapy techniques.therapy techniques.

SUBJECTIVESUBJECTIVEOBJECTIVEOBJECTIVEASSESSMENT: ASSESSMENT: PLAN:PLAN:

1.Complaint 1.Complaint 2.Onset:2.Onset:3.Location:3.Location:4.Nature:4.Nature:5.Behavior:5.Behavior:6.Course and 6.Course and Duration:Duration:7.Previous 7.Previous treatment:treatment:8.Occupation/ 8.Occupation/ Hobbies:Hobbies:9.Other \Medical 9.Other \Medical Problems:Problems:

1.Structural:1.Structural:2.Mobility:2.Mobility:3.Strength:3.Strength:4.Gait 4.Gait &Functional &Functional abilityability5.Neurological:5.Neurological:6.Palpation&6.Palpation&tapping tapping 7.Special Tests:7.Special Tests:8.Doctor's report, 8.Doctor's report, lab, X-ray:lab, X-ray:

1.Problem list:1.Problem list:

2.Goals:2.Goals:

1.Treatment /1.Treatment /Education:Education:

2.Timeframes2.Timeframes: (Frequency, : (Frequency, Duration)Duration)3.Return to 3.Return to work Plan:work Plan:

Orthopedic evaluation work sheet /Orthopedic evaluation work sheet / S O A P consists of S O A P consists of

SUBJECTIVE EXAMINATIONSUBJECTIVE EXAMINATION

The main goalsThe main goals of subjective examinations are

• to obtain information to outline the direction outline the direction and extent of the objective examinations ,and extent of the objective examinations ,

• clarify patients most functional complaintsmost functional complaints and begin to identify those problems that can be can be treatedtreated by physical therapy and those that can can not,not,

• also determine patient’s attitude( positive or patient’s attitude( positive or negative)negative) towards his condition and therapy.

The subjective examination is guided by four The subjective examination is guided by four clinical axiomsclinical axioms

• 1-The patient can tell us about the problem or treatment if we ask the right questions.the right questions.

• 2-The subjective examination should tell us what to expect on the objective examinationexpect on the objective examination

• 3- If the patient’s complaints don’t fitdon’t fit with the objective examination we must be prepared to inquire further inquire further examination.examination.

• 4-we must identify those patients who benefit from benefit from treatmenttreatment or who are inappropriateinappropriate for physical therapy because of neurogenic disorders, systemic disease, or other serious pathology.

(1)Patient complaint:1)Patient complaint: BY asking the patient simply BY asking the patient simply (What is your main complaint?)(What is your main complaint?)

• This gives patients a chance to tell in their own wardsown wards any thing that they believe its important, why they are seeking physical therapy ,including functional including functional complaints and expectations from physical therapy,complaints and expectations from physical therapy,

• Rate their symptoms on a (1-10 scale)a (1-10 scale) to get an idea of intensity of their pain or severity of their functional problems, find out how the patient’s complaints on the day day of the examination compare with other typical daysof the examination compare with other typical days

• Common complaints includeCommon complaints include : pain, decreased ROM, swelling, weakness ,loss of function, apprehension in movement .

))22((OnsetOnset • Document the original onsetoriginal onset of symptoms and the onset of

the most recent episodethe most recent episode• Specific movements , activities, or posturesmovements , activities, or postures that could have

contributed to the onset of symptoms should be identifiedidentified It can help to know the mechanism of injury for example;- “ sprain and strainsprain and strain usually involve an overuse or a specific overuse or a specific

incidentincident while, Inflammatory and systemic disordersInflammatory and systemic disorders may have a

more subtle onset”subtle onset” Patient may not be able to describe an exact mechanism of

injury so it is often misleading to place too great an misleading to place too great an emphasisemphasis on the patient’s description of onset

(3)Locations(3)Locationslocation the patient describes is not always necessarily a reliable location the patient describes is not always necessarily a reliable

indicator of the actual site of pathologyindicator of the actual site of pathology

• Patient often have referred painreferred pain• Pain that migrates from one joint to another suggests a

systemic diseasesystemic disease rather than a musculoskeletal disorder

• Pain that spreads from the original sitespreads from the original site to the surrounding tissues can be caused by inflammation or muscle spasm ,both of which are often secondary reaction to the primary disorder.

• It can help use body diagramuse body diagram to document nature and location.

(4)Nature :(4)Nature : the clinician should ask for a specific the clinician should ask for a specific description of the symptoms without leading the patient by description of the symptoms without leading the patient by

suggesting descriptionssuggesting descriptions Pain description and related structuresPain description and related structures

Type of PainType of PainStructureStructureCramping, dull, achingCramping, dull, achingDull, achingDull, achingSharp, shootingSharp, shootingSharp, bright, lightning-likeSharp, bright, lightning-likeBurning, pressure-like, stinging,Burning, pressure-like, stinging,achingachingDeep, nagging, dullDeep, nagging, dullSharp, severe intolerableSharp, severe intolerableThrobbing, diffuseThrobbing, diffuse

MuscleMuscleLigament, joint capsuleLigament, joint capsuleNerve rootNerve rootNerveNerveSympathetic nerveSympathetic nerve

BoneBoneFractureFractureVasculatureVasculature

))55((Behavior of symptomsBehavior of symptoms

• Determine A. severity. severity B. irritability irritability C. nature. nature (SIN) of the problem and D. daily patterndaily pattern of symptoms

A- Severity;Severity; symptoms consider sever if; (patient cannot maintain a position or posture due to the intensity of symptoms)

B- Irritability; Irritability; irritable symptoms are (easily provoked and take long time to resolve)

C-NatureNature of the problem;- is either mechanical (changed by movement and positioned) or inflammatory (unchanged by movement and positions)

D- Daily pattern of symptomsDaily pattern of symptoms :- (1) aggravating factorsaggravating factors, (2) easing easing factorsfactors ,(3) 24 hours behavior24 hours behavior (constant pain ,periodic pain, episodic pain)

Example (intractable constant pain at night may indicate serious pathology e.g tumor.),

))66((Course and durationCourse and duration• (1)- Determine whether the condition is in acuteacute(7-10 days) ,

subacutesubacute (10 days-7weeks) or chronic(>7 weeks)• (2)- “Stage”Stage” the disorder by determining whether the problem is

resolving, worsening or remainingresolving, worsening or remaining about the same .the natural progression of the condition should be considered too

• (3)- Important Questions Questions in determining course and durationscourse and durations 1.Was the pain greatestpain greatest when the injury first occurredfirst occurred ,or did it

Worsen on subsequent dayssubsequent days ? 2.Has the patient continued to work or to play sportscontinued to work or to play sports since the

onset of symptoms ? 3.Is this the patient’s first injuryfirst injury ,or have there been previous previous

episodes?episodes? 4. in case of multiple episodesmultiple episodes, how does this episode differ from

previous one?

))77((Effect of Previous treatmentEffect of Previous treatment

• Determine what treatment have been triedtreatment have been tried ,whether they have been helpfulhelpful, and whether concurrent concurrent treatmenttreatment is being carried out by other health car professionals.

• Knowing the specific effect of any previous treatment help the clinician to narrow treatment options and rule narrow treatment options and rule outout those that have not helped

• (8)Occupation/ Hobbies(8)Occupation/ Hobbies• Very important ,even in a non – work related injury.

functional goal sittingfunctional goal sitting depends on this often neglected area of the subjective examination.

))99((Other Related medical problemsOther Related medical problems

• Ask patient about common medical disorders Ask patient about common medical disorders • Arthritis (RA ,DJD)Arthritis (RA ,DJD)• Neurological disordersNeurological disorders• Cardiopulmonary problems (myocardial infarction MI, Cardiopulmonary problems (myocardial infarction MI,

angina ,hypertension ,asthma, chronic obstructive pulmonary diseaseangina ,hypertension ,asthma, chronic obstructive pulmonary disease• Disease (osteoporosis ,diabetes mellitus ,etc)Disease (osteoporosis ,diabetes mellitus ,etc)• CancerCancer• TraumaTrauma• Relevant orthopedic problemsRelevant orthopedic problems• Surgeries and medicationsSurgeries and medications• Current medications Current medications

))22((Objective examinationObjective examination When Planning the objective examinationsWhen Planning the objective examinations ,consider

this questions:

• What are the main problems?main problems?

• What are the probableprobable source of the symptoms?source of the symptoms?

• What are the qualities of the symptoms?qualities of the symptoms?

• What will be the focusthe focus of the objective examination?objective examination?

Clearing testsClearing tests

• Are used to assess the potential contribution of a related joint complex to patient’s main joint complaints. to clear means (rule out or implicate)(rule out or implicate) e g Quadrant test for cervical &lumbar spine ,and full squat in standing test for hip &knee.

((1)Structural Examination1)Structural Examination • General body alignmentalignment• Quality Quality of movement• Postures maintainedmaintained or avoidedavoided• Presence of muscle guarding or spasmmuscle guarding or spasm• Symmetry of soft tissues contoursoft tissues contour• Bilateral limb size, shape, symmetry , color, atrophy, limb size, shape, symmetry , color, atrophy,

hypertrophyhypertrophy• Presence of edemaedema• Presence of open wound ,abscesses ,sores, ecchymosisopen wound ,abscesses ,sores, ecchymosis• Incisions from surgeries or injuriessurgeries or injuries • Signs of inflammations or infectionsinflammations or infections• Use of assistive devices ,splints, support, and braces.assistive devices ,splints, support, and braces.

))22((Mobility ExaminationMobility Examination

when performing any mobility test (active active , passivepassive or accessory accessory ) clinician

observe effect of the test on the patient’s patient’s symptomssymptoms

• Amount of movement (normal , hypomobile , hypermobilenormal , hypomobile , hypermobile)• Should compare with the other sideShould compare with the other side

(2)Mobility examination(2)Mobility examination(a) Active mobility(a) Active mobility

• The following should be noted during active mobility testing

• 1.The range range of motion• 2.The qualityquality of motion (substitution ,apprehension ,

guarding, catching, or giving way.• 3.SymptomsSymptoms associatedassociated with movement• 4.CrepitusCrepitus or joint noisejoint noise• 5.Response to over pressureover pressure

))22((Mobility examinationMobility examination(b) Passive mobility(b) Passive mobility

• When assessing passive joint mobility the following should be considered

• 1.The range of movement available is it;- (symmetrical, normal ,restricted or excessive)(symmetrical, normal ,restricted or excessive)• 2. symptoms associated with movement

• 3.Response to over pressure applied at end range End-feels (normal or abnormal)End-feels (normal or abnormal)

• 4.Accessory movement (component motions &joint play (component motions &joint play motions) motions)

))33((Strength ExaminationStrength Examination• Is performed to1. rule out muscles as the source of symptoms,2. to1. rule out muscles as the source of symptoms,2.

to decide if muscle imbalance is a source of problem 3. to to decide if muscle imbalance is a source of problem 3. to provide base line for strengthening exercisesprovide base line for strengthening exercises

• CyriaxCyriax has identified 4 possible finding for muscle test1.strong and painless1.strong and painless (no contractile or nervous tissue pathology)2.strong and painful2.strong and painful (minor structural muscle –tendon unit ,not

neurological)3.weak and painless3.weak and painless (comp. rupture muscle-tendon unit, neurological

deficit)4.weak and painful4.weak and painful (partial disruption of muscle –tendon unit/ pain

inhibition secondary to inflammatory process ,neoplasm or fracture /concurrent neurological deficit)

• These result must be correlatedcorrelated to the subjectivesubjective findings and to the rest of the objectiveobjective examination.

))44((Gait & functional abilityGait & functional abilityGaitGait

• Assess gait with walking variationswalking variations (stopping ,starting, varying speed, sideways, backward ,crossed legs ,stair climbing and walking on uneven surfaces.

• Examination of postural controlpostural control during walking focuses on 1.base of support ,2.upper extremity movement, 3.normal heel to toe sequence with trunk counter rotation and reciprocal arm swing.

• Eg (wide base of support and arm held away means decrease postural control)

Functional abilitiesFunctional abilities• Not always indicated in musculoskeletal evaluation Not always indicated in musculoskeletal evaluation

&it differs from functional problems (which are the &it differs from functional problems (which are the work or leisure limitations the patient experiences as work or leisure limitations the patient experiences as a result of the physical problem.a result of the physical problem.

• There are 4 stages for assessments• 1.mobility mobility (ROM, initiation of movement)• 2.stability .stability (static postural control)• 3.controlled mobility3.controlled mobility (dynamic postural control)• 4.skills 4.skills (highly coordinated movments)

• Eg (bed mobilty ,transfer, kneeling, half kneeling, quadruped,)

))55((Neurological ExaminationNeurological Examination• clinician do it only if there is clues in the subjective examinationclinician do it only if there is clues in the subjective examination • Consists of series of tests to determine if the patient’s problem may be

caused by spinal nerve root involvement , peripheral nerve spinal nerve root involvement , peripheral nerve pathology or a central nervous system lesion .pathology or a central nervous system lesion .

• TheThe 3 most commonly3 most commonly used neurological test are muscle tests ,light touch sensation, and deep tendon reflexes.

• Sensory testingSensory testing for ( dermatome ,coetaneous nerve field and , ( dermatome ,coetaneous nerve field and , sclerotomes)sclerotomes)

• Deep tendon reflexDeep tendon reflex results (hyporeflexia ,areflexia or hyperreflexiahyporeflexia ,areflexia or hyperreflexia)• Neural tension testsNeural tension tests used to clear neural tissues for potential

pathology (passive neck flexion, straight leg raising )(passive neck flexion, straight leg raising )• Upper motorUpper motor neuron testing (ankle clonus test ,Babiniski’s test)(ankle clonus test ,Babiniski’s test)

(6)Palpation and Tapping(6)Palpation and Tapping

Tapping Tapping

• Tinel Tinel describes tapping a superficial peripheral nerve to identify nerve involvement (A tingling sensation is often reproduced in the distribution of the nerve being tapped)

• Direct palpation of superficial nerve can also be useful (Nerve tenderness is common at a site of entrapment)

• Results should be interpreted carefully ,as positive testspositive tests can some times be found in normal subjectsnormal subjects

Palpation examinationPalpation examination• Include 4 structures a. skin b. myofacial soft tissues c. joints 4 structures a. skin b. myofacial soft tissues c. joints

d.boned.bone

• Skin changesSkin changes 1. moisture and texture whether (moist and smooth or dry and scaly) 2. temperature 3.mobility

• Myofascial soft tissues;-Myofascial soft tissues;- clinician can feel 1.( myofascial restriction soft tissue mobility) 2-ruptured tendon ,torn muscle belly in case of trauma 3.tendon thickening 4.trigger point and muscle hardening)

PalpationPalpation• joint Clinician can feeljoint Clinician can feel 1. the capsulecapsule and its normal thickening (ligament or retinaculumligament or retinaculum) should

be felt and distinguished from abnormal thickening ( eg plica )thickening ( eg plica ) 2.Palpate joint effusionjoint effusion and compare with uninvolved side 3.Swelling Swelling can be measured volumetricallyvolumetrically or circumferentiallycircumferentially 4.Distinguish between localized edemalocalized edema (acute trauma) and general limb general limb

edemaedema (vascular insufficiency) 5- acuteacute and chronic edema edema (firmer and thicker woody feeling)

• Bone 1- the attachment of ligament and tendonattachment of ligament and tendon 2- bony enlargementsenlargements (DJD , fracture healing )

))77((Special TestsSpecial Tests

• Last section of examination

• Special tests used to differentiate differentiate between possible causes of the patient's symptoms.patient's symptoms.

• eg (Anterior apprehension test for shoulder joint anterior instability )

))88((Doctor’s report ,Lab, and Doctor’s report ,Lab, and Radiographic findingsRadiographic findings

• The clinician correlates the subjective correlates the subjective and objective findingsand objective findings with other information that is available (doctor’s (doctor’s report, X rays lab, and other tests.report, X rays lab, and other tests.

• To ensure the evaluation done without without biasbias , this correlation should be done at conclusionconclusion of the evaluation instead of instead of at the beginning.at the beginning.

Assessment:Assessment:Problem list &GoalsProblem list &Goals

• Based on subjective subjective and objectiveobjective examination findings the clinician develops an initial problem list

• Physical therapy problemsPhysical therapy problems can be of three types1.Symptomatic 1.Symptomatic (pain ) 2.Physical2.Physical (decreased ROM, muscle weakness) 3.Functional3.Functional (the work or leisure limitations the

patients experiences as a result of a physical problem.)

Symptoms magnificationSymptoms magnification• The ‘ M-A-D-I-S-O-N’M-A-D-I-S-O-N’ mnemonic guide for identifying

psychophysiological factors;• M MultiplicityM Multiplicity. When one symptoms goes, another comes. The

patient presents a history of bizarre or non-organic symptoms in multiplicity

• A Authenticity.A Authenticity. The patient seems concerned with convincing the clinician that the symptoms are real than with the symptoms themselves.

• D DenialD Denial the patient refused to consider the possibility that these symptoms may be psychogenic

• I interpersonal variation.I interpersonal variation. Symptoms get better when the patient is having fun and worse when professional is around

Symptom MagnificationSymptom Magnification • S strangeness .S strangeness .No one else has ever had any thing exactly like

this patient has• O Only youO Only you can help ! Patients are setting the clinician up for a fall

"all other doctors before you were in competent ,but you will figure out what it is.”

• N Never varies.N Never varies. symptoms are always terrible and are theatrically described with superlatives.

• When these factors are present treatment still be initiated if the patient has objective physical findings that correlate with his or her complaint.

GoalsGoals • PrognosisPrognosis Estimate current prognosis of the

problem . • (Prognosis is the clinician’s educated (Prognosis is the clinician’s educated

judgment of treatment’s potential success. It judgment of treatment’s potential success. It is based on the severity, irritability and is based on the severity, irritability and nature of the problem ,the estimated patient nature of the problem ,the estimated patient compliance ,and goals of treatment.)compliance ,and goals of treatment.)

• Goals.Goals. There should be a goal for each problem Goals should be (Specific ,Measurable, Within (Specific ,Measurable, Within

time limit )time limit )

PlanPlan• While specific treatment programs are based on

the patient’s problems and goals there are four component of treatment common to all patients :

• 1.conrtol symptoms1.conrtol symptoms• 2.restor function2.restor function• 3.modify daily stresses3.modify daily stresses• 4.prevent recurrence.4.prevent recurrence.

Thank youThank you

References

• Evaluation Treatment & Prevention of Musculoskeletal Disorders (Volume 2 - Extremities) 3rd Editionby H. Duane Saunders 

• Physical Rehabilitation - Schmitz, Thomas, OSullivan, Susan, Fulk, George