What to Expect When You’re Attending a Physical Therapy Evaluation

The first visit to physical therapy is your initial evaluation. It is a 1-hour session dedicated to understanding your condition both from your story and your body. From this, a plan is developed that helps you achieve your functional goal(s). This becomes the foundational building block for all other visits. Below is what you can expect during your physical therapy evaluation at BaySport Physical Therapy.

How to relay your story to your therapist to get the most out of your treatment session:

The first visit will begin with your story. This is where you inform the therapist of any information you find relevant to explaining your condition. What, where, and when are the key players. Below are some key areas you will want to cover.

  • What happened if there was an injury? Otherwise, when did your symptoms begin?
  • Where on your body are you affected? Does your pain travel to any other body parts or stay local to one place? If it does travel, where does it travel, and how often?
  • When did your symptoms begin? How much time has passed since it began, and how has the intensity of your symptoms changed over that time? Does the intensity of your symptoms vary throughout the day?
  • Be as descriptive and detailed as possible to help paint the whole picture.
  • What do your symptoms feel like? Is it sharp, dull, achy, numb, or tingling? Does it come and go, or is it constant?
  • What aggravates your symptoms? List all the activities that make your symptoms worse, whether it is things you do during the day, sports-related, or even sleeping.
  • What eases your symptoms? For example, ice/heat, certain positions, medications, etc.
  • Have you had any treatment for your condition? This can include massage therapy, previous physical therapy, chiropractic care, medicine, etc.

The PT will follow up with questions to fill in any gaps and discover contributing factors (if any) that may affect your treatment.

  • What is your medical history? Any conditions you have been diagnosed with, whether or not they contribute to your current condition.
  • Have you injured this body area previously? If yes, what helped, what made it worse, and did it fully resolve?
  • Do you take any medications? Having a list already created can be helpful; then, we can take a quick photocopy and move on.
  • And typically, the final question is: Is there anything else I need to know that can help me to treat this condition?
  • And typically, the final question is: What are your goals for physical therapy?

From there, the Physical Therapist will physically examine your body. This will include the use of measurement tools and their hands to assess a variety of components.

The physical therapist may:

  • Measure range of motion using a goniometer or inclinometer
  • Measure strength utilizing a tensiometer or manual resistance
  • Measure flexibility using a goniometer or inclinometer
  • Assess joint mobility using graded movement from their hands
  • Assess balance utilizing various tests/measures on differing surfaces
  • Assess functional movements that you perform in your everyday life
  • Examine body parts above and below the area of complaint. The body works as a unit; it is key to look above and below to see how the area of complaint could be impacted.

The physical therapist will:

  • Ask for permission to place their hands on you. The nerve endings in our hands give us a lot of good information regarding your condition.
  • Ask questions throughout the session to keep learning about your area of complaint and keep you an active participant.
  • Always make sure you feel comfortable; this is our number one priority. You should feel completely comfortable during the entire session. This includes asking questions throughout and having an open dialogue with the therapist.

The findings from the tests and measures help paint the whole picture. We need to understand your limitations to create a plan for your rehabilitation. From this information, a plan is developed with the patient, so it fits their lifestyle and schedule. The plan includes:

  • A full review of the findings from the testing performed during the initial evaluation.
  • Discuss any exercises to be performed at home with all parameters fully explained.
  • Recommendation for upcoming scheduling visits with duration and frequency.
  • A general overview of the patient’s functional goals will be achieved with the plan for upcoming treatment sessions.

Collaboration is key to making sure the plan can be implemented. The patient must understand the plan and feel like it fits into their lifestyle.

The patient can now move on to the front desk to schedule upcoming visits, as this is the conclusion of day 1!

About Jamie Clauson, DPT
Originally from San Jose, California, Jamie graduated from Archbishop Mitty High School, where she played 1 year of soccer before eventually needing 3 ankle surgeries. This experience is what kick-started her love and passion for physical therapy. She proceeded to graduate from Samuel Merritt University with her Doctorate of Physical Therapy in 2012. Aside from her passion for physical therapy, Jamie has a special love of baking. Anything from cakes to cookies to pies, she is up for a challenge and always trying new recipes. Jamie also loves the outdoors – beach, hiking in the redwoods, spending time with her husband and son, and cheering for all the local teams – Sharks, Warriors, and Earthquakes. Jamie has primarily worked in an outpatient orthopedic setting serving a diverse population of patients – post-op, gait/balance deficits, weekend warriors, and general orthopedic pain/ limitation. She uses a combination of manual therapy, therapeutic exercise, and education to work with each patient to achieve their goals. To further benefit her patients, Jamie is trained in myofascial decompression, kinesiotaping, and BFR, which she can incorporate into her treatments

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