The Objective Assessment 

Hopefully we’ve got through the subjective assessment smoothly and kept the person in the zone which they need to be in to engage with the appointment.

Now is the moment that we begin to look at the person’s body. For some patients this can be easier because they just have to do what we ask and the questions are over, the physical realm can be much easier than the cognitive, for others it can be by far the worst.

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A moment to make a change and prioritise the person’s mental state is now. Towards the end of the subjective we need to be thinking about what sort of assessment we are going to do. How are we going to adapt it given the information we have just received. Going into the assessment you may have found information in the notes or through conversation with the referrer that you will need to do something a certain way. This may be so clear that it is agreed and negotiated from the outset. It may be that we agree with the person that we won’t ask them to undress or that there will be short appointments, or that we won’t touch a certain body part. Or this could be a general theme that we are expecting. As the end of the subjective draws close it’s time to make a clearer decision on what the objective will look like. This is obviously pretty normal, we decide which bits we are interested in looking at, which tests we plan to do etc, this will need to be done as well but a highly prioritised decision-making factor needs to be the persons’ psychology. How will they respond to that test? How will they respond to me asking them to lie on their back? How will they respond to me standing behind them? How will they respond to me touching their neck from this position? Given what we know about the person we need to be able to quickly make adaptation decisions based on how the person is likely to respond emotionally to what we are about to do. We must not necessarily prioritise the most effective way for our logic process to find out what is wrong and what treatment we are going to provide. As well as considering how to do the physical part of our assessment to minimise what will hurt, we need to consider how to do our assessment in a way to minimise psychological distress. We must consider how we are going to get there and sometimes we will not be able to do the things we need to do. Sometimes we need to do things in a way that is not the best way for us, but it is a way that means we can gather enough information to be better at making a functional decision.

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As we get more experienced, we can make better decisions quicker because we will recall past decisions and not be trying to weigh up the current information we have just received and make novel solutions. Things will go wrong, we will learn from them and then we are able to quickly pull it out for next time. But often we will have to produce novel solutions in the moment. This constant adaptation and novel solutions are why it becomes tiring.

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I consider that when a physio can consistently make a novel adaptation within the moment to explain something, perform a test or teach something that avoids triggering a negative response from the patient and is done so in a seamless manner as though this is always the way that it is done or said, or to present it as though you always do it this way in this situation is when that physio has really become competent in the field of mental health.

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We may need to decide to change the entire purpose of our assessment. Instead of the purpose being to work out what is wrong and what treatment pathway we’re going to take, we may make the decision that the primary purpose of the objective assessment is to help the person build trust that we understand the nature of their condition. It is often insufficient to tell someone that we understand and the real trust is built by showing someone that we understand. If I tell someone that I understand then they may give me a chance to show them. But much like an exam it helps to show our working out. If at the end of the subjective we explain to our patient, the changes we are about to make to our assessment and why linked to the information that they have given us then we will go further to building that trust. Then we can keep repeating that reasoning as the assessment goes on. As we keep articulating it this will keep it prominent in our thoughts so that we do not keep slipping back into our assessment routines, but it will also keep advertising that we considering exactly what they have asked us to.

An example would be that we need to assess hip pain, but we have discovered that the person is hypersensitive to touch and will be in pain for days afterwards if we grip them too tightly. Because this hypersensitivity is mediated by the sympathetic system the sensitivity is higher than it normally would be during the appointment. So, the pressure that we will need to apply to do our assessment is not possible today, but it could be by session 3 if we get session 1 and 2 right. The purpose of the objective assessment now becomes to show the person that we understand their hypersensitivity to touch and that they can trust you not to hurt them and that you will take in into account when working out what is wrong and what to do. The first thing is to explain relevance of the sympathetic nervous system to the hypersensitivity. Making sure not to say that the problem is in the person’s head.

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                  “You’ve probably heard of something called the flight or flight system? It’s something that we have to think about with appointments like this. Appointments like this will always be at least a bit stressful so someone’s flight or flight system will always be a more ‘on’ than normal during something like this. The flight or fight system has the ability to amplify pain and make us experience more than we should. Imagine a field mouse that’s being chased by a barn cat. It’s flight or fight system is on full, and it’s run away and hidden. The mouse is hiding and all its senses are turned up to the maximum to protect it from being caught by the cat. Its fur is all standing up and at the slightest sound or sensation it will run. The mouse will need to run at the slightest sensation to keep it safe.If the mouse is hypersensitive to touch then when the cat goes to pounce the mouse will feel the rush of air being pushed in front of the cat as the cat jumps towards them. The sooner the mouse feels the cat coming and runs then the more likely the mouse will be to get away to safety. This is why we feel more when our flight or fight system is up, so your hypersensitivity is probably going to be worse today”

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Using visual images to explain can often be useful and linking to something which the person is already aware of is also useful. Creating the visual image of the mouse will help many people ‘feel’ what we are saying and using the idea of a scared animal is something that people already know and it also takes it outside of the human realm. Creating separation from themselves decreasing the chance that it will be interpreted as their fault.

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We now need to explain what we are going to do about that. What would our assessment normally look like and what are we going to do instead.

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                  “So, what we can do is not do any tests that involve me gripping and squeezing or holding tightly. There are still some tests I can do but what I’ll do is try to hold your leg, but can you let me know straight away if you think that it will cause you an increase in your pain”

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Then we need to keep pointing out what we are doing and not doing through the assessment. This both keeps it prominent in our mind so that we actually do it but it also shows our patient what we are doing. People have no idea what we would normally do so if we do not tell them then we are losing an opportunity to show.

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The assessment is now spread over several sessions, and we have increased the likelihood that by session 3 we will have got to where we need to be and done the tests we need to in the way that we need to. We could just do a short appointment and split the assessment up, do it in bits and try to achieve the same thing. But to do so is missing an opportunity to show a patient our values and we are not doing as much as we could to increase the likelihood that our intervention will be successful.

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If we choose to keep the assessment as the primary purpose of the objective, then the skill is to keep the person within their optimal zone in order that the appointment can go ahead.

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We should know from our earlier learning of the patient if there will be any focal points that we need to be aware of. Touching someone’s neck for example.

There are certain moments to be aware of through the assessment. Positions of vulnerability and positions where we are invading a person’s personal space. We need to be aware of situations like these:

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Standing behind someone

Person lying flat on their back

Person face down

Person bending forward

Moments when your body is very close to the patient

Moments when you are leaning over a patient

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We need to be constantly asking ourselves how our patient is managing in terms of their stress level with what we are asking them to do. When we ask someone to do a movement a prominent thought needs to be to ask ourselves how a new request has affected them. In practical terms sometimes this will be the most prominent question we ask ourselves for requests which we know from experience that are likely to be challenging. For other requests that we know are less likely, the question will be lower down in our hierarchy of thoughts, but it will still be near the top and we will still have a low threshold for acting. Our attempts to be aware of how our request has affected our patient needs to be unseen. We must not make it obvious that we have asked the person to do something and then we are hyper aware of how that may have affected them. If we are looking for something, then the instincts of the other person will be that there must be something to find. If one member of the herd is hyper aware of a potential threat, then the others around them will be more likely to survive if they too are hyper aware too and ready to run. It is an important primal instinct which we all have and is if someone’s conscious mind is already less in control and the flight or fight system already more dominant then it is going to be something which has a greater degree of effect in that moment. What the person will notice is us changing pattern and this change in pattern will be what we need to avoid. We need to hide our interest in how a request has been received. This is why it is important to continue with the same rhythm while we are assessing. The same rhythm of our speech the same rhythm of our movements.

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When we are standing behind people, we will trigger their flight or fight system. So, we will need to do something to mitigate this. We have a few options. We could not do it at all. This may be entirely necessary, especially with aggressive patients. We could do it for truly short periods, switch to something else and keep returning in front of people. This can work, but sometimes it is the event/moment of going behind someone that will escalate their flight or fight and not a longer length of time behind someone. If we spend a shorter length of time behind people, then we need to make sure that we are still being calm and slow and not rushing what we are doing when we are behind someone. We can try to occupy the person’s mind while we are behind them. This can be an effective choice. Some clinicians will chat away to people while they are standing behind someone. They will hold a generic conversation that they will have begun prior to walking behind someone. The conversation can be general and not related to what is being done. This is a good skill and difficult to do both of these things at the same time. I would struggle to do a complex assessment while also holding a generic conversation. Unless that conversation was something which I was just going through the motions of and I was saying something which I knew well. I do not know that I would trust myself to have enough mental capacity left to still be thinking about the assessment I was doing. It would be important for what is being said to be sufficiently engaging to occupy the person’s attention. It is possible to present a conversation that we have prepared or rehearsed but to present it as us being fully engaged. My approach is to explain what I am doing. I will say what I am looking for and what I am seeing and what my logic process is. We can also often move around in front of the person while we are assessing. Break up the moment. We can come around in front of someone and make eye contact, say a few things, and then return.

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Lying on our back is an inherently vulnerable position, all our soft under belly is exposed and unprotected. An animal that is being submissive will roll onto their back and show their belly. We need to be aware of this situation and not leave people there too long. When setting up our rooms we need to be aware of not having a bright light directly over the bed as this is what the person will be lay there staring at. We need to move quickly but smoothly and efficiently in this position. We also need to us the same strategy to keep the person’s mind occupied while here. A normal physio approach would be to do all the supine tests while the person is supine. The logic would simply be that this is most efficient and does not involve the person having to repeatedly change positions. If someone has a lot of pain moving positions can also aggravate this. This would be another example of elevating the importance of mental state in the decision-making process. It can be important to break up the time spent in supine lying for tests. Asking the person to change position and do tests in side-lying for example. This would be a judgement call based on our understanding of that patient in the moment. But we must not assume that efficiency and physical pain reduction are the only factors which we should consider in our decision-making hierarchy.

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If the person is lying face down their soft underbelly is protected but they are vulnerable as they have such limited sensory access and they cannot move and respond quickly. If someone is on their knees and face down, they can suddenly get up if they need to. Face down is still a vulnerable position. Taking the same approach of moving quickly but calmly, do not linger. Keep talking and engaging and break up the position. Shifting into side-lying intermittently even if it is for a sham test. Side lying is close to the foetal position and is protective and calming.

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There are moments when we must get close to people when they are in a vulnerable position such as supine or prone. We need to be aware of when our body is getting close to someone. When we are doing passive motions of someone’s leg in supine we would normally stand with our body close to the physio bed. Holding someone’s limb at arm’s length may be more appropriate. This is particularly important for tests of the shoulder when someone is supine or prone. We need to be aware of where our body is, and the increased sensitivity people can have to this. It can be important to take a step back and do these tests at arm’s length.

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Leaning over a patient is something to be avoided, if at all possible, I’ve seen the physio’s lean over the face of people and drape their clothes over the patient’s face with no awareness of the sense of claustrophobia this is causing someone. Keep people at arm’s length and if we must lean over someone, it can be important to look away from them as we do it.

A patient bending forward is a position to be cautious of, we need to avoid being behind someone as they do this if we can. We can be behind someone for a moment to understand and see what we need to do but then move quickly off to the side even if this is performative. Then if we need to see how the person returns from forward flexion we can ask them to bend forward again while we are standing off to the side and then during the return from forward flexion we can return to behind them for this portion of the movement.

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The skill is to be able to constantly assess how the patient is responding and keep their mental state as a high priority in our decision-making process about what we are going to do next and how we are going to do it. We need to be looking for cues that the person’s mental state is changing and they are slipping out of their zone needed for the appointment. We then if we need to employ our strategies as and when appropriately. Some patients will have their own strategies to manage situations like they are in. The patient could be with you and taking a mindful approach, focusing on their breathing and their sensations. If they are doing this, they will not want us to be talking while doing the assessment, so we need to adapt and be silent. But still moving calmly and not overly invading someone’s personal space.

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A response from patients to be aware of is them drifting into a freeze state. We can be doing our assessments, and the patient can appear to be passive and relaxing into the assessment but in fact they are drifting into a freeze state. This same presentation could also be a partial dissociative state which has begun as a response to the stress of the appointment. The primary skill will be to catch this situation early and pre-empt it and keep the person in their optimal zone. Once it has begun it needs to be caught early and a substantial change is needed in the situation of the appointment. One approach would be to take the focus from the patient and to place it on us. We can ask the patient to change position from wherever they are, if sitting on a chair, sit on the physio bed, if lying down move to sitting, if standing move to sitting. It could be the correct thing to do to move rooms if that is possible. A change of the environment will act as a reset. Then we can make ourselves the centre of attention by demonstrating something, bending, arm lifting, gait pattern whatever could be appropriate in the moment. The show would need to be with sufficient ‘energy’ to hold attention and to shift the attention away from themselves and onto us. This can then act as a reset and we can return to the assessment and probably take a different approach to the way we were doing the assessment to maintain the needed zone. A different approach would be to begin a conversation about something none-physio related. This is an approach often seen. We can ask a question about something we know about the patient, ask how their pet is, ask about something we know their interested in. Shift the nature of the situation from assessment to social. Again, to increase the effectiveness of this some change in physical situation is useful. Ask the person to move into a new position which is a normal position like sitting as though this was the next position for the assessment but then change tack and shift the situation social by asking about something we know the person is interested in. Once then able to return to the assessment do so.

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The person can drift into a freeze state or partial dissociation, and it can be that we cannot effectively catch them and move them out. The approach can then be to end the appointment and try again at a later date. This may not be the best strategy for the patient even though it will feel kindest in the moment. Many patients will prefer you to continue and get the information that you need to help them so that they do not need to do this again. From what we know about the patient we can make this decision and continue with the assessment; in this situation we need to recognise that we no longer have a great deal of access to the person’s conscious mind. We need to communicate very basically, “lift up your arm” not “Lift your arm up to the ceiling”. It may be that the communication needs to become even more basic by saying “do this” and lifting the person’s arm for them and putting it down and then they repeat it. If our patient falls into this state, it can be important to have them somewhere to be afterwards before going home. Patients can leave appointments in this state and then collapse in reception and lie on the floor or be found in the car park wandering trying to find their car. If the patient is going into this state, we need to be able to make plans to give them somewhere to be and recover afterwards before leaving. 45 - 90 minutes sitting comfortably on their own in a room that we can check on will likely be sufficient. Then once the person’s freeze state has settled, they will be safe to return home