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Chapter 7 presents physical therapy examination, evaluation, and goal setting information.

INTRODUCTION

The purpose of rehabilitation is to enhance health and function. Appropriate intervention must be based on careful analysis of the factors that may affect the person's current and future health and contribute to their activity limitations and participation restrictions. This analysis starts with examining and evaluating the person's physical and functional status and other areas relevant to health and function. After identifying the person's impairments and activity limitations (functional limitations), the therapist estimates the patient's potential for functional gains. The findings of this assessment are then considered in the context of the person's priorities, role requirements, social support systems, physical environment, and resources. Together, the individual and their therapist establish goals to optimize health, activities, and social participation.

EXAMINATION AND EVALUATION

Examination and evaluation are the foundations of any physical therapy plan of care.a The therapist requires a thorough and accurate understanding of the person's status to identify areas of strength and weakness and potential roadblocks to progress. The therapist's evaluation of this data provides the basis for developing individualized goals and a plan of action tailored to the person.

In addition to providing the information required for setting goals and planning treatment, the therapist's examination establishes a baseline in all of the areas addressed. Documentation of the patient's initial status is needed for later comparison, facilitating the detection of any improvement or deterioration in the patient's condition.

The examination and evaluation process should continue throughout the plan of care, with the therapist assessing for changes in the individual's status. By monitoring for any significant changes in medical, physical, functional, and cognitive status, the therapist obtains feedback on the effectiveness of the plan of care. This feedback allows the therapist to make adjustments to the established plan of care in order to obtain the highest level of function and return to participation.

Periodically, the therapist should perform a thorough reexamination and evaluation. These repeat evaluations will enable the therapist and individual to assess progress, reassess goals, and update the care plan.

A thorough examination and evaluation at discharge are also important to provide information on the functional status of an individual at the conclusion of the program. The discharge evaluation is an important source of information for the individual, who should be given a clear explanation of their status and potential areas for future progress. Finally, the discharge evaluation provides an opportunity to assess the effectiveness of the established plan of care. Reflection on the therapy plan of care allows the therapist to evaluate the therapeutic strategies employed and confirm these strategies for similar cases or alter their approach in the future.

After discharge, follow-up examinations are critical. During follow-up examinations, the person living with spinal cord injury (SCI) and ...

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