A Physiotherapy Perspective
Purpose of the talk:
This talk is not intended to teach physiotherapists how to conduct medicolegal assessment and then produce a report.
When I started thinking about the physical assessment of an individual, I thought of all the parts of the assessment that make up the whole, things like range of movement or ROM, tone, balance and so on.
I then considered what it is that makes an evaluation of a person’s physical state uniquely a physiotherapy perspective.
What is the purpose of a physiotherapy medicolegal report?
- Physiotherapists, like all the other experts are there to assist the court to reach a fair decision by providing impartial information.
- We inform the court about the client’s previous health, any pre-existing disability and their previous physical functioning in contrast to his or her physical function at the time of the evaluation.
- We provide detailed information about the individual’s functionality together with in depth analysis of the movement, the biomechanical forces at play and ultimately a realistic picture of what the future will be like for this person – from a physiotherapy perspective.
Your primary responsibility in the preparation of the report is not to the attorney who appointed you and your report should provide the same information and inferences whether you are appointed by the plaintiff or the defence. You have a dual responsibility to the client and to the court to provide unbiased and reasoned discussion regarding the client.
Firstly, where should this be conducted? Consider the following clients:
- The person who manages in their home but decompensates outside of their home
- The semi- conscious person
- The child on the autistic spectrum
- The nervous or frightened person
- The person with whom there is a language barrier
In summary, I think that the client should be evaluated in a place where they best perform and demonstrate their problems.
How would you handle the nervous client that comes to the evaluation alone?
- Get collateral information from family, carers, teachers, treatment therapists etc. Only if the person that is being evaluated gave permission.
- Be aware that problems can arise when the person confabulates, has a psychiatric condition or simply provides inaccurate or false information which appears at first glance as accurate information.
For me personally, I will always read the letter of instruction so that I know what I am being asked to do.
- The client’s function before the injury took place together with their past medical history
- A history of what happened and when
The pre-incident function should include information on
- Previous health
- Hospital admissions
- Previous accidents
- Persons job
- Social history
- History of the event
- Therapy history
- Aids appliances
- General observations
When considering pain, always consider how much, how often, where, type of pain etc.
The objective assessment
- Evaluation of specific joints
We all have a degree of tension in our muscles when we are at rest, this is our tone. When it is too low, people have difficulty in turning a muscle on and when it is too high, other muscles cannot overcome this “always active muscle”. I think of tone as a turn off/ turn on problem.
In terms of range of motion, consider whether the person can actively or passively reach full range and what the end feel is like.
In people where the specific power of various movements cannot be tested in isolation, (eg young children or very confused people) function provides a lot of information about the person’s strength.
Balance – consider static responses as well as dynamic balance during movement. There are a number of good but simple objective tests of balance, and these are helpful.
With sensation it is important to remember that compromised sensation will impact negatively on motor learning.
Reflexes –My preference is to comment specifically on those reflexes that will influence or alter motor function.
Co-ordination – I use the traditional finger/nose and heel/shin tests but I am also interested in the timing and rhythm of the client’s movement as well as their ability to activate specific muscles appropriately during movement and whether they contract smoothly or in an off/on pattern.
If a specific joint has been reported to be painful, this will be specifically examined and range and power would form part of this, as would palpation of the joint, special tests eg of menisci or PAs or glides and observations.
When I look at an individual’s function – say in walking – I am noting what is happening but also hypothesising about why it is the way it is.
Different types of assessments
There are 4 main types:
- Neurological: explain the neurological sequelae related to the incident and the impact that this has on present and future function.
- Orthopaedic: Again, standardised tests should be included provided they are pertinent.
- Paediatric: will include parts of neurological or orthopaedic assessments as needed but you should also discuss schooling, emergence of milestones (possibly including the loss of some of these because of the incident in question), deformity, balance and falls, functional movement, fatigue levels and so on.
- Pain: pain evaluation and the orthopaedic evaluation.
There should be a logical progression from the assessment findings, the clinical and therapy histories to the analysis and recommendations with enough discussion to:
- Highlight problem areas and indicate why these are problems.
- Adequately explain complex items that you have assessed and detail their expected effect on function and relevance to physiotherapy intervention.
- Refer to relevant literature regarding anything from the condition of the client to the standardised testing you have provided or the treatment and equipment you are suggesting.
- Discuss and justify the kind of intervention that you are recommending.
The impact of one part of the findings on another should be described.
There should have been a detailed description of functional movement in the section on this, but the analysis, discussion or formulation (whatever you want to call it) should detail (e.g. relevant biomechanics).
From this analysis/formulation/discussion the needs should become quite clear and the need for intervention, aids and appliances should then flow from this.
Compiling a joint minute
It is supposed to be a frank discussion regarding what the client’s needs are and how these should best be managed so a proper discussion needs to take place to provide the court with your combined wisdom. This can be done in person, on the phone, Skype or by e-mail. But it is not correct to get a draft version of a minute and simply accept it with no discussion.
Habilitation (rehab for those who acquire disabilities early in life or congenitally) vs Rehabilitation (rehab for those who have experienced a loss of function). Is there a difference?
Rehabilitation: Needs to involve the person with a disability and their family or carers as partners
What is the physiotherapist’s role?
According to the WHO
- Training, exercise prescription, compensatory strategies
Is there an end to rehabilitation?
- Yes (simple and time limited issues eg: straight forward fractures).
- And No (complex and life changing problems eg: Retinopathy of Prematurity, Traumatic Brain Injury, Spinal Cord Injury, after polytrauma or with progressive conditions).
Arbitration vs Court
- Arbitration was a little less formal – but not much.
- My report preparation was the same.
- My preparation for an appearance was the same.