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 blocks for all other visits. Below is what you can expect during your physical therapy evaluation at Los Gatos Orthopedic Sports 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 and all information you find relevant to explaining your condition.

  • What, where, and when are the key players.
    • What happened if there was an injury? Otherwise, when did the pain/numbness/tingling/etc begin?
    • Where on your body are you affected? Does your pain travel to any other parts of the body or does it stay pretty local to one place? If it does travel, where does it travel, and how often?
    • When did the pain begin? How much time has passed since it began and how has the intensity of pain changed over that time? Does the intensity of pain change throughout the day?
  • Be as descriptive and detailed as possible to help paint the whole picture.
    • What does the pain/symptoms feel like? Is it sharp, dull, achy, numbness, tingling? Does it come and go or is it constant?
    • What aggravates your pain? List all the activities that make your symptoms worse whether it is things you do during the day, sport-related, or even sitting/sleeping.
    • What eases your pain? List anything that helps relieve your pain/symptoms: use of 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. Below are just an example of additional information the physical therapist may need.
    • 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 really helpful. Then we can just take a photocopy and move on.
    • And typically the final question: Is there anything else I need to know that can help me to treat this condition?

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 a 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 and 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 all of the tests and measures, again, help to paint the whole picture. We need to understand your limitations in order 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.
  • Discussion of any exercises to be performed at home with all parameters fully explained.
  • Recommendation for scheduling of upcoming visits with duration and frequency.
  • A general overview of how 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 plan must be understood by the patient 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 the Author

Jamie Clausen

DPT

Education: Saint Mary’s College of California, B.S. in Biology/Samuel Merritt University, Doctorate of Physical Therapy

Fun Facts: Originally from San Jose, 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 degree in physical therapy.

Aside from her passion for physical therapy, Jamie has a special love for baking. Anywhere from cookies to cakes to pies – you name it, she loves to bake it. In her second life, she will likely own a bakery. Jamie also loves to be outdoors (especially at the beach), spend time with her husband and son, and cheer for the Sharks, Warriors, and Earthquakes.

Jamie has primarily worked in outpatient orthopedics serving a diverse community with a variety of conditions including, but not limited to: post-op rehabilitation, gait/balance deficits, weekend warriors, and general orthopedic pain/limitations. She utilizes a combination of manual therapy and exercise to work with patients to achieve their goals. To further benefit her patients, she is certified in myofascial decompression and will typically incorporate it, and matwork Pilates, into her treatment sessions.

Curriculum Vitae