Data Collection

Data collection guides decision making for activity progression and communication with the supervising physical therapist. The PTA should be documented relevant data in order to guide the rehabilitation plan and promote optimal function. Examples of data to collect to inform clinical decision making and care planning include:

Maximum protection phase

  • limb appearance: color size, scar healing, edema, atrophy
  • pain: levels, type, activity related, use of medication, ice, compression, etc., for pain management
  • posture: weight bearing habit in sagittal, frontal, and transverse planes, compensation in the spine, pelvis, and lower quarter, postural abnormalities
  • limb circumference: typically measured at joint line, 5-10cm above and below the joint line
  • use of braces and assistive devices: is the patient using them as indicated consistently and appropriately? are they in good condition
  • exercise and protective activity adherence: is the patient using PRICE, limiting WB activity, performing self-range of motion as directed? any barriers to exercise adherence?
  • range of motion: passive and active assisted only for maximum protection
  • aerobic exercises: activities that maintain overall cardivascular fitness

 

Controlled motion phase

  • skin, particularly mobility of tissue and/or incisions
  • pain levels, location, activity restrictions
  • continue with posture monitoring, swelling monitoring, PROM, and use of braces or least restrictive and most appropriate assistive device
  • strength tests
  • endurance for partial weight bearing and non weight bearing strengthening
  • balance and postural control in static standing on one leg, with or without supports
  • active ROM and motion control in open and closed chains
  • strengthening progression quality and adherence
  • gait training quality, distance, device, pattern, compensation, step height

 

Return to function phase

  • endurance (sets, reps, running, jumping)
  • stability and mobility during agility drills
  • functional movements and activities: squatting, kneeling, pivoting, jumping running

 

Signs indicating a need to communicate with the supervising physical therapist include:

  • recurrent or abnormal swelling or redness
  • complaints or reports of popping, clicking, or "giving away"
  • persistent loss of extension or flexion inconsistent with healing phase
  • significant indicators of poor patient adherence to joint protections (e.g. premature return to sport, discontinuing bracing, etc)
  • pain levels that are persistently high at rest or during activity