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Objectivity in physiotherapy assessment

P hysiotherapists are clear about the meaning of objective and subjective information when assessing a patient. Objective data are considered to be a set of ‘facts’ representing

the patients current status; the blood gas results, X- ray changes, goniometry measurements or lung func- tion tests. Subjective information is used to embellish the objective facts: the patients’ attitudes, opinions, social history and the physiotherapists interpretation of the facts (Goldberg, 1994; O’Shaughnessy, 1994).

Objectivity and subjectivity

Objective data are useful because of their clarity and simplicity; an oxygen partial pressure of 6 Kpa is bad in anyone’s language. Objective information also allows you to see clearly how the patient is pro- gressing, judging the patients’ health against a learned set of normal values. Conversely, subjective data are riven with bias and personal interpretation, and so are only used for background information. There are few clinical deci- sions that are made on the a basis of such subjective, informal, unprovable assumptions. Objective data represent no such thing. They repre- sent a narrow, positivist view that all patient informa- tion can be reduced to a finite number of interlinked variables, i.e. material that exists in the real world that is waiting to be perceived by you. Some perceived experiences become so universally understood that they become known as ‘objective reality’. So in most areas of the world a green traffic light means ‘go’. Higgs and Titchen (1995) stated that:

‘An important aspect of the development of higher cognitive skills and clinical reasoning abil- ity is the ability to construct and use knowledge. The construction of knowledge requires the indi- vidual to process experience and to develop a rep- resentation of reality. This could be described as developing constructs which help to explain or interpret reality, or engaging in mental abstrac- tion and interpretations based on experience.’

There are very few objective features of the world that are universal. What you experience of the world is a social reality. Everything you see, do or have an effect on requires your brain to interpret the inter- acting. You then interpret this and place meaning upon it. No two people will look at the same X-ray the same way (Hughes, 1990) — ‘what is food to one man is bitter poison to another’ (Titus Lucretius Carus, 99–55BC).


So the objective data given on an X-ray, i.e. the pat- terns of light and dark, can be interpreted by a skilled therapist as meaning that the patient has a large left pneumothorax with some mediastinal shift, probably secondary to traumatic rib fractures. Taking the objec- tive information and applying subjective interpreta- tion to it is a core skill of the therapeutic assessment.


Objective information requires perception. In humans perception comes from the senses. You take the objective data in and from then onward it becomes a subjective experience. It becomes framed by your experiences as a therapist, your eduction, prejudices, opinions, etc. In essence there is nothing that can be perceived by the therapist that does not require subjective evalua- tion. Blood gases, for instance, are numerical repre- sentations of objective data, but they are worthless unless the therapist recognizes when they are abnor- mal and relates them to the patient and the therapists prior experience of respiratory problems. When therapists are trained, the successful ones are those that can perceive information, filter that which is useless to them, subjectively interpret the informa- tion and develop solutions (Caws, 1988). Pain has always been perceived as a subjective human experience (Warga, 1987; May, 1992), but most therapists are aware of only quantitative meth- ods of assessing pain. To assess pain and its daily variability is an essential part of the therapeutic process and most therapists make subconscious interpretations of a patients pain. When it comes to interpreting the patients pain the physiotherapist first needs to give meaning to it. Normally the physiotherapist listens to the patient telling them how it feels, and may see the pain on their face. It will mean something to the physiother- apist because of his/her own pain experience, although he/she can’t feel the pain him/herself. Going on to assess this pain it seems ludicrous then that the physiotherapist should try to add the com- plicated, unnecessary mental step of translating a perceived feeling, rooted in emotion, experience and empathy into a numerical pain scale (Mattingley and Falconeralhindi, 1995; Waterfield and Sim, 1996).


Physiotherapy is not the only profession having to come to terms with its duality: nursing and the social

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Objectivity in physiotherapy assessment

professions have for some 20 years attempted to address these problems and there is a great deal that we can learn from their experience (Porter, 1993; Schutz, 1994; Playle, 1995). Physiotherapists consider the terms objective and subjective every time they assess a patient and yet few appreciate how misused they are as a core con- struct of physiotherapy. Physiotherapists feel that


Therapists believe that they understand the difference between objective and subjective information.

When assessing patients, therapists believe that they use both types of information.

Therapy assessments are, however, entirely subjective.

Subjectivity is the basis of our decision making.

Effective decision making relies on the assimilation of subjective interpretations of events for effective action.

they can be objective about assessment, but most are failing to acknowledge the difference between robotic data collection and skillful, subjective deci- sion making.

data collection and skillful, subjective deci- sion making. David Nicholls Senior Lecturer School of Health and

David Nicholls Senior Lecturer School of Health and Community Studies Sheffield Hallam University

Caws P (1988) Subjectivity in the machine. J Theory Soc Behav 18:


Goldberg A (1994) Farewell to the objective analyst. Int J Psychoanalysis 75: 21–30 Higgs J, Titchen A (1995) Propositional, professional and personal knowledge clinical reasoning. In: Higgs J, Jones M, eds. Clinical Reasoning in the Health Professions. Butterworth-Heinemann, Oxford Hughes J (1990) The Philosophy of Social Research. Longman, London Mattingley DJ, Falconeralhindi K (1995) Should women count — a context for the debate. Professional Geographer 47: 427–35 May C (1992) Individual care? Power and subjectivity in therapeutic relationships. Sociology 26: 589–602 O’Shaughnessy E (1994) What is a clinical fact? Int J Psychoanalysis 75: 939–47 Porter S (1993) Nursing research conventions — objectivity or obfuscation. J Adv Nurs 18: 137–43 Playle JF (1995) Humanism and positivitism in nursing — contradic- tions and conflict. J Adv Nurs 18: 137–43 Schutz SE (1994) Exploring the benefits of a subjective approach in qualitative nursing research. J Adv Nurs 20: 412–7 Warga C (1987) Pains gatekeepers. Psychol Today 21: 50–6 Waterfield J, Sim J (1996) Clinical assessment of pain by the visual analogue scale. Br J Ther Rehabil 3: 94–7

British Journal of Therapy and Rehabilitation, May 1996, Vol 3, No 5


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