My treatment philosophy is guided by 2 core principles: 1. I optimize my patients' time frame of recovery as much as possible. 2. I empower my patients to be as independent in their rehab as much as ...
My practice as a physical therapist is guided by 2 core principles
1. I aim to optimize my patient's time frame of recovery as much as possible.
2. I aim to make my patients as independent as possible in their own rehab and recovery.
In this article, we'll explore the first principle. To read about the second principle: link.
Being able to follow these 2 principles as well as other factors are the reasons why I love being a physical therapist. To read more about this, click here.
I conclude physio treatments when one of two things are achieved: the patient’s goals are met in a way that completely satisfies them or I judge that they need to be referred elsewhere.
To achieve this, constant improvement is needed at each physical therapy follow-up. This improvement can be seen either in the patient’s conditions and their goals or for complex cases, in our understanding of their condition.
If such an improvement is not achieved, we need to troubleshoot:
Is the exercise plan given not optimal? Do we need to add or change anything? Were the exercises good in the beginning but are now too easy to give any progress? We would spend a part of the next session testing other exercises to see how we can improve our exercise program to get back on track.
Is the patient’s environment undoing the work we do during our sessions and with our exercises? For example, someone with an elbow injury could be seeing minimal progress despite going to physio and being diligent in their exercises, if their job requires them to overuse that elbow and irritate it. In this case, I would strategize with the patient ways to reduce whatever is irritating them in their environment while still being able to function and do their daily tasks.
Is the patient performing the home exercise program at the recommended frequency? If they are not, then 2 things are likely. 1) The plan was not adapted properly to their unique condition. For example, many patients work long hours in jobs that give little time for a break. Thus, it would be better to give exercises they can perform standing and quickly rather than exercises that require a long setup process. 2) The goal of the exercise was not explained properly enough in the physical therapy session. It is hard to take time out of our busy days to regularly perform an exercise (and some need to be performed very regularly!) when the reason why the exercise was given is not clear to us.
Is it perhaps our understanding and classification itself of the patient’s condition that is flawed? The treatment of a patient’s condition sprouts from our understanding of it. If that understanding is wrong or flawed, then the treatment plan will not work. In this case, it is worthwhile to review the patient’s case history together to ensure we did not miss anything and to see if we need to do more tests to shed some light on it.
Let’s dig deeper into the last paragraph.
I use the McKenzie-MDT method as a framework for my practice. According to it, conditions tend to fall into 3 classifications which all demand a different management strategy:
1. Directional: these patients have a directional preference and are rapidly reversible. Directional preference is a movement that, when performed at the proper load and frequency, improves the patient’s symptomatic and mechanical presentation rapidly. You can read two actual patient examples in my 2 previously published case studies on the neck and the back. Patients with referred pain are also included in this group. I've also written a case study on referred pain.
2. Proper load management: There is no directional preference to rapidly improve the patient’s condition. In this case, we treat the patient by teaching proper load management and specific conditioning. An example of this would be a tennis elbow, which can last for a long time: we need to find the right exercises at the right load to allow the affected muscles to strengthen and heal properly. For a concrete description of how I approach teaching load management to my patients, you can read this article on knee pain.
3. Non-mechanical: In this case, there is no directional preference to be found or a specific movement to load manage. For many, healing would be done mostly through time. In physio, we would focus on creating a tailor-made exercise program to target the patient’s specific goals and limitations. For a few, if the condition deteriorates and/or severely impacts the patient’s QOL, we may need to refer to another healthcare professional.
These 3 classifications are treated very differently, and this is why it is so crucial to have the right classification in mind when treating a patient. For many cases, one classification becomes much more likely at the end of the evaluation, and thus we are able to make our treatment plan around it. How I treat my patients is the same way as I evaluate them: I either try a specific manual therapy technique during the session or ask them to perform a specific exercise. Whether that technique or that exercise helps them or not, they will give me good information and help me confirm or deny a classification.
For some patients, it takes more than one visit to confirm a classification (usually up to 3). I never hesitate to take the time to properly confirm a classification and rule out others. It is much better to spend an extra two or three days to fully confirm a hypothesis and come to the right conclusion, rather than treat a patient under a wrongful classification for 2-3 weeks, see no improvement, and then have to go back to square one.
As physical therapists, we are trained to make a list of the patient’s problems and a plan to address them. These usually include things such as pain, mobility, strength, balance, endurance, etc. These are all important goals necessary for the patient’s functioning.
However, the most important goals are the ones that the patients are coming to the clinic for. When I track my patient’s improvements, I do so subjectively and objectively. Objective improvements would be being able to move the shoulder more after surgery following an exercise program I gave, or an increase in strength measured with the dynamometer. Subjective improvements are the improvements that the patient themselves report to us: an increased performance at their job thanks to having less neck pain when sitting, being able to play ball with their son confidently…
Subjective improvements trump objective improvements in most cases. A 5% improvement in shoulder mobility is not of much use if it does not translate directly into an improved quality of life for the patient. Being able to stand on one leg for 20 seconds instead of 10 seconds won’t satisfy a patient who is still struggling to walk outside their home to get groceries.
This is why I strive to dig deeper into these basic goals taught to us in physio school. What activities are currently being limited the most by pain? What is a daily chore that the patient has been avoiding due to their decrease in strength? How can we make them stronger and more confident to do that chore?
Objective improvements are of course still important to give a more precise measure of the patient’s rehab progression. Sometimes, objective measures show an upward trend but the patient would not be reporting any personal improvement in their day-to-day activities.
This means one of two things: 1) It may simply take more time for the subjective improvements to catch up to the objective improvements. A 5% improvement in mobility may not mean much right now, but if it turns into 20% after a week or two, it is more likely to translate to a more subjective improvement or 2) We are going in the right direction with our treatment plan, but we do not have the optimal plan. I usually explain it with a compass analogy: getting both subjective and objective improvements would mean that we are heading straight North, directly to our destination. Getting only objective improvements with minimal subjective improvements would mean that we are still heading in the right direction but are not taking the fastest route to it; we are going North-West or North-East!
My goal as a physical therapist is to better understand a patient’s condition in order to get them better. Sometimes, that means understanding that I am not the right professional to help make them better.
There are two scenarios in which I refer a patient elsewhere:
1) Clear red flags on the evaluation: A few months ago, a young man presented himself to his evaluation wearing a splint on his thumb. He had gotten into a ski accident and sprained his thumb. After a thorough interview and examination, I concluded that he had likely fractured his thumb and wrote him a letter to bring to his doctor presenting my findings and suspicions, so that he may obtain an x-ray.
Red flags go beyond just fractures. Depending on the patient’s age, previous history, and symptoms, we as physios are trained to recognize alerting signs that would bring us to refer a patient elsewhere.
2) The patient has stopped improving in my care after we’ve ruled out the first two classifications. This goes back to the previous section regarding the three common classifications of patients. When a patient is judged non-mechanical (they do not indicate directional preference and a load management exercise program does not grant results), my role is to closely monitor their conditions and provide a program to help them adapt their daily routine so that they may best function as time helps in their recovery. In some rarer cases, when I see a deterioration in their condition or the progress has halted completely, even after changing the exercise program, it is necessary to refer the patient back to their GP for a consult.
As physical therapists, we want to help people; it is why most of us chose this vocation. It can sometimes feel like we’ve failed our patients when we need to refer them elsewhere. But it is not a failure to get our patients the help they need. It is better to recognize our own limitations and that we cannot help everyone. The alternative to referring out is much worse: we don’t recognize a red flag in the patient and they don’t get the imaging and escalation of care they need, or a patient keeps coming back to physio despite not getting any improvements, which would be a waste of time and resources.
Even if the patient ends up being referred out and not treated in physio, it doesn’t mean that our time spent evaluating and treating is wasted. A proper physical therapy assessment holds great value in telling the next healthcare professional what the patient has (a red flag or a non-mechanical condition), but also what he does not have: a problem that I can treat.
Two family doctors I spoke to told me that they almost always referred a patient with a musculoskeletal condition to a physical therapist first before prescribing them further imaging and meds. They reasoned that the therapist would, after a week or two of treatment, conclude whether or not that escalation of care was necessary. If they did, then they (the family doctors) would be much more confident that escalating care was needed for that patient.
If any of the information or stories in this article speaks to you, feel free to check out my profile to read more of my articles or to book a 1-hour private room evaluation with me.
If you’d like to discuss any of the points raised in this article in more detail, I would love to speak to you. You can contact me by email at firstname.lastname@example.org or by phone at 438-801-0417. I currently offer free no-strings-attached 15-minute phone call sessions to discuss how I can best assist you.
Here are some suggestions of articles I have written recently, organized by topics.
Knee pain: case study 1
Shoulder pain: case study 1