Two simple changes every PT must master but hasn’t
As this spring season has rushed upon us here in the Pacific Northwest I find myself growing tired. Some days physically, but most days emotionally.
I try my best to be upbeat with the clients. To smile and smooth over any of their concerns about how many different clinicians they have been seeing during their plan of care. To tow the company line. “Excellence, 10, The Best.” But some days I just cant help it. I’m tired.
I am tired of calming down frightened TKA patients who are scared and confused about their pain.
I am tired of being the first clinician to explain the purpose of an exercise to a patient after they have been doing it wrong for the last 2 weeks.
I am tired of telling astonished care givers that PTs are more than professional people walkers.
I am tired apologizing to patients for poor results.
After a few years and many PT jobs, my tolerance has nearly run out.
It is time for a change. A massive profession wide change.
This change will impact all aspects of our profession. Patient outcomes. Satisfaction scores. Even how Physical Therapy is perceived on the national stage. And the best part is this change is easy.
Two simple non-negotiables that every PT must master. Education and Dosing.
Wait. Thats it?….
I know, I know, this sounds cliché. I assure you, if you are one of the people mentally checking out right now, then this article is likely directed at you.
Every “elite” or “guru” therapist in the country will tell you exactly what I am saying now. It all comes down to Education and Dosing.
Seriously. Go ask them…
Let me explain a bit further.
Great education is far more than regurgitating pathoanatomical tid-bits in “patient friendly” dumbed down speak. The humerus, or “arm bone,” is im-pinching on the rotator cuff muscle in your shoulder when you lift your arm like this…
Sure, explaining someones pain in terms they understand is important, but it is a far cry from what needs to be done.
Great patient education comes down to one thing – Managing Patient Expectations.
Managing expectations consists of (and is not limited to) the following:
- Breaking down pain science into manageable and actionable pieces for the client
- Letting them know what to expect with PT treatments or sessions. If you are at a clinic with crappy parking give them the heads up on that too.
- Dissecting the healing timeline into not only timeframes, but function levels, pain levels, and even emotional states (Nearly 100% of patients with pain free NWB leg injuries are frustrated by the end of 6-8wks – Tell them that!)
- Describing the rationale behind each intervention and each exercise prescribed, and normal progression.
All of these things impact the patient experience and ultimately their ability to trust you.
Trust is the linchpin that building a reputation as a clinician, or a profession on the whole, relies on. Especially in the world today, lack of information is not the problem – a lack of trustworthy information is.
Educate. Manage expectations. Build trust.
The problems with dosing stem from two main sources. Misplaced sympathy and a lack of a focused goal.
We all have dealt with the sweet little old lady who just eeks out the sweetest little groan when she struggles to do her exercises. But she has to do them! Sure, it feels good to let sweet Nanna off the hook and get back to watching The Price is Right with the volume on full blast, but that is not going to help her regain her independence at home.
Our job is like that of a CEO. A CEO does not get paid to make all of the decisions for a company. They get paid to make all of the HARD decisions.
Sometimes telling Nanna to switch off the boob-tube for the next 38minutes is the right – hard decision – to make.
One of the more astonishing observations I have made over the years is how quickly we loose sight of the goals driving each exercise or treatment. Sure, we all keep in mind long and short term functional goals overall, but the goal behind each individual exercise is often overlooked.
Referencing back to the old SAID principle (Specific Adaptations to Imposed Demands), I find it is often forgotten all together.
When compared to lifting 200lbs off of a recliner or propelling that 200lbs frame down a hallway, theraband hamstring curls come up embarrassingly short.
I cannot even begin to describe how many times I have arrived at a patients home only to find them breezing through an exercise program consisting of 12-18 exercises (most likely all sitting or supine) at 10 repetitions each! Another classic overexercised and under-challenged patient not making efficient functional progress.
To be specific we must target each exercise, and its dosing, upon a certain purpose. Strength, endurance, power, neuromuscular control? Any and all of these are valid goals.
If we really wish to build strength we must exhaust the muscle and overload it. I’m sorry Nanna but you’re going to be sore in the morning.
If we are focused on neuromuscular control, then each repetition is scrutinized for perfect form and muscle activation. No bad reps. Then the client or care giver is taught to do the same.
The list goes on.
Quick tip for strength building is this one simple phrase:
“If its not a challenge, it is not making you better.”
Once a client understands the value of “challenge” their entire outlook changes. A well trained patient should be telling you when exercises are too easy and they are in need of progression.
As we all strive to be better clinicians we owe it to our patients, and ourselves, to be better tomorrow than we were today.
By no means are these changes difficult or ground breaking. Nor do the require extensive re-tooling or education. What they do require is a renewed focus on two of the most elemental aspects of our profession.
Written by: Stephen Stockhausen DPT, OCS