We interrupt our regularly scheduled topic series (I promise Part 3: Interventions for tight hamstrings will be posted soon!) to bring you this article on principles for better treatment. This post is geared towards both new grads and veteran PTs alike, as I feel that even those of us who have been treating for a while could benefit from a refresher. Certainly this is not an end all be all guideline, but I felt that these 5 principles are a good foundation for improving your treatment outcomes with clients.
This post came about after much thought and reflection on what I felt made me successful with certain clients and what I could have done better with other clients. Enjoy!
1. Maximizing Your 1-on-1 Time
This is important, and all physical therapists know it, but it isn’t always executed well. With the pressure of increased productivity and decreased time spent with clients (i.e. traditional outpatient ortho clinics), it’s hard to perform a truly comprehensive on-going assessment/evaluation throughout your plan of care. And as a result, many times diagnoses are missed or you start on the wrong treatment path and have to back track.
Many clinics attempt to advertise that they find the “cause”/”source” of their client’s problem, however what I’ve seen in many clinics is that the therapist does not actually have time to find the source of the pain, and the client returns not too long after discharge and becomes a “frequent flyer”. So how are you supposed to find the source if you only end up with 20min of 1-on-1 time with the client?
When I worked in an insurance based model, I always tried to maximize my 1-on-1 time with clients. I had a check list of things I needed to check and each session I may only be able to check 1 thing, but I made sure to do it so that I would not have to back track. Here’s my list of items I need to check always when treating a client
- Check above and below the site of pain: Often times, unless there’s direct trauma to the area, the site of pain is not necessarily the source of pain. Don’t settle for only 1 joint above and below – make sure to treat holistically! Each session, test/check an area that could be influenced/influencing your client’s complaint. A good way to do this is to take a CEU on assessment; there are many out there, and I don’t believe that there is one that is better than all others, but the important thing is to use the assessment to it’s fullest potential. I use the SFMA and PRI for my assessments, but there are many out there such as Mckenzie, DNS, NKT etc…
- Don’t make it all biomechanical: what I mean by this is that as physical thearpists (read: movement experts) we HAVE to address the nervous system because the nervous system is what creates the movement patterns we see and treat. While we have to address the biomechanical side of issues, don’t get hung up on the roll/glide of specific joints, focus on the overall quality of movement and functional strength/patterns. Most/majority of injuries aren’t purely biomechanical in nature.
- “Every back has a front”: These wise words were spoken by my program’s director Dr. Kapasi, PT, Ph.D back on my first day of PT school in Anatomy. Remember, we are dealing with HUMANS, therefore not everything is about the bones and muscles. Sometimes back pain can be caused by inflamed kidneys, and it is important to know when to refer out. Utilize your differential diagnosis skills – the jump from a Master’s to a Doctorate was partly based on improving/increasing the differential diagnosis skills of clinicians. Don’t perseverate on a pure biomechanical model.
- Test/Re-test: Lastly, you need to know you’re on the right track, so make sure to test/re-test OFTEN! Not just on 30-day re-evals. Every session, you should be assessing and checking to see how your client is progressing, even through simple observation – it doesn’t have to be a formal objective test!
2. Motivational Interviewing/Listening
Many times as a PT I feel like I’m my client’s counselor more than a PT. However, part of our job is to LISTEN to our clients and their story. Knowing the right questions to ask and actively listening to their answers will lead us to the “why” of their problems. Our clients are very smart, and they will unknowingly give us the missing piece that we’re searching for. Make sure to always ask “how” and “what/when” questions – the “why” is for us to figure out. “How did you hurt yourself”, “When did this all start?”, “What makes it feel better/worse?”, “How are you coping with this, currently?”.
Sometimes we need to ask questions (through conversation, don’t be weird about it!) not directly related to their injury – are they currently dealing with any external stressors in their life?, any previous injuries growing up?, any pertinent past medical history (this is important because often times clients will only report history that is related to muscles/bones when they come to see a physical therapist).
And above all – LISTEN to their answers. A wise man (Dr. Kapasi, again) once said “God gave us 2 ears and 1 mouth for a reason – so we can do twice as much listening as talking”.
3. The Power of Positive Language
What we say to our clients matter! And directly affects their perception of their injury. This is especially important when dealing with chronic pain diagnoses. When I treat, I always try to re-direct my client’s focus from “pain” and what they can’t do towards positive outcomes such as functional improvement and what they are able to do now, even with the same level of pain (still demonstrates positive progress though pain is still present). When clients meet with MDs and they receive a “medical diagnosis”, many will research it on WebMD, and come in to our clinics with anxiety and fear due to what they’ve found on the internet – we need to break their pre-conceived notions!
Above, I mentioned that we need to address and treat the client’s nervous system (think biopsychosocial model). Using positive language/imagery/visualization can decrease our client’s anxiety levels, decrease their fear of movement, and subsequently change their outlook on their condition. Negative thoughts can indirectly increase pain perception, and therefore, the physical manifestation of pain within our client.
4. Don’t Over Treat
I think this one pertains more to new grads, though seasoned therapists could benefit from this one as well. When I was a new grad, I felt that every client needed manual therapy, every session. This is not the case. In fact, this leads to over treatment and can aggravate a client’s symptoms. Sometimes clients only need tactile cueing and proper movement coaching to improve. When a client is close to discharge, they should not require 30min of manual therapy – should they really be discharged if you have to “mobilize the distal tib/fib and tibiofemoral joints for an entire session?” (this is not including discharge for insurance reasons…). How do we know if we’re about to over treat? TEST/RE-TEST!
5. Confidence vs. Arrogance
Lastly, know the difference between confidence and arrogance. Clients can tell the difference, don’t be arrogant. You can be confident and assertive without sounding arrogant and pretentious. Again, verbal and body language matter. Make sure to not hold yourself as if you’re “better” than the client, build rapport and earn their trust – don’t be demanding, be empathetic. This can be frustrating when dealing with tough clients who aren’t adherent with your plan of care – where you know they could be progressing if they just followed through with your plan. Maybe you need to try another approach, maybe you need to find out why they aren’t adherent – what are their barriers to compliance? Don’t just assume that the client does not want to participate (you may have some who fall under this category but that should be a small percentage).
As an added bonus – don’t put down other professions to prove your point. It makes us (PTs) as a profession seem petty and desperate. Let your results speak for yourself!