How To Make A Great Start To Your Patient’s Treatment Plan Even Without A Diagnosis
Posted By: Andy Barker
Before you even get chance to explain what is going on…
The symptoms you have, how long you have felt unwell and other possible important information like any possible allergies…
The doctor just gives you some pills and shows you the door.
You would hope this would never happen.
Clearly the doctor needs to ask you some questions and examine you to diagnose your issue and THEN…
Prescribe you with the right medication or advice for your illness.
If the doctor did not do this and just gave you some random pills because it sounded a bit like a chest infection…
Or a patient last week, responded well to these same pills…
You would consider this poor practice, maybe even malpractice.
But many therapists do this very same thing day in and day out.
You go through your assessment and even if you are unsure on what the diagnosis is you carry on regardless…
Prescribing exercises or using treatment techniques you are comfortable with…
Techniques or exercises that have worked well in the past with similar patients…
Or just some random exercises that seem to be popular this week on Instagram.
This is no different to that bad doctor.
And this is why you should never start treating your patient until you are clear about what you are actually trying to fix.
This blog will detail 3 simple steps you can follow to ensure you don’t make this big mistake and ensure you can clinically reason any treatment technique or rehab exercise you use.
#1 Set Your Initial Assessment Expectations
In the therapy world there seems to be confusion about the aim of the initial assessment.
The main aim of your initial assessment is to identify what problem or problems you patient has…
Identify their end of goal of treatment and…
Outline a treatment plan to your patient, showing them how you are going to get them from injury, and back to full health.
Only when you have done these 3 things would you consider treatment and rehab.
Often if you do a thorough job of the above, you may not even get time for treatment and rehab in that first session.
If you have time for treatment and rehab in the initial assessment…great.
But you need to first nail your assessments.
If you miss important information, you might not pick up something sinister that you might need to refer on, or diagnose the wrong thing, causing you to start treating the wrong problem.
Failure to miss something sinister is clearly important as these patients may need interventions that you can not provide and would be best provided by another professional.
Failure to treat the right problem may mean your patient does not respond well to your interventions.
Maybe you make no changes to your patient’s symptoms.
Or even worse than that…
You actually make their symptoms worse.
Patients want to get fixed…usually quickly and without flare ups and re-injury.
This might seem obvious.
But first they need to understand what problems they have got and what is causing their symptoms.
Whilst you might think you are delivering a better service by including treatment and rehab in your first session you are not if you are sacrificing precious assessment time to do this.
The long and short of it is…
If you do a poor assessment…
There is a much higher chance you identify the wrong diagnosis and problems.
This results in a waste of your time, effort and energy on the wrong issues…
Where you risk sending your patient away with a home rehab plan with exercises aimed at fixing a problem or injury that does not need to be fixed.
With any initial assessment make it clear to your patient at the start of the session what the aim of the session is.
This might sound something like this…
‘The aim of this session is to find out about about you and your injury, identify your problem and for us to devise a treatment plan that is going to help you get back to the activities that your current injury is stopping you from doing.’
#2 Don’t Rush Your Assessments…Especially The Subjective
If you have set expectations about the main focus of your initial assessment that should put less you pressure on you to rush your assessments and stop you racing to give some sort of treatment or prescribe rehab.
The subjective assessment comes at the start for a very good reason.
It informs what you do in your objective assessment, particularly your special testing.
If at any point you are unsure about what your patient is trying to describe, ask them again.
Do not be worried about repeating questions or asking patients to clarify certain things.
The key to your subjective is to extract the meaningful information from the meaningless information.
Take this neck pain patient.
When taking about their injury they mention that…
‘When it was worse I was getting pins and needles in my fingers.’
At first they point and indicate it was their ring and little finger…
Then change their mind and tell you that they remember these symptoms being on the back of their hand.
These indicate very different injuries.
The ring and little finger nerve distribution might indicate a ulnar nerve issue.
Whilst the same symptoms to the back of the hand might indicate a radial nerve issue.
This might not only influence the assessments you do and in particular the nerve based tests you may use during special testing to make a diagnosis.
This vital information will also help you prescribe more specific treatment and rehab interventions.
In this case, ask the patient again.
Try to clarify where their symptoms actually were.
Then you can test this in your objective assessment.
As a general rule if something your patient reports does not make clinical sense in your head…
If your patients answers seem a little different to what you might expect given the rest of their assessment…
Then there is probably good reason why.
Maybe they are a poor historian and have forgot to tell you about some important past injuries…
Or have poorly recalled how they got injured.
Be sure their injury story makes sense and doesn’t have any gaps.
Ensure you take a full and proper past medical history and be clear about the exact end goal you are trying to achieve with your patient.
Only when you have this information and only then…
Should you progress to your objective assessment.
#3 Be Safe To Start Your Treatments & Rehab…Even Without A Diagnosis
So, what happens if a diagnosis is a little unclear?
I stated earlier that by progressing to your treatment plan and starting treating or giving rehab to your patients without a diagnosis is no different to that bad doctor prescribing pills without doing a full assessment.
The key here is ‘without a full assessment.’
Even with the best assessment in the world there will be some patients where a specific injury or structure is almost impossible to diagnosis.
Even when using scans like x-rays, ultrasounds or MRI’s.
But this should not matter.
Providing you have not rushed, you should come to the end of your patient assessment, having ruled out any possible red flags and with a list of problems you intend to fix.
These problems are not the diagnosis but the issues your patient has that are giving them pain or impacting their function, or both.
It is really important to remember that whilst we should always try to identify a diagnosis this may not always possible.
And of more importance is the fact that as therapists we do not treat a patients diagnosis…
We treat their symptoms, like a loss of ROM, strength, instability, balance, proprioception, poor movement or pain.
A great assessment, with or without a diagnosis, will give you the information you need.
It will give you a list of problems.
Prioritise these problems…
Then get to work with your treatment plan to fix them.
#1 Set Your Initial Assessment Expectations: Make it clear to your patient at the start of the session that the main aim of their first appointment is to find out about their injury, identify what problems they have and devise a treatment plan to help them get back to full fitness.
#2 Don’t Rush Your Assessments…Especially The Subjective: Take your time with your patient assessments to make sure you don’t miss anything sinister or any important information that will help inform your special testing, treatments and rehab.
#3 Be Safe To Start Your Treatments & Rehab…Even Without A Diagnosis: Providing you have cleared red flags it will be safe to start your treatments and rehab with your patient, even if a diagnosis is not clear. Prioritise the problems you have found, like ROM or strength, then get to work to fix these issues.
Hope this helps
PS. I know making sense of those patient assessments can sometimes be tricky.
If you get your assessments wrong, not only could you miss something sinister but you could end up wasting your time, effort and energy (and your patients) on the wrong thing!
If this sounds like you…
I’ll walk you through how to structure a super simple but structured assessment so you feel well prepared and confident for any patient that walks through that clinic door.
I’ll tell you the exact same questions and tests I use with every assessment I do, whether I am working with a professional athlete or a member of the general public.