Treat Your Patient NOT The Textbook
Posted By: Andy Barker
Patients never really say what they are supposed to!
What you were told they would say during their subjective assessment is not what they say in real life…
When you ask those questions, what they are meant to say and what they say are often vastly different things.
Then you get on to the objective assessment and what you think your patient might test like on the bed and what they test like, again can be hugely different!
Your heads in a spin, you are not too sure what is going on and you struggle through the rest of the appointment.
Connecting the dots between the methods you have been taught to assess, treat, and rehab your patients at University and what is needed to get patients better in the real world can be tough.
No two patients you see will ever be the same, EVER…
Whilst some may be similar, they will never present the same, have the same story leading up to and likely contributing to their injury or have the same outcome goal.
And this is the very reason, cookie-cutter assessment techniques and textbook methods of treatment and rehab often do NOT work with patients in the real world.
Keep reading to find out how to make sense of your patient assessments so you do not feel overwhelmed and have greater confidence about how to manage the patients you look after.
The Subjective Is KING
The aim of the subjective history is to find out WHY the patient is in your clinic.
Not just what the referral letter says, or their injury as such, but WHY their injury has started in the first place.
Traumatic injuries aside, injuries do not just happen for no reason.
That insidious onset knee, lower back or shoulder pain just did not start one day.
There is a story behind each patient you see, and the job of the subjective history is to unpick this story and find out WHY they have a problem.
It is all well and good finding out WHAT is going on, i.e. the patient’s diagnosis, but does this really help you to know what to do next?
You could identify a patient with patella tendinopathy and write the best patella tendon rehab programme ever seen.
But, if you do not address why that patella tendon is overloading in the first place, then the likelihood is that patient will get better, for a while…
But probably break down again.
This is usually when they go back into higher-level activities like running, the gym and sport.
You use the subjective history to dig for your patient’s story, to piece the information together from their past medical history, to find out WHY they have developed their current problem.
This can be different for every patient, even for patients that present with similar symptoms.
It could be an old ankle or hamstring injury; it might even be a problem on the other side of their body.
Your job is to find out what it is, and you use the subjective history to do that.
So, do not rush this.
Take your time with your subjective assessment, make sure you do not miss any important information and do not move on until you are happy your patients story makes sense.
Set Expectations Early
A big misconception New Grad therapists have is that they think patients want everything in session one.
By everything I mean an assessment, a diagnosis, a prognosis, hands-on treatment, and rehab.
Firstly, they do not.
More than anything they want to understand WHY they have the problem they have.
The aim of the initial assessment is to identify the problems your patient has and then put a plan together to fix them.
That is, it.
That may mean in session one that they walk away from your clinic without having had any treatment and maybe without any rehab exercises.
But what they will walk away with is complete understanding on their problem(s) and how your treatment plan is going to fix them.
Too many New Grad’s rush though their assessments, wanting to give patients treatment and prescribe rehab, thinking that they are providing a disservice if they do not.
But often, this causes rushed assessments and as we have discussed above if you don’t get your assessments right, if you don’t identify the right problems then you may find that patients don’t respond the way you want them to.
For most this will usually be a few sessions in, when your patient has not made the progress you thought they should have done.
Then you end up going back, testing different things, asking different questions.
Things that you would have picked up in the initial assessment if you hadn’t of rushed through it the first time and things that if you would have known then, may have made you adopt a different treatment approach.
Tell your patients at the start of that first appointment that the aim of this session is to find out what is going on and to design a plan to get them back to full health.
Then when they leave with this, they will be happy and will not leave feeling they have missed out because they perceived that they would be getting hands-on treatment or going home with some rehab exercises.
Textbooks Do NOT Talk
They also do not move, run, lift weights, or play sport.
Each patient you meet, whether you work in professional sport, the NHS or private practice will be different.
They require you as the therapist to assess them, their symptoms, the way they move…
How they present, their journey to your clinic room (their injury journey, not the route they came in the car) and their desired outcome goal will be different.
This is the primary reason generic rehab or injury protocols do not work.
It is impossible to know what a patient needs; what hands-on treatment techniques and what rehab exercises they need if you have not assessed them yet.
You might have an ACL reconstruction you are seeing 2 weeks post operation.
If you are going into that initial assessment already knowing what exercises you are going to send them home with then you are missing a trick.
How do you know what they need because you have not assessed what problems they have?
Maybe you are thinking you will give some exercises to help them restore knee extension as we all know this is important in the early weeks post ACL surgery.
But what if they already have full extension?
Do you just give them the extension exercises anyway?
Just because it’s worked for someone else does not mean it is the right exercise for every patient with the same injury.
Regardless of the injury, you need to assess the patient in front of you and give them the interventions they need, specific to them, at that time…
1) The Subjective History Is KING: Do NOT rush your subjective assessment. This holds ALL the information you need to find out not only WHAT is going on but also WHY your patient has the problem they do
2) Set Expectations Early: Tell your patient the aim of the initial assessment, which is to find out their problem and devise a treatment plan to get them back to full fitness
3) Treat The Patient & NOT The Textbook: Remember no two patients will ever be the same. Your job is to devise a plan to treat the patient in front of you and not what the textbook told you to do
Speaking of assessments…
I use the same assessment technique with every patient that I see.
Whether I am working with a professional footballer or treating a middle-aged mother of three in my private clinic.
The technique I use is super simple, but it gives me ALL the information that I need to know what to do next, what treatment technique to use and what rehab to prescribe.
To get the right information you just need to ask the right questions…
You can find out what these questions are on my New Grad Physio Lower Limb & Upper Limb Courses
The content I teach will help you to be able to make sense of your patient assessments and show you how to take information from your subjective and objective assessments so you also know exactly what treatment and rehab exercise to give to your patients.
You will learn how to better assess gait and how to use simple standing movement tests to identify what is causing your patients pain, NOT just where their pain is.
You will learn why traditional manual muscle testing might not give you the answers you want and discover another way to test muscle strength.
You will also see my ‘6 Step Rehab planner.’
This is the exact system that I use for every patient or athlete I work with any lower limb or upper limb injury, which tells me how to progress (and regress if needed), to manage patient symptoms and get them back to full fitness.
To book your ticket and find out more details visit www.newgradphysio.com/courses
The New Grad Physio Mentor