Critical Thinking

Do You Re-Assess? Well You Should…Constantly.

 

As a Certified Orthopaedic Manual Therapist through the Maitland Australian Physiotherapy Seminars, I may be a bit biased when I say, we must constantly be in a process of assessment and reassessment during our clinical interactions.   When I say this, I don’t mean simply performing a routine “reassessment” visit and/or note to appease insurance company regulations.  I instead mean a continuous monitoring of our patient’s response to our care.

So how should we be doing this?  The following are several examples of ways we should be assessing our patients during our interactions:

1. After your subjective examination, find out more about the interactions they had with other practitioners prior to arriving to your facility.  Learn about their feelings during those interactions.  For example, “When you went to the Orthopaedic and they told you your knee was arthritic, how did you feel?  Did this make you feel different than you felt prior to his explanation?” 

When you provide the patient with your own diagnosis, prognosis and plan of care, ask them if you were able to meet their needs.  Ask them how they feel about the information you just shared (sometimes 3x per week x 4 weeks can seem a bit daunting—Were you able to explain why you determined this plan of care was necessary and assess how they felt about this—motivation is necessary?).

2. During a manual intervention (or even during a mobility assessment, during the objective examination), assess the patient’s response to your care.  How does it feel when I do this?  How does it feel after I do this. Did you continue to have relief once you went home?  While we all have our different tricks, in the end, an input is likely just an input.  As I have talked about at nauseum, we interact with intact, complex nervous systems and the most specific tool we have is the patients response.  Assess how your patients react to you.

3. Throughout therapeutic movements (whether the approach be graded exercise or graded exposure), make an assessment to determine if the activity assisted them in moving better.  When I say this, I do understand that the assessment of movement can be a very subjective task.  I recommend simply looking at their ability to perform a task prior to the movement, and then reassess their performance, after.   For example, if you choose to have the patient perform 30 wall slides, look at their movement pre- and post- activity.

In utilizing an approach incorporating frequent assessment, you will begin to understand the patient better.  You will begin to understand how their nervous system perceives various forms of input: your words, environment, manual interventions, movement, etc. You will begin to understand what happens within your session and what happens between your sessions. 

Remember, we are much more than interventionists.  We are autonomous, high-level practitioners and it is our duty to make sure we are constantly adapting our interventions based upon patient behavior.  The days of following flow sheets are over—we should be re-writing these every treatment session. 

What are your thoughts?   Do you reassess  within session and adapt your approach or do you follow “the sheet”?

-Joe B

Check out further discussion on this subject over at RehabEdge

 

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4 replies »

  1. This is a great post and something that has been on my mind lately per some of my conversations with my current SPT. I was going to post this in response to David Butler’s post on noijam http://noijam.com/2014/04/07/123-needle-going-in-this-will-sting/ but I figure this is as good of forum as any.

    Shortly stated, we must be VERY careful that our assessment does not attempt to conform the pt. to our prejudicial biases (about the nature of their symptoms). Therefore the key is to let the pt’s expression to fully inhabit the conversation and the context that is created between the therapist and patient. If we think by asking more questions (i.e. leading the pt. with specific adjectives) or even suggesting that sensations they are feeling ARE pain we may be trying to box the pt. in to a specific category and ignoring the presentation in front of us–dare I suggest we may also be cranking up the dreaded nocebo as well.

    I have also observed students and fellow PTs asking “is this your pain?”, “is that your pain?”–over and over using the word pain. Think about it, if you wanted to trigger someones salience network (i.e. increased their perceived threat), just ask them 10 times is that your pain or is that your pain. Again letting their natural expression to spring forth will tell you much more than focusing on their response to one little word with big meaning i.e. PAIN.

    As examples, I tell my students when you are moving a post-op shoulder feel the tension of their muscles (don’t judge it) just feel it, watch the corners patients eyes (look for them to start to wince). You will know more about their symptoms than you will ever get–in real time too–via asking is that your pain.

  2. […] Patients need to be reassured what they are experiencing is “real”.  In and of itself, that concept has phenomenological undertones, but in reality, their experience is their experience.  As therapists, we must simply attempt to understand their experience, demonstrate that we are attempting to understand it and attempt to help guide them in altering it.   I suspect many of us can become fixated on looking for so-many variables that “we become overwhelmed by the noise“.   This deductive process could easily be refined to a simple algorithm:  Rule out major pathology–> Discover the chief complaint –> Reproduce it –> Attempt to alter it –> Check if we altered it by attempting to reproduce again. […]

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