[headline style=”1″ align=”center” headline_tag=”h2″]How I Stay Focused
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Last week I had written about the importance of focusing in on one impairment per treatment, two tops. In case you missed my last post, you can read it by Clicking Here.
To further on that information, I am going share what I do before and during my treatments to ensure I get the best outcomes with my patients. This is literally the template that I use when I treat my patients. See below.
[headline style=”1″ align=”center” headline_tag=”h2″]Evaluate, Treating, Reassessing
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Before disclosing my template that I use, it should be understood that I am always:
1.Evaluating
2.Treating and…
3.Reassessing
For instance, if my patient comes in with a stiff ankle or shoulder I will do a quick evaluation followed by treatment and then reassess if my treatment helped. I have found through clinical experience most clinicians forget about this simple concept because the clinic can be so fast paced. Hence, this is one of the many reasons why working on one impairment is key. Not to mention, gratification sets in after seeing it worked.
“Always be evaluating, treating, and reassessing your patients.”
[headline style=”1″ align=”center” headline_tag=”h2″]The Template
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I stole this template from one of my PT school instructors and have used it ever since. It lays a framework for choosing one impairment that you are going to work on for that day. Without further ado here it is:
1.Palliative
This part of the treatment is to reduce pain if a patient is acute or to make the treatment comfortable for the patient. This could consist of modalities, joint mobilization, heat, etc. Basically, we want to reduce their pain. It may not always be needed, especially if they have no pain.
2.Preparatory
To prepare the tissue for the main treatment, sometimes you will have to provide heat, massage, exercise, and etc to make the corrective treatment more beneficial.
For instance, if I am going to do active release technique to a pulled hamstring, I will gently massage the area before I do a more invasive technique such as ART.
This allows the patient to relax more and allow me to put more tension on the soft tissue, which enhances the treatment.
3.Corrective
The main treatment that you are providing for the day is the corrective. In the case of a pulled hamstring, I would give ART to the area.
4.Assistive
To make lasting gains on the treatment that you had provided, the patient needs to perform a HEP. This could be education, myofascial release and mobilization, strengthening, stretching, PRICE principles, etc.
In the example above, the patient could perform a 3D hamstring stretch and some form of loading program to increase the tissue’s tolerance to load and collagen repair.
It has been my experience this is often overlooked or the patient is given way too much information. Keep it simple.
[headline style=”1″ align=”center” headline_tag=”h2″]The Big Rocks
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Another key point in staying focused is to work on the most influential impairment for that day. For example, if a patient just sprained their ankle, do not start working on subtalar mobility that same day even though it may have caused it in the first place. The goal is to prevent the injury from worsening and follow basic principles of rehabilitation.
Conversely, if a patient comes in with anterior knee pain but is able to still run, I will probably go after a deficit in foot mobility.
When I went through Gary Gray’s fellowship we learned about three key areas of the body that impact the rest and where most dysfunctions originate at. This is usually where I start with my assessments or the weakest link I had found in my examination. These three key areas I am always thinking about in my treatments and evaluations:
- Foot and ankle
- Hips
- Thoracic Spine
When these areas aren’t functioning optimally, it becomes apparent why the injury occurred in the first place. Even though it is important to figure out the culprit, the injury itself still needs treatment. Thus, I may give some complimentary ankle and soft tissue mobilizaitons in conjunction with loading of the hamstring.
By the way, if you are interested in learning more about these areas I would sign up for a course at the Gray Institute by Clicking Here.
The big rocks of the body are the feet and ankles, hips, and thoracic spine.
[headline style=”1″ align=”center” headline_tag=”h2″]Examples
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So now that we have laid the basic framework, lets go over another example of applying this form of treatment to an individual with a tight anterior shoulder capsule.
Palliative:
When a patient has a tight anterior joint capsule, the patient may or may not have discomfort. Ideally, they should present with pain into end ranges of external rotation and extension and with mobility deficits. Assuming this were the case, heat could be applied to help relax the shoulder and reduce pain.
Preparatory:
To prepare for my main treatment, of grade III and IV joint mobilization, I may start this patient off with grades I and II to increase synovial fluid around the joint.
Corrective:
To ultimately get some plasticity to the joint I would provide repetitive and end range stretching of the capsule with grades III and IV or mobilization with movement.
Assistive:
In order to help maintain the mobility of the shoulder that was gained during treatment, the patient could carry this over with their HEP with movements that stretch the capsule. Since we want to keep mobility, in this case, I would prescribe higher repetitions, more sets, higher frequency throughout the day, and at least 10 second holds to keep plasticity.
[headline style=”1″ align=”center” headline_tag=”h2″]Conclusion
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Staying focused and working on one impairment per treatment is crucial to patient success. By following this simple template, evaluating the big rocks and/or addressing the most important impairment at the time is vital. Not to mention, always assessing, treating, and reassessing. If you do take the time to do this, even though it appears mundane and simple, your patients will reap the rewards. I promise.
Give this framework and try and let me know if you have any questions.
