Practitioner Seed #9: Know when to Go & when to Woah!
We have all experienced that sinking feeling when you see your patient LIMP in for their review consultation!
Why have they come back in a worse condition than when you left them?
Were you too heavy handed with the manual therapy?Was the exercise dose too aggressive?Did you try to continue the running program when that reactive achilles tendon had other ideas?ORWas it something that the patient did outside of your control?
The commonality in all of these examples, is that your initial assessment missed the mark from some perspective!
As a new graduate, clarity on where your patient is coming from, where they are right now, and where they need to go, can be a tricky conundrum to process all within the constrains of a 40min consultation. In those early years it can take a couple of appointments before you gain a solid grasp on the diagnosis & degree of irritability, let alone the personality & motivating forces behind what makes that individual tick!
Missing the mark early, may impair efforts toward building trust and ultimately, detract from the therapeutic alliance. There is a convincing body of evidence highlighting the importance of a strong therapeutic alliance in achieving successful outcomes for our patients (Babatunde et al, 2017).
So to become a world class clinician, achieve optimal outcomes for your patients & build a reputation that in turn spreads the ‘Goodwill’- You must first & foremost cause no HARM! This requires developing an internal index of patient irritability.
That is, part of your role in those initial consults, is to set up a process of- Irritability Profiling
As an example you have a patient who presents with low back pain.
Combining these yellow flags with with what we know about neural tissue sensitivity – This patients irritability profile has a very narrow bandwidth. It is easy to flare them up – So your common sense prevails and you proceed ULTRA CAUTIOUSLY with your dosage of manual therapy & exercise. Your clinical judgement suggests that this might be a nerve root closing down issue, so you opt for gentle opening up movements. The last thing you will do with this person is ask them to lay prone on the plinth! They may not get back up!
This patients irritability profile has quite a wide bandwidth. He is tolerating high loads physically, and psychologically there are very few barriers toward achieving an outcome – which is, to reduce pain in an activity he is already doing. Your rehab program here could be more substantial ; heavy strength training to address neuromuscular deficits, aggressive mobilisation to restore ROM, all the while maintaining confidence in his ability to tolerate the ‘heavy handed’ approach.
Now let’s leave the comfort of your clinic cubicle & get into the thick of the sporting action!
You are on duty at your local match, relaxed but ready for a curve ball to be thrown your way!
A player starts to jog off toward the boundary and you know something is going down – It’s not their turn for a rest yet!
They are jogging slowly, no visible limp.
This player is a renowned ‘speedster’ of the team, covering a lot of ground with high speed running.
They have had a ‘chequered’ history when it comes to soft tissue injuries, having suffered 5 previous hamstring injuries and one rec fem.
The player hasn’t even arrived to the bench and you have already started to deduce a hypothesis!
Upon questioning, the player describes a gradual onset of localised hamstring tightness, over a length of 3-4cm. This has been stable for the previous 10min of play, and the player reports being able to reach about 80% speed prior to onset of symptoms.
Your clinical tests exhibit awareness on contraction & length testing, but your HHD reports full symmetrical force production, and length is also L=R for ROM.
What do you do? Do you GO OR do you WOAH?
At this stage the coach is breathing down your neck and you MUST MAKE A CALL!
The player is in your ear – “I’m fine to go back, get me back out there!”
There is pressure coming from all angles!
>This truly is a tricky decision to make – here you have a player who might have a G1-2 injury, however the mechanism would not suggest severe tissue structural damage. Plus you have an eager coach and a persuasive player!
Further information that needs to be considered:
- What is on the line? What does winning mean? Is it a final or a preseason match where a loss is inconsequential?
- Is this player an accurate reporter? Have they not let you in on the full story?
- Always RESPECT the players past history – Being the single biggest predictor of subsequent soft tissue injury, past hamstring history is not to be taken lightly!
The Verdict………………
Play it safe! Stick you tour guns and deliver the facts with conviction!
Barring a grand final or an important final in the lead up to the big one, we would advise that this player is removed from match conditions.
It’s your job to suggest that we WOAH!
It’s likely this player has a Grade 1 injury, and subjecting them back into the trenches is too high a risk with the potential for more extensive tissue disruption to occur
The player will accept your decision in the cold light of day!
Some key take away points that you can integrate into your practice:
Understand irritability
Start Irritability Profiling your patients
Reflect on tissue specific characteristics of irritability
Consider the psychosocial elements that impact irritability
Become skilled at processing lots of information, quickly!
Practice the craft of decisiveness
Stick to your guns!
Reference:
1.Babatunde F, MacDermid J, MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC Health Serv Res. 2017 May 30;17(1):375.
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