Importance of Thorough Assessment and Incremental Treatment Progress

Dr. Jordan Berry // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Spine Division faculty member Jordan Berry discusses how slowing down in the clinic both with evaluation & treatment can give clinicians a clearer picture of patient symptoms. Going slower early in the plane of care allows clinicians to better understand if treatment is creating meaningful change or not, thus allowing treatment to accelerate over time. The alternative of attempting to perform multiple treatments to multiple regions each visit can actually complicate clinician understanding of a patient's progress, slowing rehab down significantly.

Take a listen or check out our full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

JORDAN BERRY All right, good morning, PT on Ice Daily Show. This is Jordan Berry, Lead Faculty for Cervical and Lumbar Spine Management. It is Tuesday, so that means it's Clinical Tuesday. Today we are talking about why in the clinic you have to slow down to speed up. Because if I was reflecting on what is the feedback that I give to most clinicians, either myself that I'm watching clinicians treat, or I'm doing case reviews, working through challenging cases with clinicians, or if we're at our cervical or lumbar live course, we're chatting through some of the more challenging present presentations and patterns. Probably the most common feedback that I found myself giving is telling that person to slow down, right? And you have to slow down in order to speed up the rest of the plan of care. So I want to unpack why if you slow down during the initial eval and during the first few subsequent follow-up sessions, you are going to be able to in turn speed up the rest of the plan of care and maximize your outcomes in the clinic. I think the quote, slow down to speed up, could be somewhat interchangeable with do less, better, right? Which we always talk about in the clinic, doing less, taking your time, but doing a better job. But I want to talk about why specifically slowing down is going to allow you to speed up over the long haul throughout the plan of care. And putting this together and this idea, I have to give a shout out to the book Unreasonable Hospitality by Wilgie Dara. I love that book. If you have chatted with me at all over the last year, year and a half, you know that I love that book so much. I've read it multiple times. And it's something that they talk about in that book as well. The idea of slowing down to speed up. They're talking about it more. So if you're not familiar with that book, you've got to read it. It's about it's about a restaurant and how they grew that restaurant to be the best restaurant in the world So they got ranked number one a few years back and one of the concepts they talk about is slowing down taking your time and making sure that you have everything correct up front as you're servicing that table or waiting on that table to make sure that the rest of the meal goes smoothly. And I love that idea. I think it was because prior to PT school, I was in restaurants. I worked in the restaurant industry pretty much my entire life prior to that. But the idea of slowing down in order to maximize your outcomes applies to the clinic too. And so I want to talk about two case examples. and how we would apply that in the clinic. CASE EXAMPLES: WHEN GOING FAST GOES WRONG Okay. So first case example, we're going to call her Kathy. So Kathy rolls in and she's got a bunch of symptoms. She's got neck pain. She's got shoulder pain, some referral up into the head, maybe some paresthesia down into the forearm and hand. The whole works, right? We know that patient. And during your initial evaluation, day one, right? You're definitely trying to figure out where the symptoms are coming from. In addition to all the other things that we would be trying to do during the initial evaluation. But one of the primary things is you're figuring out what is the primary symptom generator, right? What area am I going to intervene on day one? And let's say that you go through the objective exam and a bunch of things show up. So you're going through cervical active range of motion, you're going through the cervical segmental exam when you're testing the joints and both of those things provocate symptoms. But then also, let's say you're testing the shoulder and in range flexion brings on symptoms and you challenge external rotation manual muscle test, right? And that brings on symptoms. You palpate the posterior rotator cuff and that lights it up. So we've got a bunch of things on board day one. Here's the fork in the road that separates novice from expert on deciding where you're going to go with that initial treatment. What does a novice do with that presentation day one? They try to attack all of it. So in that, let's say eight to 12 minutes of that initial trial treatment, they try to shove all of the cool stuff as many things as they can into that initial treatment. So maybe they do, let's say cervical retraction, let's say some distraction, they're cracking the upper thoracic spine, they're cracking the neck, they sneak in some soft tissue work to the shoulder, they're loading external rotators, the whole thing. And let's hope, number one, that they've done some sort of reassessment throughout. Likely, if they do a reassessment at all, it's at the very end, after they've done all of these interventions, And let's say the patient, Kathy, let's say during the retest, she says, okay, that does feel a bit better, right? I don't have as much pain. Here's the problem. Here's the trap. Regardless of whether or not the patient is feeling better, right? And whether or not they improve over the next session, you have just set yourself up for disaster. because you have no idea what treatments actually helped the patient and they have no idea what treatments actually helped. So over the next few days between this session, the next session, they have absolutely no idea what they should focus on, what area they should be focusing on, what they should be paying attention to. And more importantly, during the next session where they come back, you have no idea of how to press. Because you threw everything at it, well, really your only choice next session is to continue to throw everything at it. So next session, you've got to crack the neck, you've got to crack the upper back, you're doing the soft tissue work, the retraction, you're loading the shoulder, maybe some dry needling now, some soft tissue work, right? You're doing all the things because you did that initially and now we've just got to continue with that. In other words, because you were trying to go fast, You've number one, likely failed to dose anything with enough intensity to actually make a meaningful change. And number two, if you plateau, let's say on visit four, visit five, you literally have no idea what to shift to or where to go because you threw the kitchen sink at it. So you tried to go fast early on and you wound up slowing yourself down over the longterm. Now on the other hand, right, the expert, that initial evaluation after you do the objective exam and all the things show up, what if you stepped back and said, you know, Kathy, we're seeing some different things here. We have some things that showed up in the neck, some things in the shoulder that both brought on your symptoms. However, for today, I'm only going to treat the neck. We will treat the shoulder over the next few sessions, but today I'm only going to treat the neck so that we know over the next week or so what things are actually related to the neck and changing. Now I want to say here, I don't think it matters if you treated the neck or the shoulder day one. I think what matters is that you actually just chose one area and you stuck to that one area. Because let's say she comes back, let's say Kathy comes back next session and she's feeling a bit better. Well, because you only treated the neck, you now know exactly how to progress things. You can say, okay, Kathy, that's great. I'm glad actually everything's actually a bit better than what I was expecting. So now we know the symptoms are primarily coming from the neck, not the shoulder. Now we can focus here. or if Kathy comes back and maybe she's not doing so hot, right? You're not seeing the symptom change that you would expect, right? It's not ideal, but you can still spin it now in a positive way. You can say, okay, Kathy, that's great information. That's not the changes that we were expecting, but what that does is confirm that maybe it is the shoulder that's driving more of the symptoms. So today, if you don't mind, I'd love to change gears and focus now on the shoulder, and we will be able to track this forward and see what kind of symptom change we get from that. But either way, you can now dial in the rest of the plan of care, right? You started out slower. You took your time during those first few sessions to understand the presentation. And now you're going to speed up the progress over the next few visits. And you're going to end up making more change over the longterm than that novice clinician that wanted to throw everything at it from the start. Most complex clinical presentations are just simple presentations, simple patterns stacked on top of each other. I repeat, most complex clinical presentations are just a few simple presentations stacked on top of each other. So all you have to do is take your time and tease them out one by one to figure out what is causing what and what is affecting what. And that will guide how you move forward. Okay, example number two. So it's a little bit shorter, a little bit more simple, right? So let's say Kathy rolls in more simple presentation. She's got some unilateral low back pain referring down into the glute. You go through your objective exam, lumbar active range of motion, pretty limited in all planes and recreate some symptoms. So it's pretty stiff and a bit painful, specifically flexion, super limited. She bends forward, no reversal of the lumbar spine, segmental exam, super stiff, hip totally clear. And you decide, um, for your initial trial treatment that you want to do, you want to mobilize the lumbar spine, right? You want to see if we can improve some of that motion. And let's say you choose that sideline lateral glide, non thrust mobilization. Side note, if you don't know that, that, that lateral glide mobilization, you've got to learn that. We teach that in the live lumbar management course for sure. That is by far my most used non thrust mobilization to the lumbar spine. Anyway, let's say that you choose that and you dose that for two to three minutes. Kathy gets up and let's say you reassess flexion and she's got a nice five degree change in range of motion. So she improves by about five degrees and a little bit less pain. Now, nothing miraculous, but you see a small positive change. Okay, here's that same fork in the road of novice versus expert. So if you were to ask that clinician, the novice clinician, what are you going to do next? Almost always they are going to say, well, I'm now going to do blank, which is some other cool intervention, right? Well, I'm going to do some dry needling. I'm going to do some decompression with cups. I'm going to crack their back. I'm going to do this exercise. It's something different. On the other hand, what does that answer look like from the expert? When you see that small positive change, what are you going to do next? More. You're going to do more of it. So you say, Kathy, get back down there, right? You mobilize your back for another four or five minutes. She gets up. You see another small positive change. What do you do next? You get back down there. You keep working the thing that is working. The expert sees the change and doubles down and does more of it. Maybe you change your angle a bit on the mobilization, maybe you do both sides, maybe you work up and down the lumbar spine again, but you are not leaving that intervention while it's still giving you additional benefit. You ride that horse until it bucks you. If it works, great. Do more of it. Instead of trying to cram everything that you possibly could during that session, right into that one session, focus on the thing that is working and just increase the intensity. And now the patient has one thing to focus on. They know exactly what is actually changing their symptoms and you can sell the next session. Just say, Kathy, when you roll in here next time, we're gonna add a little bit of A, B, and C on top of the thing that we already know is working. And now you can take your time, right, and you can stack interventions on top of each other. So many times in the clinic, when I'm reviewing the quote-unquote challenging cases with clinicians, when they're telling me what they've done, right, throughout those first few sessions, They typically have done at least one intervention that has given some change, some positive change, some improvement. And I always ask, well, why didn't you do more of that? Why did you actually go to this instead of just doing more? And it's crickets. We're so obsessed with doing things, with trying to give the person more interventions, more of our skillset. instead of just doubling down on the thing that's working. So I will take something in the clinic, an intervention is working. Let's take that lumbar spine mobilization. I will just hammer it until it doesn't work anymore. Right? So if you're retesting four times during a session and every time it gets better, just continue to use that same intervention until on your test retest, it fails to give additional benefit. it will simplify your clinical reasoning, slowing down with your intervention, again, allows you to speed up over the long haul. So think about those two examples this week in the clinic, slowing down to speed up. So early on in the plan of care, focus on tackling one area, commit to it, and watch your decision making throughout the rest of the plan of care become so much more clear. And once you do have that treatment that's working, commit to it and ride that horse until it bucks you. Until when you retest, it gives you no additional benefit. But if it does, you stick with it. Those two things together are going to allow you to maximize your outcomes in the clinic. All right, would love to hear thoughts on this. SUMMARY If you want to learn more about this or that technique that we mentioned or any of the clinical reasoning around it, we've got a few live courses coming up. Let's see, for cervical management, we've got one in February in Simi Valley, California. We've got two in March in Kuna, Idaho and Longmont, Colorado. And then for lumbar management, we've got one in March in Cincinnati that is actually sold out already. And then we've got Milwaukee, Wisconsin at the end of March as well. So that is it, team. Have an awesome Tuesday in the clinic. If you're coming to a cervical or a lumbar live course, we will see you soon. Thank you.

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