Developing a Game Plan for Patient Care

Dr. Mark Gallant // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division Leader Mark Gallant emphasizes the importance of having a well-coached and appropriately dosed set of exercises for patients. He stresses that these exercises should be ones that the therapist is extremely familiar with and knows exactly how to prescribe. By having a clear understanding of these exercises, the therapist can confidently explain to the patient the objective criteria and expectations for progression.

Mark acknowledges that sometimes our egos can hinder us, leading us to believe that we can come up with a better plan for each individual patient based on the information we have at that moment. However, he argues that research has shown that the human brain is a sensitive instrument that responds quickly to changes. Therefore, having a preset plan of exercises allows for consistency and efficiency in treatment.

Additionally, Marj suggests that having a set of exercises that can be progressed by increasing work volume, range of motion, load, or speed, while keeping the exercises relatively similar, can be beneficial. This approach allows the patient to become more efficient with the exercises and increases their buy-in. It also reduces stress for the physical therapist and ensures that enough time is given for each intervention to make a meaningful impact.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

00:00 - MARK GALLANT What's up PT on ice crew we got Instagram here YouTube over here. I'm Dr. Mark Lantz coming at you here on Clinical Tuesday, lead faculty in the ice extremity management division, alongside Lindsey Hughey, Eric Chaconas, and Cody Gingerich. Happy to be here this Tuesday. Before we get rolling, a couple of housekeeping things. We've got a few more courses for the extremity division coming up here for 2023. I'll be in Woodstock, Georgia, second weekend of November. and then Cody and Lindsey each have opportunities early December, so check that out on the ICE website. More importantly, if you've been looking to get a certification through ICE and the overall ICE cert seemed like a bit much to chew off right now at this stage of your career, we are happy to announce that we've launched the Ortho cert. If you take the two spine management courses, cervical management, lumbar management, the extremity management course and total spine thrust manipulation, take a short test at the end of whichever the last of those four that you take, you can become ortho certified. So that is officially launched and on the website. So definitely head over there and check that out and we hope to see you on the road soon. 01:39 - INDIVIDUALIZED CARE So today what I want to talk about is individualized care. your ego is killing our profession. And what I mean by that, or what we mean by that, is that when we go around the country and we mentor folks, or we help out and talk through cases with individuals, watch people treat, one thing that we're starting to see as a trend is that folks are jumping around quite a bit in their plan of care. So that patient comes in for one visit, they're given a certain set of manual therapy techniques, a certain grouping of exercises at a specific dosage, and then each subsequent visit that person comes in, the plan dramatically changes. They're given a new set of exercises, there's different manual therapy techniques done. They are getting a completely unique plan of care each visit. And what we're recommending is that there needs to be a plan, that for any given pathology, you have a plan of what this is typically gonna go like. With that individualized care of jumping around from place to place, visit to visit, what we believe is that it is a reaction to old school physical therapy, what we like to call physical therapy 1.0, where a person would walk into a clinic, they would be put on a new step or a bike for five to 10 minutes, the physical therapist would wave the ultrasound wand on wherever their area of pain is, and then they would be given an exercise sheet. And it would be very specific to, here is the foot and ankle exercise sheet. Doesn't matter what you have going on, here is your foot and ankle exercise sheet. Here's our shoulder sheet. And if you were lucky, you would have a tech that would take you through that. If you were not one of the lucky few, you would either be given that to go run through in the clinic on your own, or even worse, just sent home with this exercise sheet. 04:17 - INDIVIDUALIZED PLANS OF CARE So we swung the pendulum hard to everyone gets an individualized plan depending on what they show up with the clinic that day. So if their pain has changed, if what the exercise is looking has changed, then we ditch the entire plan and then we're going to go to this very individualized thing each visit. The problem with this is it's hard for the patient to buy in if everything changes each visit. They're not sure what the plan is. Humans love to have a target in a bullseye. So if that person knows like, ooh, here's the plan that we laid out during the first couple visits. And here's where I am along that plan. It allows them to be more bought in. They're going to comply with the plan more. They're going to be more adherent to the plan because they can see the target they're shooting for. And they can very clearly see where they currently sit on that plan. In addition to that, if we're jumping from thing to thing all the time, we're actually likely not giving any one intervention enough time to do its thing. So we know with exercise, the research is fairly clear now that exercise for musculoskeletal pain is the most bang for your buck intervention from a cost perspective and from a getting the job done perspective. It takes time. If we're jumping from thing to thing every visit, then we're likely not giving those interventions enough time to actually make changes. And in addition, it takes people time to get used to doing an exercise. So if we switch to exercise each visit, we're not allowing that person to become efficient with that exercise. And then finally for us, if we're seeing anywhere, depending on what type of setting you're in, between six and 20 individuals a day, creating six to 20 unique plans of care. Every single visit for every single person becomes wildly exhausting. I've lived it. Everything that I'm saying here, I have personally done for many years. That type of physical therapy becomes exhausting. And it's likely part of the reason why we have such a high burnout rate in our profession. If the expectation is a unique individualized plan of care for every individual, every day. That becomes a lot for any one given physical therapist. Whereas if you know, for X pathology, for my rotator cuff related shoulder pain folks, I know that I can modulate their pain, decrease their symptoms with these three to four manual therapy techniques. I know that my bread and butter early on exercises are gonna be these four to five exercises that I can coach extremely well, that I know exactly how I want to dose, and that I have an expectation of when the person can do these, what the next group of exercises that I'm gonna move on to, and I can clearly explain the objective criteria to the patient of what that's gonna be. Now, our egos often get in the way of this, because many of us, myself included, I'm speaking to myself more than anyone, believe that for any given person that comes in, that we're going to be able to give them a better plan based on the information that's coming that day than the preset plan before that may seem more cookie cutter that we're afraid of. What we know about the human brain, now having a lot of research over the years, it is a very sensitive instrument and it's going to respond quickly and rapidly to what's changing in the moment. So therefore your plan or what that person is coming in can be highly deviated by anything that's happened to you that morning or that day. If you had a stressful interaction with your boss, if the kids were having a hard time getting ready for school, if someone called you right before the patient came in and gave you some bad news, that is all going to very dramatically sway what happens in that session and how you go about what you're going to do in that session. Even more dramatically, our patients are in pain. which means that their nervous systems are gonna be all over the place. And so their drama and their brains are gonna be very sensitive and that is also gonna shape those interactions. So we're leaving a lot of interpretation to that interaction. Whereas if we have a plan that we know if this is looking like this, I'm gonna go this way, if this is looking like this, this is how I go based on the plan for this pathology, we are far less likely to succumb to the sways of any given day. When we look at other professions, professions that have higher stakes than physical therapy typically, we see that they use systems and plans to deviate from those in the moment sways. Pilots are the easiest example to talk about. When you have a pilot, it doesn't matter if that pilot is on his second day of the job or if they have 36 years of experience. That pilot has a checklist for almost everything that could possibly happen on a plane. If the weather looks like this, this is our checklist of what we're going to do. If the wind changes this way before we land, this is what we're going to do. And that pilot follows the checklist, not what they're feeling in the moment based on their experience. So much so to the point where there's a second person there, the co-pilot. whose primary job is literally to say, hey, why aren't you following the checklist? We got to go back to the checklist. We know this works. 99.9% of the time go to the checklist. 09:30 - RECIPE REPETITION  For those of you who have been following ICE for a long time, our CEO, Jeff Moore, spent a lot of time working in restaurants and kitchens. And if you were lucky enough to take a class with Jeff or got to spend some time with Jeff, we used to always get all these stories about his time in the kitchen. And a lot of those things I still think about to this day, the stories he told as far as patient care. And one of the main ones that stuck with me was a chef that he worked with, who now has a Michelin star, by the way, told Jeff that for any given recipe, you need to cook this 1,000 times before you start to deviate from the plan. Doesn't matter if you're the greatest chef in the world, you don't add salt, you don't add fat, you don't add any flavor profiles until you have cooked that recipe 1,000 times. Because that 1,000 times is going to allow you to see how this thing really responds, what could possibly go wrong, what could happen, how you really get the full breath by committing that much. That's the same with our plan of care. There is no way that we can confidently say to the human in front of us, for most people what we see, if you follow this plan, this is where we get to. If we're changing the plan all the time, we never get to experience that to show the patient and to say confidently. So we want to have the plan for any given pathology that we're going to give most people. Another example, is the 12-step plan in recovery. I am not in recovery myself, so if I'm butchering this, I apologize to anyone who is in recovery. But with the 12-step program, it's 12 steps. You run the steps, and people who have addictions all over the country have been using this 12-step program to help deal with their said addiction. And when you look at that plan, it's a simple, not easy plan, and you follow those steps to a T. Again, same as the co-pilot, they have a mentor or a sponsor who helps them work those steps. If that person is struggling or deviating, what that mentor's job is to do is say, hey, make sure you go back and are following these steps and are not deviating. So lots of examples of really solid professions and organizations that use a plan to get the job done. 12:07 - STICK WITH THE PLAN: MODULATE PAIN, INTRODUCE MOVEMENT, PROGRESS MOVEMENT So what should the plan look like for us, for any given patient? When you have a pathology, rotator cuff related shoulder pain, plantar fasciitis, things that you need to know. Early on, what are the manual therapy techniques or exercises that you know can modulate pain and decrease symptoms for most people? Have a few of these that you know you can do effectively and work for most folks as part of your plan. Then have your bread and butter exercises. What are the exercises that are gonna be the main, let me back up for a second. Before you have your bread and butter exercises, what are the few exercises that you're gonna have that are for that irritable patient that you know before they can tolerate a lot of load that we're gonna give them? So your pain modulation techniques, your lower level exercises that are not gonna overstress the tissue while we're trying to calm this down. Part two, what are your bread and butter exercises? What are the handful of exercises that you know tend to work best for any given pathology that you can coach really well, that you can dose really well, that you can manage workload really well? And then finally, what is the criteria that that person needs to demonstrate to move on to their more advanced exercises? And then a final piece to have in your mind is what does this look like If the person does have a flare up or relapse, how do we coach them? What point in the program do they go back to if they are indeed not ready to progress? So again, what are the things that can modulate pain and that can calm symptoms down or exercises that are not going to require a lot of stress to the tissue while things are calming down? What are your bread and butter exercises for any given pathology? What are the most common things that you're going to give in most people's plans? And then finally, what are you going to have as your criteria to progress these people on and having a game plan if they do flare up or regress? What this is going to allow, it's going to allow the person to go, ooh, I know exactly where I am on Mark's plan of care at this time and where I need to go to take the steps to move forward. It's also going to allow you to not have to switch exercises so much. You're not going to have to get overly creative with your exercise prescription. And by doing this, what you're typically going to be changing is same exercises, but you're going to be increasing the work volume. You're going to be increasing the range of motion. You're going to increase the load on the exercise and you're going to increase the speed on the exercise while keeping the exercises relatively similar or the same so that the person can become more efficient with that exercise. It's going to allow the patient to buy in way more. It's going to take our stress way down as a physical therapist. And if there is that small percentage of folks who do indeed need a more nuanced program because they are actually not responding over time, or they're having a lot of trouble adhering to the plan, it's only a small percentage of the folks, which takes a lot off of the mental stress for us as physical therapists. Love to hear what you all think about this in the chat. Definitely hit us up. Love to see you on the road in Woodstock, Georgia next month. Cody and Lindsey have courses early December. Check out the ortho cert on the website. Have a great day in clinic today. Hope you all crush it. See you soon.

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