Dr. Cody Gingerich // #ClinicalTuesday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Division faculty member Cody Gingerich discusses the importance of focusing on the subjective exam during the first 2-4 follow-up visits to ensure patients are making appropriate progress.

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

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everybody, Alan here. Currently I have the pleasure of serving as their Chief Operating Officer here at ICE. Before we jump into today's episode of the PTI Nice Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at signup to receive a one-month free grace period on your new Jane account. CODY GINGERICHAll right, good morning PT on ICE daily show. My name is Cody Gingerich. I'm one of the lead faculties with the extremity management. What I wanted to come on here today on our clinical Tuesday and talk about is when things are not going to plan. Specifically the subjective exam on visits two, three, four. Okay, so when people come in and they say, hey, you know, I don't think this thing has gotten any better. I'm feeling potentially even worse, or they had a flare up since the last time you saw them on that initial eval. And what then does that subjective exam look like when they come in on visits two, three, four? How do you dive into, do you need to make an adjustment on your plan of care? Do you need to make an adjustment on dosage? Do you need to make an adjustment on anything? Or do you stay the course and you dive into really heavily on what exactly happened? Okay, so that's what we'll talk about today. If you did a good, really good initial exam, right? And you're like, man, this thing presents like I expect. We're going after it. You choose a dosage and a diagnosis that you feel confident in what you have given that person leaving your clinic. And let's say they come back in in one week. Most of the time I'm seeing people on a once a week basis, but even if they come in later on that week and they come back in and they're like, ooh, you know what? We are not really feeling any better. They come back in, something happened, flared back up, and now you have a pretty difficult conversation, right? Because on an initial eval, if you felt confident, you probably provided that confidence to the patient of like, Hey, you know, I think we found this thing. This is definitely coming from your shoulder. Probably the more of those muscles in the back of your shoulder. And you know, if we do these two, three exercises over the course of the next couple of days, I really think things are going to get better. Right. And then they come back in and all of a sudden that confidence is not as high because they're like, Hey, you know, this is not getting better. And then what, where do you go? Where does that conversation lead you?

GATHER MORE INFORMATION BEFORE YOU ABANDON SHIP So a big thing that I want to emphasize today is you need a lot, a lot of information from that person subjectively before you decide to abandon ship on what you were doing. Okay. And the reason being is there are so many variables that can happen in that time from when they left your clinic to when they show back up. Okay, and if you did that really good initial exam and you're thinking like, hey, I'm really on this thing, then your first initial thought when somebody comes back in, shouldn't always be a, oh, we did the wrong thing. More times than not, you want your curiosity to be, hey, okay, what did you, first of all, did you do the things exactly as I prescribed them? Secondarily, what did those couple days in between actually look like? A lot of times our patients have no real understanding of what actual movements can be their aggravating factors. When you did their exam, their subjective exam, and you asked for aggravators, then you did your objective exam, you found their aggravators. That does not necessarily mean that the patient understands then that those particular movements are going to aggravate them. They know the two or three that they told you, but there are so many other things in life that could potentially also be aggravating factors for them. And they're not going to be able to always put those pieces together. So go into that first conversation with curiosity and be saying, Oh, okay. You know, that wasn't exactly as I expected it to go. I thought we were really on the right track, but I want to dive into what did those couple of days in between here look like? Like, what, what did you get into? You know, what did you, um, spend your time doing? What did you do at the gym? If you were going to the gym, all of those types of things. Did you do those exercises we talked about as I prescribed them, or did you feel like you needed to do extra because they weren't hard enough? or did you not particularly do them? And that is going to start that conversation in a much better way than you just saying, oh, okay, in your brain, like, oh, okay, well we definitely did the wrong thing and we need to fully go back through an entire new eval and figure this thing out again. A lot of times those patients somewhere in that subjective are going to give you some clues on what actually was going on in their day-to-day life. A couple examples of that, okay? A big one, if we're talking about like a gluteal tendinopathy, okay? So think glute med tendinopathy. Potentially you've given them some kind of leg lift, maybe a side plank, some kind of glute, maybe side steps with a band, glute need, strength training, blood flow type of thing. Okay. Well, let's say that person also, you did not tell them, you didn't really even have this discussion of like other things that they potentially could be doing, or a lot of people try to manage their own symptoms. Okay. So if you didn't potentially give enough explanation of, Hey, this blood flow thing is the thing you need to do when you are hurting. I have seen many, many times where they are consistently stretching and stretching and stretching that glute med, bringing their knee across their chest into more of that like pigeon pose stretch. And if we're dealing with the true tendinopathy where irritability is fairly high, that can be a pretty significant aggravator to those tissues, even though the patient feels like it is helpful because it's tugging on the thing that is bothering them. Okay. So then they come in and you're like, man, they did the exercises. This is a pretty clear cut. Like this is glute tendinopathy. I don't know exactly what else it could be. Cause my hypothesis list, like we checked off, like we cleared the back, nothing's going on there. Um, but then they start talking about like, Oh, the only thing I can get relieved for, like, I spent all day just like yanking and yanking, trying to stretch. I'm stretching a bunch. And so then that has to be a, oh, okay. That conversation goes into, hey, I know right now that feels okay, but what we really need to do with those tissues is get some blood flowing to them. And what is actually happening is when you're sitting all day and then stretching, we're actually almost occluding blood flow and taking away more blood flow than what can get to it. And so all of those exercises that I gave you, although they feel like work, are also the thing that's going to make it feel better And you can use that as a symptom reliever. But we need to pause on stretching for the time being. And that language needs to be also relatively clear on this is a temporary pause. Temporary pause on this thing, it is not a you should never stretch your hip end of conversation, is a right now that is something that's aggravating you. So we still have a really good plan in place, but we need to control that variable and decrease that stretching time. Another thing that you'll start hearing is like, they'll be like, you know, I didn't do anything. If maybe your conversation the first day was around like gym movements and not life movements, um, You know, same type of conversation with the glute med temnopathy. I've had patients come back in where they were climbing a ladder all day. They were doing some housework, they were up and down on a, you know, a ladder and they don't really bring that up when you're saying, when you're going through your subjective, you know, what did, what did you do? And they'll say, well, I, you know, I avoided squats for the time being and I didn't do any deadlifts, but I did your exercises. So I just don't know why, you know, things could have flared up. But then you dive a little deeper. Oh, what did your weekend look like? And they're like, Oh, you know, I had a, I had a bunch of yard work to do. I was up on the, up on the house doing gutters and it was up and down standing on that ladder. And that position of the ladder has them essentially loading that glute, glute tendinopathy all day long, a ton of time under tension. And so now all of a sudden you're saying, okay, well now we need to pull back on that. Or over the course of this next week, you don't have any more yard work to do. So now let's go after this plan that we had in place. Okay, so subjective exam on days two and three or visits two and three when they come back in are vitally, vitally important to be able to really take a deep dive. Like that conversation may take an additional 10, 15 minutes if they are not moving in the direction because you want to be as curious as possible because you already did your due diligence on the initial exam.

CONTROL EVERY VARIABLE BEFORE YOU CHANGE YOUR PLAN So don't immediately assume that you're in the wrong and have that patient conversation of what did exactly your day look like? What have you been doing to try and self manage this thing? And you know, what have you done in the gym? You've also can talk to people, they have no real understanding. I've had patients where they go to the gym and they did a rope climb, sandbag carry, Ski erg workout because they felt like it wasn't a shoulder heavy Exercises they were avoiding their shoulder because everything they thought sandbag was mostly back, you know Skis like core type of thing and rope climbs you're using your legs to pull yourself up. So you're not really pulling I And again, it's just one of those things where you have to educate those people significantly on like, look, I know you don't feel like it is, but the reality is you're using a ton of that shoulder, especially the posterior, your cuff on all of those exercises. And you are not really avoiding any of those aggravating factors. So be a little bit more explicit on your, what movements could potentially be aggravating. That's also when you learn the type of human you have in front of you and how much you need to give them reins or really pull back on those reins. Most of the time I try to err on the side of giving people a little bit more leeway. I don't ever like to tell people there's nothing that they can't do. It's just a matter of like how much and the volume and intensity and those type of things. Visits two and three is when you actually learn that person and how much reins you can give them. And you might need to start controlling more variables as a therapist for them, okay? And so that might be the time where you say, hey, this movement is out. I need you to really pay attention to when you're standing and when you're sitting and where that hip is in space. I need you to completely avoid this particular set of movements for these next two weeks to make sure we can calm symptoms down. That's when you learn if that person has an actual like throttle on them or not a self throttle Can they actually? Determine on their own what they can push through and what they can't and if you can determine that they come in and they are worse and they did a bunch of stuff that you would say, man, that was pretty reckless given the thing that you were dealing with. Now you as a therapist and the expert in the field can say, you know what, this is out, this is out, this is out. I need to make sure I'm controlling every variable in your life right now until this thing gets a little bit more calmed down. Okay. And that's where you need to put your foot down every once in a while with a few patients and say, Nope, that's not happening this week. You're taking this time off or you are going and doing more cardio based exercises or you are doing XYZ, not a, hey, I want you to pay attention to this and that. This could aggravate it or could not, but give them leeway and they come back in and it's worse. and you're like, man, that was pretty reckless. Now, as a therapist, you're saying, nope, we're doing this, this, and this. This is a temporary thing, but in order to get this under control, now I'm telling you what you're doing and what you're not doing, okay? Because that is your expertise now on the line. If you give them a bunch of leeway, and they come back in and they're worse, and you don't ever have that conversation of, you know what, nope, this needs to happen this way, then they just assume physical therapy doesn't work for them, right? Well, it's not physical therapy. It's not what you've chosen. It's all the other variables that you don't have control over. So you need to start having a little bit more control as much as you possibly can. You can't control everything, but as much as you possibly can on what's going on there. This is also the time where you ask about food, sleep, nutrition, and stress, okay? Hey, over these last three, four days, how did your sleep look? Were you getting good sleep over these last three days? What does your nutrition look like? Is it as you typically do or did it change at all? Did you go to any parties? Did you go to anything outside of the norm? Are you having any type of particular high stress environment right now? Do you have a deadline at your work that you're trying to get done? Is your kid sick? Is whatever the case may be, all again, factors in that subjective exam that need to be dove into if things aren't going well. Okay? These are all just making sure that you are on the right track and aren't abandoning ship too early. The other thing is if they come in and they're worse, you also want to be like, give them confidence in saying, Based on what we found the first time and based on the exercises that we gave and this thing that you did over the weekend or whatever the case may be, I can actually give you more confidence that we are on the right track. We just need to dial that in a little bit closer. We either need to cut the exercises that I gave you in half, like let's say all those variables have been controlled and they're still coming in like, man, I'm just really flared up. Well, then that was your fault on giving them a little bit more, not reading that the irritability quite as well. And that happens. I've done that plenty of times. That needs to be like, Oh, okay, cool. You know what? We're going to cut those exercises in half, or we're going to pull one of them totally out. That one was a little bit more than I think you were ready for. We'll bring it back in and maybe a week or two, but over this next week, now all of a sudden we need to just dial that one exercise in and make sure that that's not aggravating and your tissues can tolerate that. If everything else has been pretty clear and there wasn't anything out of the norm that you weren't expecting, then you just overdosed their tissue a little bit. Great. You know what? Sorry that you were a little bit feeling rough the last couple days, but I know that if we pull this back, we should be in pretty good shape moving forward. Okay. All of those things need to happen before in your brain you say, oh I messed up, we treated the wrong thing, and we need to fully switch gears and go to our second hypothesis. Until you have controlled all the variables, you have asked all of the questions related to nutrition, sleep, stress, plus what they did in their non-gym, just daily life, Have they done your exercises? You need to have all of that information, and it needs to be in your brain, like pretty much, hey, everything is pretty close to exactly as I would expect it, before you'd say, I think we should recheck this exam, and might go after that second hypothesis on our list. So that's the big thing, is trust your instincts first, whatever you found, if you did a really good initial exam, whatever you found, When they come in that second, third, fourth visit on those subjective exam, when they come in, make sure you're super curious. Go after all of those variables, figure out all of those variables. Once that's all been controlled and they're still not going as you would expect, that then is the only time where you would start to switch that hypothesis list. So overall, Be curious on make sure that that second, third, fourth visit, that subjective exam is is very stout and make sure that you are really doing a good job on understanding that person in front of you. Where's their headspace at? Are they able to tolerate what you've given them? Do they know how to pull back on exercises if they need to? Or do you need to be the one that says nope, you're pulling back on this thing you have you know, shown me that you don't have that ability. So for the next couple of weeks, I'm your boss on, you know, what you can and can't do. Always making sure that it's a temporary thing.

SUMMARY Okay. So that's when things don't go as planned, right? Make sure that that subjective exam on the second through fourth visit is super dialed in and you know that you can, uh, have a good solid impact and still give your patient the confidence that they need moving forward. And it's not a, um, you know, hope, just hoping for the best and throwing things at it and, and hoping it sticks. And now your brain is all over the place. Okay, looking forward, extremity management. If you want, there's a couple seats left in Bellingham, Washington, May 18th and 19th, and then we got two courses running on June 1st and 2nd, one in Texas and one in, oh man, I just lost it. I believe it is. in Wisconsin. All right, Texas, Wisconsin, June 1st and 2nd. So jump on both of those. There are courses, there are seats open on both of them. So check us out. Find Mark Lindsay or myself on the road with extremity management and we will see you tomorrow.

OUTROHey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.