People Make the Program, Not the Therapy: Four Rules to Practice By
By Perry Nickelston, DC, FMS, SFMA
Say goodbye to cookie-cutter treatment programming – toss it, get rid of it, abandon it and lose it. You get the point. Your patient deserves more. Every person is unique in what they require to get well. Everyone wants to get out of pain. Pain is a very powerful motivator for change. I have yet to meet anyone who actually enjoys being in pain. However, what individualsneed to get out of pain can vary greatly. This is where your clinical expertise is the game changer. You also need a "human element" that is critical to long-term success.
Working in-the-trenches for almost 15 years, I've come to understand a few things. Trial by fire, you might say. During this time I have discovered what I like to call the "Core 4" rules for treatment programming and patient care. Follow these simple rules and your outcomes will improve. Break the rules and ... well, you know.
Rule #1: Patient History Is 90 Percent of Your Diagnosis
Listen to your patients. Listen to understand, not simply to respond. What is the one factor that is uniquely different for every conceivable pain syndrome you treat? The life and history of the person standing in front of you! The who, what, where, when and why of their lives tells you a tremendous amount of valuable information if you are observant enough to listen for it. And I am not talking about the SOAP notes information required for insurance documentation.
Patients are in your office 2-3 times a week for maybe 30-45 minutes at a time, depending on your treatment programs. What are they doing the remaining 23 hours and 45 minutes of the day (most of the time unknowingly) to sabotage their program? You formulate an examination based on your intake history to confirm or rule out your initial diagnosis. Take the necessary time to ask questions and then listen.
Rule #2: All Pain Is Not the Same
Do you treat pain or do you treat people? Big difference! For example, a patient enters your office to get help for knee pain. Do you perform a cursory knee and spinal examination, and transition each patient into the same therapies? Some people get better, some people don't. Why? Perhaps it was a follow-the-dots treatment program for knee pain. If it worked for one person, then it should work for another, right? Wrong!
Many things can cause knee pain. Perhaps it's a fixated ankle or hip, maybe even an unstable hip, or referred pain from a trigger point. It might even be a problem on the other side of the body causing a compensation pattern on the painful side. Would you treat them the same? I should hope not. So the takeaway here is, treat the person not just the symptom. I have a feeling your patients will like that option– and their pain will, too.
Rule#3: Conditions Change With Movement
Static examination of pain syndromes with patients on a table takes on an entirely new dynamic when you add movement into the mix. The anatomical approach to treatment follows basic kinesiology and is often complicated by assumptions in isolation. There is nothing basic about movement. Movement is varied and complex. For example, a knee you are examining with active and passive movements totally changes when you add gravity and load to its ability to stabilize. Don't fall into the trap of assuming that a knee that is non-painful during orthopedic evaluations will be the same when you ask them to do an overhead squat pattern.
Now, many clinicians would neglect looking at that knee in a squatting motion for fear of irritating the area or causing more pain. That is what you are supposed to do! Determining what movement patterns provoke, eliminate or reduce symptoms is the key to an effective examination process. Get patients off the table and watch them move, because moving is what they are going to do all day long when they leave your office. Might be nice to know if they have dysfunctional movement patterns, wouldn't it?
Rule #4: Get Rid of What Does Not Work
If you are doing something that does not get the results you want, make subtle changes until you do. Oftentimes it is a slight change that can make the biggest difference in your outcomes. Legendary martial artist Bruce Lee once said, "Simplicity is the key to brilliance." Wow, what a powerful and true statement. Monitor your patients for progressive improvement or deterioration in program design. Don't be afraid to intervene and change strategies along the way. The body will tell you if it likes what you are doing. If it does, you get positive results. If it doesn't, then you don't. How simple is that?
The magic number 4 works for me. I want to see a change in a condition within four sessions; and if I don't: new strategy. Hold yourself accountable. Your patients will, I can promise you that.
Bonus Rule: Stop Chasing Pain
Pain is where your problem ended up, not where it started. So often it's easy to get caught up in treating symptoms while overlooking causative factors outside the site of pain. Most of the time, the symptomatic area is just a compensation for an underlying non-painful dysfunctional problem. Take the necessary time during your evaluations to look at everything, not just where the patient hurts!
Don't focus on the painful site, focus on the pain source, a recurrent theme in my Core 4 rules. Remain open to the possibility that some problems may be beyond your scope of practice and a referral is necessary. Here are several compensation and dysfunctional patterns that can wreak havoc in pain syndromes:
"People don't care how much you know, until they know how much you care." Motivational speaker Zig Ziglar said it best with this one. Every day we make decisions that affect both the short-term and long-term health of our patients. Take that job seriously. The whole is greater than the sum of its parts, but do we act on that belief? Remember why you are in this profession. It's about people first. Remember that and you will be far ahead of the game. I promise you.
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