The Therapeutic Exam

exam2

“But I have               in my spine.”

“Oh I can’t, my                is really bad.”

“I guess I’ll just have to live with this                  .”

Fill in the blank with your own patient comments, but they are all essentially the same. Some gigantic, devastating, destruction is occurring inside of their body…and there’s no hope.

I don’t know if it’s funny or just sad, but the fact that such a large amount of patients respond to such “terminal” (i.e. chronic) conditions with statements like “I’ll just have to live with it..” should be telling of the misconception we’ve given to patients and society alike about their health “conditions.”

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Sometimes the best medicine we can give a patient is information… and knowledge. Information about the acute condition they are faced with, or information about the neural mechanism of pain — highlighted with thought provoking examples in research of how pain is merely a perception, an alarm system.The knowledge is a different animal though. This kind of knowledge gives power to the patient. This kind of knowledge tells the patient that they are okay. That they are safe to return to activities. That pain may be there, but does not indicate a tissue problem. That they have progressed beyond the timeframe for tissue healing (a good thing!), and that you have found no evidence for any sinister cause for their pain.

Now, that’s all nice when you lay it out there like that, but many people have been dealing with this pain for some time. They have struggled with the uncertainty of what’s going on inside their body. What kind of damage or destruction is occurring as a result of every wrong movement they make. So how are YOU supposed to come in and tell them they are “fine” and “have nothing to worry about”?

Well, the answer is simple my friend… you need to examine that patient and prove it to them! What I mean is…don’t skip over the minutiae of the clinical exam you learned way back in PT school. Run through the dermatomal, myotomal patterns. Do a quick check of DTRs. Ask some extra red flag questions. Perform a couple of extra special tests (even though you may cringe on the inside)…maybe even take some vitals. Some may say those things are only necessary for patients who have obvious signs or indication. Some may say that the clinic needs to run efficiently and performing those items would be a waste of time when your better clinical judgement says otherwise. But I say differently! Patients want the proof..they want to know what you know and how you know it. In this day of information and mistrust, you need to show your patient how you came to the conclusion you’re presenting to them.

In many cases, this requires you doing — rather than saying. This is where the examination becomes therapy in its own right. The patient gets the needed information AND knowledge that they are otherwise healthy. That this chronic pain is simply that…chronic pain. That it’s not indicative of a degenerative change in the spine. That their bulging disc and out of place sacrum are normal variants and not actually out of place, respectively. That their pain is present not because of these normal age related changes, but despite them. And that with continued activity they will likely see a lessening in pain and a greater overall ability and function.

Give your patient a thoughtful, in-depth, therapeutic examination — instead of a quick run through those outpatient orthopedic clinics are notorious for. Pay attention next time your patient is fixated on one cause for pain. Maybe he needs to know how his foot structure is not related to any back pain. Maybe she needs to know that you’ve checked her strength and sensation according to each lumbar segment and that (combined with other findings), you have no reason to think that the bulging disc is a significant — if at all — contributor to her long standing back pain. Maybe we need to help these patients decrease their hyper-vigilance.

Maybe we need to show them they are okay…

-Spencer

 

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2 thoughts on “The Therapeutic Exam

  1. Pingback: A Year in Review | PTbraintrust

  2. Pingback: Top PTBT Posts of 2015 | PTbraintrust

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