A few weeks back Chris wrote a great post on Sequencing Your Treatment Session. His post focused heavily on manual treatment and the importance of checking and rechecking your asterisk (concordant) sign. This post is intended to be a quick and dirty outline regarding how to prioritize interventions from start to finish. Not all apply to every patient, but knowing the sequence is fundamental.
1) Brief Subjective/Objective Recheck: This should be viewed as a mini-reassessment. Was there any change in symptoms since their last visit? How did they tolerate the their HEP? How did the patient respond 24-hours after the last treatment? Objectively, are the same restrictions and movement impairments present?
2) Manual Therapy: During the objective, you likely found a joint restriction or movement pattern that needs correcting. Perform the necessary manual techniques and re-check your asterisk sign.
3) Corrective Exercise: Performing corrective exercises immediately following manual therapy will maximize the patient's ability to find and recruit muscles that were previously not recruiting normally.
4) Functional Warm-up: The warm-up should increase core temperature targeting the muscle groups that are dysfunctional. Examples: bicycle, total gym, elliptical.
5) Power Exercises: Incorporate power/ plyometric exercises following the warm-up when the muscles are not fatigued. Since form is essential during these exercises, performing them while the muscles are fresh is very important. It should be noted that not all patients will be ready for power-type exercises during their first few visits.
6) Strength Exercises: Strength exercises include those performed in the 4-8 repetition range, 3-4 sets with 2-3 minutes of rest between each set. Similar to power, not all patients can tolerate pure strengthening early on. Many times patients require a few sessions of neuromuscular re-education and form re-training prior to pure strengthening.
7) Conditioning and Endurance: Often we find ourselves going directly to this stage following a functional warm-up. Since pain and movement impairments our the primary focus early on, performing conditioning or retraining exercises is acceptable. The dosage of these exercises is typically 3 sets of >10 repetitions with less rest in between sets. A main focus is on proper form and controlling the movement throughout the ROM.
8) Warm Down
Appropriately structuring a treatment session is a key component to the patient's success. One question you need to continually ask yourself: "how do you dose pain?" There is no perfect answer. Pain generally leads to muscle inhibition and form breakdown which often categorizes the patient in the conditioning and retraining exercises section. As your patient progresses it is essential to perform the exercises in an appropriate order to maintain form and maximize gains throughout the session.
James Heafner PT, DPT, OCS:
Owner and lead physical therapist at Heafner Health, cash-based physical therapy in Boulder, CO. Areas of expertise include orthopedic and manual therapy, functional movement, pain science, and movement science.
In May 2013, I earned my Doctorate in Physical Therapy from Saint Louis University. After graduating from the Harris Health Systems Orthopedic Residency in October 2014, I moved to Boulder, CO. Since living in Boulder, I have started my own cash-based PT practice, earned my OCS certification, and teach for the OPTIM Fellowship and COMT program in Houston TX and Scottsdale, AZ.
Chris Fox PT, DPT, OCS: Physical therapist at Foothills Sports Medicine & Physical Therapy in Scottsdale, AZ and regularly lectures at the Phoenix Campus for NAU's DPT program and for Optim Manual Therapy's COMT program. Completed multiple advanced manual therapy courses implementing aspects of biomechanical analysis. He received his DPT from Saint Louis University in 2013. Completed Scottsdale Healthcare's Orthopaedic Residency (now Honor Health) in July 2014. He became a Board Certified Orthopaedic Specialist in 2015. Level I Expert in FMS and SFMA , Kinetacore FDN Level 1 certification, and IASTM Technique course completion. He would like to pursue further education in McKenzie Technique, Dry Needling, Strength & Conditioning, Orthopaedic and Manual Therapy.
Brian Schwabe PT, DPT, SCS, CSCS:
- Board Certified Sports Physical Therapist (SCS) at Elite OrthoSport in Santa Monica, CA which specializes in treating collegiate/professional athletes and clientele from the Beverly Hills, Hollywood, and Santa Monica areas.
- USC Sports Residency Trained Physical Therapist (<1% of all PT's residency trained)
- DPT from Saint Louis University
- Future plans/interest include:
1. USAW, SFMA & Catapult Systems technology for NBA teams
2. Pursuing a position as a sports physical therapist &/or Strength coach for a Division 1 athletic medicine department or professional sport team.
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