Performance Hacks for Physical Therapy Evaluations

What if there was ONE tool that could help you learn orthopedic evaluations as a student physical therapist (SPT)?

What if this same tool reduced errors? And was easy to use, low-tech, and cost $0?
Would you use it? What if I told you that tool was a checklist…

​When you are first learning how to perform orthopedic evaluations as an SPT, the demands on your attention can be overwhelming. Within your evaluation time frame- say you have 20-30 minutes, you must: take a subjective history, perform comprehensive testing (range of motion, strength, joint play, palpation, and special tests), as well as move the patient efficiently through multiple body positions (supine, prone, standing, sitting, etc.), and finally you must distill all of this information into a differential diagnosis. Whew! It is a lot to think about when you first start off! Any tips and tricks to improve efficiency, accuracy, and consistency of your physical therapy (PT) evaluation are truly valuable. ​

One tool that I have come to rely upon in learning how to perform a consistent and effective evaluation, in a timely manner is The Checklist. As I’ve written about before (Can A Checklist Make You A Better PT?), checklists have been used in various medical settings with positive outcomes (improving patient outcomes, reducing medical errors, and guiding treatment decisions). The checklist does not only function to reduce errors, but I believe it can be an effective learning tool for guiding appropriate practice when learning how to perform PT orthopedic evaluations.

If you want to get good at the evaluation process, it is not enough to just practice evaluations. You must take a hard look at HOW you practice evaluations. There has been a lot written about this concept in scientific journals as well as the popular literature on expertise and skill learning. (1,2,5) In order to improve a skill to the level of “mastery” or “expertise”, you must practice that skill in very specific ways. The way you practice must include focused attention as well as a means for receiving reasonably timely feedback. As students, some of this feedback can come from our professors, some can come from peers, but much of our feedback is self-delivered feedback.

​Setting up conditions for practicing evaluations is not so different from how you might approach (or teach) someone who is learning a new movement skill. The complex skill, either movement skill or orthopedic evaluation, must be broken down into its component parts and each part practiced to the extent that it is performed correctly.

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Here are three key areas for optimizing your evaluation practice (and how checklists can help):

1. Break Down The Evaluation into “Sets and Reps”
     1st “Parts” Practice > 2nd “Whole” Skill Practice

• Practice 10 “subjective” patient interviews in a row, then practice 10 “objective” patient exams in a row (if they are not all close to the “perfect” way you want them- do it again. Use the checklist to assess your accuracy/completeness).  
• Only once your “Parts” are consistently very good should you go on to doing a full practice evaluation: practicing the “Whole”
• If you need to break this down into smaller “Parts” to improve your consistency and quality, do it! For example: practice assessing shoulder AROM 5x in a row, until it is automatic.  

2. Increase the Quality of Your Practice Reps
     “Practice” the way you want to “Play”

• Well documented in the learning science literature is the idea that “practice does not make perfect. Perfect practice makes perfect”
• Checklists can increase the “quality” of your practice reps
• If you practice an evaluation completely “by memory” and are forgetting pieces, I hate to say it, but this is how you will most likely perform

3. Your Evaluation Should Be 75% Identical EVERY TIME
​     The Fundamentals Must Be Automatic Before You Get Fancy

• You need to become a robot: With the exception of special tests/add ons your flow in evaluating a certain body part should be predictable and scripted (e.g., AROM > PROM > MMT)- once this is automatic, then and only then will your higher level clinical reasoning and differential diagnosis skills improve
• You must minimize errors of omission (leaving out key items) (Use The Checklist to make sure you have performed every piece and in the correct order)
• You must minimize errors of commission (doing unnecessary tests), If 75% of your evaluation is the same every time- you have more cognitive resources to decide what is MOST important for that other 25%, make it count!
• Speed/efficiency is developed second (I believe that “fast and sloppy” is never a good place to start. I tend to believe that it is best to start off with a slow but “technically” correct skill and the speed will come).
• If you are always thinking about what comes next, you cannot effectively listen to the patient and evaluate their response (again your exam flow must be automatic). 

As clinicians, I think there is a natural desire to want to feel the state of “Flow” early on- that everything is clicking and you are utilizing a unique combination of scientific “truths” and intuitive judgments in your evaluations. But, flow and mastery take time to develop. So, I would argue that as you are starting out, the number one priority should be to make your evaluations as consistent as possible- almost to the extent of feeling “boring” or rote. This idea, I think is well expressed by famous psychologist, Mihaly Csikszentmihalyi, who coined the term “Flow” (4) and is author of the book: “Creativity: Flow and the Psychology of Discovery and Invention” (3). In this book, he writes,“You must first learn your craft and then set it aside.”

​I’m off to practice my evaluations…
 -Leda McDaniel, SPT 

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Please Visit Her Website For Examples Of Her Orthopedic Evaluation Checklists

Leda is a current Doctorate of Physical Therapy (DPT) candidate at Ohio University and upon graduating in May 2019 is interested in working with orthopedic patients with chronic pain. Leda recently published a book about her experience of personal recovery from chronic pain, which you can find on Amazon:
https://www.amazon.com/dp/069212120Xref_=pe_870760_150889320
You can also find her blogging at: https://sapiensmoves.wordpress.com/

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References:

1. Brown, PC; Roediger, HL; McDaniel, MA. Make It Stick: The Science of Successful Learning. Belknap Press, 2014.
2. Coyle, D. The Talent Code: Greatness Isn’t Born. It’s Grown. Here’s How. New York, NY. Bantam Dell; 2009.
3. Csikszentmihalyi, M. Creativity: Flow and the Psychology of Discovery and Invention. New York, NY. HarperCollins; 2013.
4. Csikszentmihalyi, M. Flow: The Psychology of Optimal Experience. New York, NY. HarperCollins; 1990.  
5. Gladwell, M. Outliers: The Story of Success. New York, NY. Hachette Books; 2008.