Reinforcing the Need for a Systematic Approach

A few months ago we had a post, discussing the need for utilizing a system with evaluations,the obvious benefit being that of identifying contributing factors to a potential regional interdependence. It is incredibly easy to become narrow-minded when we see the script for a patient, especially when post-operative. I have been trying to instill this mindset into my student on her final clinical rotation.  She had her first initial evaluation a couple weeks ago that served quite the lesson. An elderly woman presented with a referral for s/p TKA. Upon patient description of pain and observation of movement, I quickly recognized that this patient was not simply limited from a recent knee replacement.

As this was my student's first initial evaluation on this clinical (and first ortho one in months), I can understand being a bit nervous and focusing in on the knee. The patient had complaints of vague thigh pain and the need to do a wider examination became even more apparent. I encouraged the student to perform a lumbar spine examination and slump test. Both back and the thigh pain were recreated, suggesting lumbar involvement to the current impairment level. While I typically prefer using the SFMA for evaluations, I typically do not do so with post-surgical patients. That being said, I do still have a system that I run through in assessing surgical patients. For example, in any lower extremity or back surgery, I assess lumbar/hip/knee/ankle mobility and strength, SIJ pain provocation tests, hip scour/FABER/POSH tests, neural tensioning, and segmental mobility. Based on the surgery, sometimes a modification is needed, but I still like to assess each area for potential contribution to the patient's pain and limitations. The benefit of having some form of a systematic examination results in lowering the chances of missing true causes and sources of the pain. Both are listed because the source of pain is not always the reason pain occurred in the first place.

While this was a difficult patient to evaluate, I am happy that my student was able to experience it so early in the rotation. It served a perfect example as to why we need to be thorough with our examinations, no matter the referral. Since then, she has done an outstanding job of taking a more global approach with each assessment. Physical therapists often go years before recognizing the need for development of a system. While this post might appear somewhat redundant to the previous posts we have had on the topic, the value of becoming more efficient clinicians can not be over-emphasized.

-Chris