Sequencing Your Treatment Session

Going into my first clinical when I was in PT school, I put little thought into how I would sequence each treatment. The order we perform an examination is a little more defined. We have detailed this in our Case Discussion section with each patient. But a treatment session may have a little more variety depending on the setting in which you work. Is there a format we should follow?

I actually recommend a relatively brief version of the format of the examination. Start with the subjective. Find out how your patient responded to your last treatment session. Did anything new happen? Was there a problem with the HEP? Was there soreness? Questions like these help you gauge an understanding of how your patient was able to tolerate the intensity of the previous treatment. In many cases, it may direct you on how you formulate that day's treatment. If a patient in a core stabilization program caused a lot of soreness afterwards, it may be appropriate to revert back to the prior level in the program. We need to continually check on our patients to make sure the rehabilitation is going in the proper direction.

Next, I recommend a reassessment of the structures that were targeted during the initial evaluation. For example, if I found decreased mobility of the AA joint on the eval day, I would definitely be sure to reassess that prior to performing a manipulation - if warranted. With daily activity, joint mobility, flexibility, etc. can easily change due to something that happened between treatment sessions. And if a previously hypomobile joint is now normal, why mobilize it? Now I am not saying we should perform a complete re-examination of the objective section, but if the plan for the day involved manual therapy, I recommend assessing the targeted structures first. In cases like SIJ Dysfunction, maybe you reassess the pelvic alignment each session. How thorough you need to be is determined by dysfunction location, severity of injury, and various individual patient factors.

After finding the dysfunctional areas of mobility, I typically perform my manual therapy. My goal is to give the patient as much mobility in the limited structures as possible to the norm. Any limitation can lead to a compensation of hypermobility in adjacent or distant structures that may be the source of the pain. With the sedentary aspects of our lives, degeneration has become an expected normal development. While we would like to acquire true normal motion in everyone, it is not always feasible. I should note that some clinicians may prefer the patient do a warm-up prior to manual therapy or the reassessment as that may have an impact on treatment performance and clinical findings. Personally, I determine the need of a warm-up based on each individual patient. (I also should note not every patient requires manual therapy).

Once I have completed my manual therapy, I go back to reassessing. Is the previous hypomobile joint now hypermobile? Is the previously painful motion or action now pain-free or less painful? We need to be certain our manual therapy had the desired outcome. As Nick Rainey states in a previous guest post, this is know as an asterisk sign (test-treat-retest). We may find that our previous assessment was inaccurate or that we need to spend a little more time with manual therapy in order to reach our goal.

It is at this time that I proceed to therapeutic exercise/neuro re-ed. I truly believe it is important to complete your manual therapy first before moving this stage. With manual therapy, we often acquire new ranges of motion due to changes in joint mobility/tissue length/neural tension. While this is important, it is essential we use exercises to lock in the changes. We must retrain the body to move in those new ranges; otherwise, we are setting the patient up for re-injury. As Gray Cook has said, our bodies adapt dysfunctions often as a form of protection. If you free up the dysfunctional tissues, you are putting the patient at risk.

Finally, I recommend finishing up each treatment session with another subjective portion. See how the patient immediately responds to that day's work. Some treatments have an immediate effect and again can impact our plan for the next session. As is typical, every patient is different and may require a different sequence for the treatment. This is merely an outline of how I work with my orthopaedic patients typically. There are more than a few indicators for adding, subtracting, or re-ordering the plan for that day!

-Chris