It’s unfortunate that many physical clinics have limits on the amount of time you can spend with a patient. We all want to spend a ton of time with our patients, especially in the later stages of rehab when there is so much to do.
In this episode, we’re going to talk about some strategies on how to deal with these limitations.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 320: Fitting Everything into a Physical Therapy Treatment Session
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Transcript
Student:
Garrett from Iowa asks, “For ACL reconstruction patients early on in their recovery, how many days per week do you like to see them and how long are your treatments? I find it challenging to get to everything within our 40-minute treatments, two to three times per week.”
Mike Reinold:
This has got to be one of the most common questions that students and new graduates from PT school probably ask. Right? I feel like we’re inundated with exercise ideas on social media. We have all these grand ideas on things we want to do with the people, and then we get to our structure within our work setting and we have to try to fit that square peg in a round hole. Right? And to me, I think this is one of the most frustrating things that physical therapists do. They say, “I don’t have enough time to do what I want to do with my patients.”
So heck, I know Lenny and I came from an uber busy outpatient setting where you saw, I don’t even know how many we saw… 20, 30 people a day. I know a lot of people are like that. I wonder if we start this off with a couple of opinions from people, maybe Kevin, maybe Lisa. You’ve recently transitioned from an insurance-based model, that probably was quite similar to what Garrett is dealing with, to a one-on-one, cash-based setting. So, you obviously now have a little bit more time. But I’m curious, from your perspective, some of the things that you would recommend somebody like Garrett do. I don’t know, Kev, you want to start off? I saw you nodding your head there. Do you want to start the one off?
Kevin Coughlin:
Yeah, sure. Yeah, it’s definitely an issue that you have to plan for when you work in an insurance-based setting. So, generally my strategy with that would be, try to figure out what type of insurance they have and get some idea if you can, about how many visits you might be able to see them for. There are certain plans where maybe you get 20 visits per year and that’s it, and then it resets every year. So, then in those situations, you know kind of where you’re starting with that person and how long you’ll be able to see them for. And I know Garrett is specifically asking about early in their recovery, and I think then it is good to see them two times per week because you want to make sure that they’re healing well. You want to make sure that you’re getting back their range of motion. You’re kind of setting them up for early success.
Later on with the ACL specifically, they’re going to be doing a lot of stuff in the gym. So, if you can kind of front load some of those sessions, and make sure that you’re hitting all the most important things early on. Later on, you can really just do a good job of showing them their home program, and maybe working with a strength coach in their area if they’re doing some of their exercises in a gym. And the later rehab, even though that stuff’s super important, we can kind of keep a pulse on that and what they’re doing on their own, and make sure that maybe you get them in down the road every one to three weeks, and you’re retesting strength, you’re making sure that they’ve been doing their home program, you show them progressions that you’re going to have them do on their own. But I think early on it is important to make sure that you’re setting them up for that later success.
Mike Reinold:
That’s awesome, Kevin, and I really appreciate how you delineated some early phase versus late phase, and using ACL as an example, because that’s a really long rehab process that has a lot. As a physical therapist, we want to do it all. We want to do from day one all the way to the end. We want to do all the advanced stuff, but you could argue if you’re working in a setting where you have a max of 30 or 40 minutes, that your setting isn’t set up to do that. So meaning you probably shouldn’t even consider that that is what you’re going to do. That’s not a service that you’re going to be able to provide.
So, I like that concept of if you’re in that setting, do you front load everything, and be more hands-on, and set them up for success? Because if they get behind, it doesn’t really matter how many visits you do down the road. Once they’re behind, they’re behind, and it’s really challenging to get caught back up again. So I like that.
Lisa, what do you think? I know you made the transition too, not as recently as Kevin, but a little bit more than some of us here. Anything from your perspective, that you’d recommend?
Lisa Lowe:
I mean, I feel like the way Kevin described being more of the facilitator, of connecting the person to different strength coaches or different places that they could utilize to actually make their rehab effective, was usually the way that I took it too. Because the setting I was in, the standard visit was actually only 30 minutes. So then you talk about people being five minutes late, and that’s like no time.
Mike Reinold:
Yeah. I didn’t even consider that. That’s a really good point.
Lisa Lowe:
I didn’t have the ability to see more than one person at a time, just with the way it was set up. So, it kind of just was what it was. I mean, did a lot of what Kevin was talking about. I was lucky and honestly, I sent people over to Champion to work with strength coaches as their supplement, for the most part. But that was the resource that I knew was smart to use for a rehab client who just needed more strength time and eyes generally on them, that they weren’t able to get during PT. So, I think, like Kevin said, I think it’s all about developing your network in the area and having resources to share with your clients. Because maybe with that kind of setting, you do just become their game plan person and you do the hands-on stuff that they can’t do for themself, but then you make sure that they know what to do outside of PT time to really make their progress.
Mike Reinold:
It’s like you’re the guide. You have to guide them through some of the things, which makes sense. I feel like that leads us, Jonah, I know as a strength coach in our facility here, one of the things that you really harped on us recently as a physical therapy staff was that we need a really great way of transitioning people from rehab to the gym, and to communicate with our coaches to make sure that they’re getting everything they need. Jonah, from your perspective as a strength coach, what sort of things do you want to learn from the PT? What’s the best way to make that relationship work, so you can help PTs that are in a setting like this that are limited with time? What would you want to know?
Jonah Mondloch:
Yeah. So, a couple of things. First I think by this point, especially in a longer rehab process, as the PT you know that patient or client really, really well, so you can fill us in on a little bit of everything. Even the emotional side of what they’re like, do they get really stressed when they’re having little flare ups because we know those things happen, and that can help guide how aggressive we can be with somebody. I know, Dave, we’ve had a bunch of different ACL patients we’ve been working with, and they all have those subtle differences as a personality. So, I think when you know the patient really well, that’s a big one that some people might leave out. But then also the more obvious stuff, like the general guidelines in terms of are there soft tissue or mobility restrictions we’re working on, are there weaknesses or imbalances in asymmetries from side to side?
And just giving us those general guidelines of, this is the phase of rehab they’re at, these are the things we’re working on, they really need to build up strength right now, and then letting us kind of take it from there. Giving us a heads-up on the types of exercises or things that have maybe been a little bit more problematic, so that we know what to stay away from. But letting us kind of use our expertise once we have those general guides of, this is the stage they’re at, this is what we need to work on, they’re not quite ready for this, or we just started trying this, so you can slowly implement more of it. Depending on where they’re at in that process.
Mike Reinold:
That’s great, Jonah. And what I appreciated a lot from what you just said there was that, as a strength coach, you probably have a hundred things that you could or want to do with the person. Right? But knowing what the priority is maybe, perhaps from the rehab perspective, will help assure that you know are tackling those. Because there are tons of things you can do with these people. Right? There are so many avenues you can go and so many different approaches. I think knowing what’s the biggest emphasis would be good. So, I don’t know, I wanted to get some thoughts from the PTs that have worked in a more high volume setting too, on how they manage this a little bit. Dan, you got anything you want to add?
Dan Pope:
Well, I was going to go back to Jonah’s point a little bit. One of the things I think is helpful, and I think it depends on the coaches, I think one of the things we take for granted is that we have really good strength coaches. And I think back to when I was a strength coach and I was given a post-op patient, even if they were cleared to do activity, I was really freaked out, and I felt like I didn’t have a ton of guidance, and it was scary. And I think that’s challenging because a lot of the PTs don’t always have the knowledge about how to progress people to a higher level. So, it’s literally like they finished their baseline rehab, and they’re sent to a strength coach, and they’re really not ready for higher level conditioning, so it’s challenging. I think one of the things that’s kind of helpful for me, because I’m always a little freaked out if I’m sending someone to a personal trainer. Right? Because I don’t want them to do something they shouldn’t, and they’re probably freaked out about the same.
So one of the things I’ve done with some of the Champion coaches like Jonah, is that I introduced the new stuff as a physical therapist, the more kind of “dangerous” right, in quotations, and then once they’ve tolerated that for a few weeks, then I can say, “Okay Jonah, we’ve done this for a few weeks. I just want you to advance it a little bit. I’m not concerned this is going to be a problem, we’ve already done it.”
So, if you have a short session to spend with your athletes, maybe you don’t have to focus on quad strength because you’ve been hammering that for the past six weeks, eight weeks, and the strength coach is already doing that too. You can introduce some of the plyometrics and slowly start to progress some of those things. So your sessions kind of become, all right, let’s kind of leak some new stuff into the program, let’s start to advance a little bit. And once we know that’s tolerated well, then I can kick that over to Jonah and say, “We’ve already tried this. I feel very confident that you can start to do more of this yourself.” And that way you’re just introducing new things. You don’t have to spend a lot of time on the old stuff you’ve already kind of shown that it is fine for them do on their own or with the strength coach.
Mike Reinold:
That’s awesome, Dan. Great addition to that. And based on that, I’m curious Diwesh, from your perspective as a strength coach, how would you recommend a physical therapist find a good strength and conditioning facility? If that’s sports performance or personal trainers or wherever it’s like, what are some of the things that you’d recommend to a PT that is looking to set up a new relationship and make sure that they’re working with somebody that is going to help their patients?
Diwesh Poudyal:
This part can definitely be a little tricky. I think we all know that the barrier of entry for a fitness professional is pretty low, and we don’t quite know how many people are experiencing working with rehab clients. How many people have enough advanced knowledge to take in the information from high level conditioning and strength conditioning, but also understand that end of the rehab and the struggling athlete. So one barrier that you can look for as far as preference goes is CSCS. We kind of look at that as gold standard. So, look for a coach that is CSCS certified. The other thing that you can kind of see is, and I can relate to this personally, but I also know a lot of interns that have come through, even friends coming up through undergrad and stuff, I think it’s pretty normal for a lot of strength coaches to have done a stint as a rehab aid.
So, having someone that’s worked in a rehab clinic or rehab setting before to some degree, just so they can relate a little bit more, they can have an understanding of what transitions from high priority and range of motion and function looks like, versus high priority and strength and power looks like. So I think building relationships, and talking, and asking people just like, “Hey, what experience do you have working with the injured athlete?” I think stuff like that can definitely be a good way to sort people out, because like I said, that barrier of entry for a fitness professional is pretty low, and you don’t want to send someone a rehab client and they’ve never worked with anyone injured before. I think that goes to what Dan was saying, they’re probably going to be stressed out, they’re going to be freaked out, and you’re probably not going to feel good as a PT being unsure of whether they’re going to get good training and good coaching or not.
Mike Reinold:
Yeah. For sure. For sure. And don’t be afraid to go visit somebody too, right? Go check out their facility. Right? Mike, what do you think?
Mike Scaduto:
Just to add to Diwesh’s comment. Something that I would look for would be a strength and conditioning facility that specializes in the sport that the athlete plays. So, for an ACL tear, we know the most common sports may be like soccer, something like that. If there’s a gym or a strength and conditioning coach that kind of specializes in soccer, they may have more experience dealing with ACL return to sport for soccer players, but they also understand the demands of the sport that they’re trying to get back to. So, that’s just another avenue to kind of go down, is find someone that specializes in that sport.
Mike Reinold:
That’s awesome. That’s some good advice, too. I want to get one more perspective, because I really want to answer this question well for Garrett. Maybe go to Dave on this one. So Dave, I know you’re a really organized guy. I know you write good programs, you’re very thorough with your stuff. How do you organize these sessions? How do you make sure that you get the most out of these sessions when you’re in a limited time? What did you do when you were in a busy outpatient setting? I know that’s something that probably really bothered you, just knowing you as a person. So, I’d love to hear your strategies for what you did.
Dave Tilley:
Yeah, I think one of the key, maybe it’s relevant to this, but also just all injuries in general, is, you know, you have to really take a step back and think about one, what do they need me for? What things can’t they do on their own? I think there’s also some times when it would be ideal for you to do everything with them, all the strength, and then all the consultation, stuff like that. But in reality, after you teach someone a program, I don’t know if you need to sit there and watch them do clamshells, right? And watch them do everything if they’ve really mastered that. So, I’m a big fan of that. Which is, really take a step back. All right, early post-op, they need me for range of motion, they need me for soft tissue, they need me for this.
But advanced out phases, as Jonah and I were talking about, when I look back and I look at who I have access to, or what I can do with my time. I’m like, all right, well they really need me for consultation of workload around the pathology, and teasing that line of when we’re loading maybe the graft, or the joint or their knee in general, just a little bit too much.
So, they need my brain. They need my brain to synthesize what they’re saying and say, use my clinical expertise based on the information I know from research. And then they need me to translate that to Jonah. And like Jonah and I talked, a lot about how programming for athleticism is very different than programming for tissue tolerance. And so that’s what I think you need to do when you really think about it. It’s like, what do they need me for? And then what can be outsourced to someone who has maybe more expertise at that? Or just what can they do on their own?
The second thing about that, is I think it’s not always a popular answer, because maybe you’re not getting paid for the time, but the more work you can do on the outside of the session to figure out what drills really are effective? What things really are good use exercise-wise? What’s the best way to sequence this to get the most time out of it?
I’d rather do a lot of research in studying what EMG data is the best for activity in certain muscle groups, and what exercises seem to be the most efficient, and build a basic program that someone consistently does, versus there’s definitely something to be said about getting information from social media. But if you follow all the newest exercises that everyone is doing, and you’re trying to get it all in, you have 39 exercises in a program. I’d rather do a warmup, a soft tissue, one A, one B, two A two B, and a finisher, in a solid 40 minutes and have someone leave accomplished, than be doing a bajillion different exercises. So, that’s what I would say.
Mike Reinold:
And you know what? I actually wonder, Dave, if all those people doing the fancy exercises on Instagram, if they’re doing the same thing as you? They’re just showing that one fancy exercise that they do every day and it looks like that’s all they’re doing. You don’t see the one A, the one B, like you said. You don’t see the boring ones, they just want to show the fancy ones. Dan, did you want to add something to there? Sorry.
Dan Pope:
I was just laughing because you guys know how smart Dave is and how much information comes out of his mouth so quickly. I feel like his sessions are like that, too. Every once in a while Dave’s out and I get one of his patients, and it’s like a 30-minute session and it’s like an hour and a half of stuff. I’m like, “Oh my god!” And I’m trying to run through it as fast as I can.
Mike Reinold:
And the only thing I would add from maybe a slightly different perspective from what everybody else has answered here is that, in terms of the systems and the process behind it, divide your sessions up. So, you have your hands-on time and then you have your supervised time. And I think if that person needs to be exiting the facility exactly 40 minutes after their session, I think you need to change that model, to be honest with you. I think that’s just really unlikely to do. Maybe it’s 40 minutes that you’re working with them, but then that’s where we have flow sheets that patients go through exercises, and yes, you have to spend some time teaching them that, and showing them that, or have the students do it. Right? But once they have that though, you can unlock 30 minutes of amazing productive TRX that you wouldn’t have done. Now you have your 40 minutes with that person plus this amazing TRX session. So, don’t underestimate that. I think that’s really important. So, anyone else on that? Did we nail that? Or anyone want… Dan, you want to add a little bit to that?
Dan Pope:
I’m sorry. Yeah. I’ve got to say this. But I think one of the things you guys have showed me…
Mike Reinold:
No, this is good.
Dan Pope:
…And I think it’s really helpful is that idea of a system. Right? On so many clinics, everyone does so much different stuff, from clinician to clinician. And I think the other part is that it’s hard to have a program that kind of everyone goes through and maybe all of the ancillary staff know and understand, because you could have someone else go through a lot of the program with a patient after you’re allotted maybe 30 minutes, whatever it is. And if that’s a system that everyone in the clinic knows, that’s way easier than trying to give them 10 new exercises every week, and then having someone in the corner do them with terrible technique, or something like that because you’re with your next patient, and you can’t really coach them. So…
Mike Reinold:
Awesome. Yeah, no, I totally agree. And I think it’s worth spending a little extra time on this to answer Garrett’s question. Because I think it’s so common. I think most of our students would probably agree that these are questions they have. They’re like, “Oh gosh, how am I going to do this.” Right? How am I going to fit this all in? Just remember, take a step back, start simple, get those low hanging fruit and knock them out of the park in those 40 minutes. And you get more comfortable with your rhythm, like the cadence of your sessions and stuff like that, then you’ll slowly build as you get comfortable with it.
But just make sure you’re knocking out those major things first, and you’ll be successful, and then over time, you’ll just get more and more successful. So, think of it that way, Garrett. So, great question, Garrett. I think a lot of people shared that, so I’m glad that you reached out with that. I really appreciate that. If you have questions like Garrett, please head to mikereinold.com, click on that podcast link, and fill out that form to ask us a question, and we will see you on the next episode. Thanks so much.
