On this episode of The Ask Mike Reinold Show, we talk about the steps we take to develop a plan with our patients and clients, and then build our programs. This is often a very daunting subject to students and new grads, but by following a simple systematic approach, you’ll get better in no time. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 188: How to Develop a Physical Therapy Treatment Plan and Program
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Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about how we develop our treatment plans and our program strategies for our patients and clients.
Mike Reinold: All right. What do we have for questions today? Who’s up? I got it. Whoa. First day.
Austin: Yeah. I got it. All right. We got Ty from Sarasota. What’s up Champion crew? I love the content on this podcast and thanks for taking my question. I am a DPT student about to graduate in a few months. I feel that my school has done a great job teaching how to identify and diagnose pathology but is not given as much when it comes to treatment and program. Do you have any advice, resources, examples, et cetera on how I can better understand how to program treatment for a person coming to PT.
Mike Reinold: All right. That’s a pretty common question. I bet. Done a really good job with diagnosis, especially medical diagnosis. I think we’re getting a better understanding of that as we’re getting into the doctor of physical therapy and direct access and all that stuff.
Mike Reinold: So really good job with diagnostics. But now you’re confused with how to develop a treatment plan. Students quickly… I don’t know. King, what do you think? Do you agree with this question? How did you feel? Do you feel like you are prepared?
Mike Reinold: Were you… I mean do you guys feel you… go in order. Was there anybody prepared well for treatment?
Andrew King: I think our school did a great job preparing us.
Lenny Macrina: Go Hawks!
Mike Reinold: Why?
Andrew King: Because they give us a good idea of what to do like initially versus advanced and intermediate. So kind of where to start, what patients can tolerate and how to progress as and what to look for to progress.
Mike Reinold: That sounds like it’s pretty good right there. That understanding… I think that’s the basics of treatment. Understanding how to start, where to start and how to progress. I like that. That’s a good one. What about you guys?
Student: I agree with the question. My school focused a lot on the diagnosis did a great job and we learned the basic starter interventions but after that it wasn’t… Where I learned all, mine was the clinical experience, the less of actual in class besides like your basic starter.
Mike Reinold: So that’s a good point. So maybe you know this is another good reason to make sure you have good clinicals. What about you guys?
Evan: I think just my experience as a strength coach for the last four years has been able to implement into physical therapy pretty well.
Mike Reinold: That probably helps too because you already understood how to develop things like strength and power and mobility and stuff like that.
Austin: Yeah. Our program was just heavy on exercise, prescription, and stuff like that. And we were able to take courses for advanced interventions where we learned more programming and things like that. Having a sports elective too. So you have to learn more…
Mike Reinold: That’s good. So I think that’s part of the problem is we don’t have a minimum basis in college on what you need to learn. So I think a lot of people are very good at diagnostics and you spend a lot of time with that. And then with experience you get better with treatments. So… All right. Where do we start I guess, is the question on how to help somebody? Where do you go from a new grad and how do you figure out what to do with treatments? I mean, I don’t know. I get that we have a million directions we can go. And does anybody have initial advice you want to start with? And then we’ll go from there.
Dan Pope: I’ll start a little bit. I think part of it is that you have to have a population in mind. So for us, we all have specific niches. So if you have a six year old that doesn’t want to get back to anything in particular and maybe any old intervention will help for the low back pain. But do you have some with low back pain is trying to get back, let’s say a squat, apparel or something along those lines.
Dan Pope: There’s a very specific set of exercises you can start with and work your way up over the course of time. And at least for me and my niche, my population, I think Evan kind of hit it really well. I actually found that most of the students that I worked with in the past are not very good at exercise prescription, and they’re very good at kind of the basic stuff when they have to advance. They just have no idea how to do that. So for me, I think it’s really important to learn the basics of strength conditioning. And learn how to work with people from that perspective. So any resource from there would be helpful I think.
Mike Reinold: Right. So I guess that’s maybe one approach if you’re feeling insecure about your knowledge on how to help people with that is… Let’s start with that. Maybe instead of being so diagnostic specific, what you do is you start to think in your mind: “All right. How do I help people?” Well, we have to work on mobility. We have to work on strength. We have to work on their own muscular control. We have to work on endurance or power or whatever. Maybe you have all these domains. And you start thinking about each one of these, what do I have for strategies to improve mobility, improve strength, improve power. And then seek each one of those kinds of buckets out. Maybe that’s a good way to start based on what Dan said.
Dave Tilley: Yeah, I would agree. I think looking back on it, what I was kind of most insecure about was the initial treatment or plan of care after somebody has an acute injury. So I really didn’t know how to help. Someone who’s a post op joint for a knee or stuff, I felt a little bit how do I touch? I don’t mean to hurt you and I follow protocol stuff. So there was that piece of the medical side, but then I have.. Didn’t have a great mat of foundation for strength conditioning coming out of school.
Dave Tilley: And so I felt that was where people weren’t necessarily having surgery but they were hurt. They need strength programs. I didn’t know how to program well. So for me it was just finding mentorship for both of those things. Cause I knew that was what I was weak at mostly. So finding people online I think is really important. If you don’t have good finding people online. I followed your guys’ course and I felt like I didn’t have that immediate post op problem solved with my clinical education. So that was really help online. And then strength conditioning, I just shadowed strength coaches.
Mike Reinold: Yeah. And you kind of learn that way a little bit through that. I guess what it comes down to is a lot of times is we get caught up in the diagnosis and not what’s right in front of you and you start saying, well what do I want to do for treatment for to tell for memorial pain instead of taking a step back and just kind of figuring out what’s wrong with the person. And that’s our approach at Champion, which we tried to do is we try to look at them more holistically and then come up with a checklist of things they need and stuff.
Mike Scaduto: I think it definitely all starts with your assessment and your evaluation. And part of the evaluation assessment that we use is moving screen and I think we all use it to find out what they can tolerate in terms of what exercises they’re going to be able to tolerate. So there’s a squat and lunge, step down and things like that. So if someone comes in with knee pain and they can tolerate a squat and they can’t tolerate a single leg step down, then I’m probably going to have them do some squats and build up to this single list of down. So I think that helps guide your treatment plan. You find out what they can tolerate day one and build upon that and progress them over time basically.
Mike Reinold: So I think too that the point of what Mike said here is that we have a systemized approach here of how we look at people. And when somebody comes to us with say shoulder pain, we’re going to evaluate the shoulder pain and try to figure out if we can understand why and come up with a diagnosis. But that doesn’t mean that that is everything we do. That is part of it. The other thing we do is we try to figure out what’s sub optimal that maybe put them in that position. So maybe things that we can increase their functional capacity, not just perhaps work on their shoulder pain. So it’s almost like we have two buckets of treatments here is let’s help with their pain.
Mike Reinold: Well, it’s the reason why they’re here and their injury, and the precautions, and the strategies that are involved with that. And that’s what you learn in school. And then the secondary part is, okay, well let’s take a big step back. All right, they have knee pain. All right, well I know there’s things I can do to help them with their pain. Okay, good. Well, what else can I do? Oh, they can’t do a step down. Why can’t they do a step down? What happens? And then you figure out a strategy with that. Oh, they don’t have any ankle dorsiflexion. Oh, they, their hips are weak or whatever it may be.
Mike Reinold: And you find these things, you create this checklist of sub optimal things, and then at the end you take a step back and you figure out what you have. And when you’re young and you’re a student, you’re going to have a crazy checklist. There’s going to be things all over the place. And you’re going to have all these things, then what you need to do is just figure out what’s the most impactful things, what’s the thing that is going to give the most bang for the buck initially and start with that. And I think that’s our big strategy. Anybody… I think that’s a good strategy. What about when it comes into the actual treatment, what do you guys do for your programming. Do you have anything specific you guys want to add to that?
Lenny Macrina: I just want to add that I was fortunate when I did my student, it sounds like he’s a student, she’s a student already in a DPT program and you’re probably going out on clinicals to make sure you set your clinicals up at spots that historically have probably a bigger staff where you can bounce ideas off different PTs and just a staff that is respectful, that has a group of PTs that you really look up to and are known in there… Inviting their facility or known in their community. Cause I was fortunate. I got… I did an internship at HealthSouth but Mike and I had Kevin Wilke and probably 10 other PTs that I could bounce ideas off of and get in their minds and pick their brains and just observe from a distance what they’re doing. And I think that was very helpful.
Lenny Macrina: That’s how I got a lot of my base of exercise, which is watching other PTs, everybody saw it, copycats each other. And everyone’s doing the same stuff because you just follow what the other PTs are doing in your facility. So as a student you go on your internships, you got to have that in your head. That’s one of your goals is to get as many exercises under your, in your mind and in your notebook for your future. So I would definitely, try to really do that. I think these guys are hopefully doing that too. They just observing all five of us as we go and hopefully they are just putting little notes in their head, mental notes of what they could do for their patients in the future. So that’s one strategy that I’ve used and I’m always copying Dan, whatever Dan does out here.
Dan Pope: Of course. Yeah. I was kind of going back to what Mike was saying about the program. I think this is a little bit challenging because if you’re trying to work with an athlete that wants to get back to a higher level. Let’s say they have Achilles tendon problems. If you look at some of the Achilles tendon literature, it says, okay, do some sort of Achilles tendon strengthening somewhere between twice a day and every other day. So I think what happens is that you get a pretty good idea of what the baseline should be. But the high level stuff is what’s challenging for physical therapists. Figure out how to get back to it.
Dan Pope: So from a program perspective, what you said is figure out the needs. So does this person want to be able to run five times a week? Okay, great. That’s awesome. Five times a week, 30 minutes. Right now we’re doing three days a week worth of calf raises. How do I bridge that gap? So maybe three months down the line I’m running five days per week and then you start working backwards and just progressing and slowly over the course of time. And that’s probably been the way I’ve done most of my programming to help people get to a higher level.
Mike Reinold: I think that’s great. As a PT we often focus on what to do right now based on their limitations and what we don’t think of as the end. So Dan’s saying, start with the end in mind and then figure out a plan that builds on there. I like that. I think the only other thing I would add is that we have a really systemized approach on how we work with people here and we’ve done this over years because we figured out the steps it takes to help people get better. So, yes, a rotator cuff tear or Achilles tear or something or you’re going to have very specific things you do. But generally for people with pain that come in and they don’t have a specific type diagnosis or pathology, you just have hip pain, knee pain, shoulder pain, whatever it may be.
Mike Reinold: We follow a systemized approach and what we do is we try to break it down into three things. We talk about this a lot. This is in our Champion Performance Certification thing, but it’s mobility, control, and load. And that’s how we program when you just base it off those three things all the time and it goes in that order and they overlap. But we have to say, okay, what mobility restrictions do they have that we need to address? Great. Once that’s kind of tackled, or at least we’re working on that, what do we need for control. And for control, this is the typical physical therapy. It’s the isolated exercises. They have an isolated weakness of this muscle. They need dynamic stability of this joint. They have neuromuscular control deficits of this. That’s control. And then the third is then they have to load and that’s what we load the movement patterns that they need to get back into.
Mike Reinold: So when in doubt, come up with their checklist of things that are suboptimal and then could follow that progression, mobility, control and load. And when you do that, that’s almost your blueprint to develop a program for anybody. It’s actually easy to follow a postoperative protocol. Because it lays it out for you. It’s the person that comes in with shoulder pain. You can help them get out of their pain and then send them on their way. But they’re probably going to come back into pain because you didn’t really fix the underlying issues that they had with them. And that’s how we tackle those programs. So it’s going to take time, it’s going to take experience. But I think the more you practice that, the more you should get better at that.
Mike Reinold: So a great question. Another good one. If you have anything like that, just head to mikereinold.com and click on that podcast link. And you can fill out the form and we’ll see on the next episode.