As New Grad PTs, we often get caught up in what we “should do” and “need to do.” Getting wrapped up in our own mind can cause us to forget what the PT experience is like from the patient’s perspective. Many patients don’t know what to expect from therapy, nor do they know what information is relevant and necessary for their PT know about them and their condition. Tomorrow, before you evaluate, try to stop, take a deep breath, and think about these 5 things that your patients might not be telling you.
1. Their complete medical history
Most offices provide an intake sheet prior to a patient’s first appointment, allowing them to list medical conditions, surgeries, medications, pains etc. which can help to expedite the intake process. It’s important to realize that even if there is an intake sheet, it is necessary to review a patient’s medical history and medications with them. Sometimes a patient’s understanding plays into their omission or errors on the form. For example, a patient may exclude a controlled condition they are taking medications for or conditions that they feel are irrelevant, such as controlled hypertension, hypothyroidism, osteoporosis, or arthritis.
By reviewing medications with the patient, you can unearth unreported conditions and obtain the full story. Sometimes patients will exclude conditions if there is no option to fill it in, for example, Hepatitis C or HIV. Many patients will be hesitant to disclose psychiatric disorders and medications due to the stigma associated with those disorders. Although they are seeing you for physical therapy, these conditions, symptoms, and medications can have a drastic impact on their treatment, and it’s important to be aware of that.
“Some patients may find the attention to detail intrusive, but you should inform them that the more information you have as a PT, the better you can maximize their recovery.”
Patients may also omit certain surgeries or surgery-related information. For example, patients may not know the name or type of surgery they had on their back, neck, or knee, or they may exclude details about which side of the body was operated on. They may describe a surgery generally, such as “breast cancer surgery.”
As a PT, it is your responsibility to further investigate and obtain as much information as you can about the date, location, type of surgery, and recovery. You can call their primary care physician (PCP) or surgeon and confirm information as well. Some patients may find the attention to detail intrusive, but you should inform them that the more information you have as a PT, the better you can maximize their recovery.
2. Their biggest red flags
Direct access allows PTs to be on the front lines of the medical field and operate as the gatekeepers of further resources. This means we have a responsibility to screen patients, investigate their complaints and rule out more sinister pathologies, regardless of how typical a complaint may seem.
If needed, we can also refer patients back to their MD, or even recommend a specialist. Asking questions to address possible red flags can help you with this process. However, we are often not prepared to ask—or to interpret—patient responses to these questions. In school we are prepared for “yes” and “no” responses, but patients tend to give more ambivalent, anecdotal answers, so we will need to ask more follow up questions to make sure we are on the right track.
Low back pain is one of the most common complaints that patients bring to their PTs. In patients with LBP, it is necessary to rule out Cauda Equina Syndrome (CES). In addition to presenting with severe low back pain, patients with CES also present with some, if not all, of the following:
- urinary retention or incontinence
- fecal incontinence
- saddle anesthesia
- loss of sacral sensation
- sciatica (either unilateral or bilateral)
- lower extremity weakness
- gait dysfunction
- reduced straight leg raise
Any of these above symptoms can indicate possible Cauda Equina Syndrome. Typically, these symptoms have a rapid onset of 24 hours or less, but they can also evolve over time. It may take further questioning to understand the symptoms and severity in your patient. If the patient doesn’t have these symptoms, it can be an educational moment, and you can instruct them on how to proceed if they do experience these symptoms. However, if you patient presents with these symptoms, call 911 to get them to an ER immediately. If it is Cauda Equina Syndrome, and the pressure is not immediately relieved, paralysis, incontinence, and saddle anesthesia can become permanent.
Another detail to keep in mind is that when discussing pain with patients, the behavior of pain is important. It requires a skilled clinician to assess if a “constant pain” described by a patient is truly unchanged, constant pain or intermittent, mechanical pain. Constant pain, that does not vary over a period of 24 hours is indicative of more serious pathology.
Intermittent pain, that changes with position, activity and medication tends to be more mechanical, and less likely to indicate a sinister condition. Asking about the behavior of pain (e.g. in the morning vs. night, sitting vs. standing) and responses to pain medications and interventions can help you assess if they truly have constant pain, or if it is intermittent. If need be, you can refer them back to their PCP for further work up.
Referred pain patterns and disorders can present similarly to orthopedic pain. Taking a detailed history and assessing the pain response to movement along with testing can help to rule in (or rule out) both referred and visceral causes of pain. Similarly, for patients presenting with neurological symptoms, including radiculopathy, a neurological assessment is merited, and further referral may be required.
3. The beliefs they have about physical therapy
“Why Am I Here?”
Patients come to physical therapy for a variety of reasons. Some patients want to avoid surgery, some want to get better, and others still have outside forces, such as insurance, court cases, or family members pressuring them. Some have personal and professional responsibilities that are suffering because of the time they are spending in PT, and they want to get out as quickly as possible.
Whatever the reason, a patient who isn’t invested in PT is much more difficult to treat. Understanding what drives them to come to PT is the first step to connecting your patient to their therapy and hopefully getting them onboard with treatment. Some patients will say they’ve tried PT before—this is an opportunity to ask them specifically about what did and did not work.
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By assessing what was and was not previously helpful, you can begin to implement strategies that were effective (and avoid ones that were not). This also helps to validate your patient’s opinions and feelings, build rapport, and make their treatment collaborative.
“I Don’t Think I’m Getting Better”
Patients will often hesitate to tell you if they don’t notice improvements with PT, as many don’t want to disappoint their therapist. A good way to assess patient response to PT is to regularly ask them how they are responding, as well as if they are compliant with their home exercise program. Assessing pre- and post-intervention, as well checking in from session to session, can help you and your patient monitor their progress.
Additionally, during the intake, asking the patient to note specific activities that are difficult, impossible, painful, or that require increased time to complete can provide you with benchmarks to measure subjective gains. Regular progress notes or re-evaluations can help you take note of improvements and help you to educate your patients about predictable time frames for improvements in strength and balance.
4. The things they are nervous or embarrassed about
Constipation can be a minor inconvenience, a permanent state of affairs, or a major obstacle for patients. Often, patients do not include this in a past medical history. Many patients disclose this condition during a follow up visit, when they subjectively report how they are feeling. Regardless of the severity, if the patient confides in you about this, there are many ways that you as a PT can help.
Activities such as diaphragmatic breathing, squatting, and placing the legs on a stool while evacuating can all ease constipation. In some patients, discussing opioid-induced constipation can be helpful as well. According to the APTA House of Delegates, nutrition is within the scope of practice for PTs, so we can recommend increased water and fiber intake, refer them to their PCP, or suggest a registered dietician.
Disclosing a fall is something many patients do begrudgingly, if at all. Whether it’s due to pride, fear, or lack of awareness, creating a dialogue about falling can be an important educational opportunity for you and your patient. Many patients only consider something a fall if it involves landing on the floor, but you can educate your patients about the fact that a fall is any event that leads to unplanned or unexpected contact with the floor or a piece of furniture that is not the result of a pushing force, shoving force, or a medical event. A near fall is a loss of balance that would’ve resulted in a fall if the person had not been able to catch themselves. Identifying falls and near falls, as well as associated risks, can help guide PT goals.
There is a stigma surrounding abuse in all forms, and many victims are hesitant to share their experience with anyone, let alone a PT. Many intake sheets include a question pertaining to feeling safe at home. This is one opportunity for patients to share sensitive information or forPTs to open a discussion with their patient.
During your examination or treatment, if you notice irregular bruises, cuts, or marks, you can gently ask the patient if they are hurt, if the injury has been checked by another medical professional, and how they obtained it. Listen actively, and let the patient speak. If the patient doesn’t want to disclose, tell them that you are there as a resource for them should they ever need you. Make sure that you have resources and referrals for counselors and social workers readily available and that you are familiar with the laws about reporting abuse in your state.
5. Their understanding of their condition
“I don’t understand what the doctor my told me”
Never assume your patient fully understands their disease, prognosis, or rehabilitation potential, even if the diagnosis is on their prescription. Often, by asking when a diagnosis was received, you can begin to ascertain their level of understanding and acceptance of their condition, and hopefully begin a dialogue about it.
Ask the patient what they know about their condition, if they have any questions about it, or if they have any PT goals in mind for it. Discussing and setting realistic goals with your patient fosters a sense of ownership and control in their rehab experience. It can be helpful to have contact information for support groups, counselors, social workers, and even online resources to provide patients as well. Allowing time for them to ask questions is important, but be sensitive to their current understanding and the amount of information you provide at one time, as it can be overwhelming.
“The xray said ____. Is there anything you can do?”
As PTs, even new grad PTs, we know that imaging results are not the final word on most conditions. However, for many patients, imaging is everything. Whether it’s “bone on bone” or a disc is “bulging or herniated,” the patient’s presentation and your exam are just as, if not more important than the imaging. It is important to educate your patient about the relationship between pain, structure, and dysfunction. Focusing on functional limitations, not physiological conditions, can help to demonstrate the need for—and benefits of—PT as treatment progresses.
Remember, you are here to guide patients through their rehabilitation. Patients and PTs need to work together to achieve the best possible outcomes. People generally want to feel better, so let them know that you want to do that. Educating patients on the information that you need as their PT in order to provide the best quality care fosters an open dialogue and greater rapport throughout their rehabilitation. It shows that you care about them as a whole, not just the body part in question. This means we as PTs need to ask the right questions and empower our patients to answer fully and honestly.
Have you ever dealt with a situation where a patient didn’t tell you something relevant to their care? If so, share below!