How to Effectively Incorporate Function into Every Treatment Session

By Dr. Kate Cysewski, PT, DPT

We ask every patient, “What are some activities that your pain or symptoms limit or prevent you from doing?”  We ask this to determine what the patient’s functional limitations are and so that we understand what is important for each individual to achieve over the course of their physical therapy experience.  Over the course of the evaluation process, however, sometimes we can get caught up in the individual mechanical deficits and forget exactly how they relate to functional positions and/or activities that are important to the patient.  To keep your patient’s progress on track, try following these tips to incorporate function into every treatment session:

1.     Evaluate the Functional Positions/Activities that Reproduce Symptoms

            There is a reason that the patient is having pain or symptoms in that posture or activity, so have the patient perform it and look at it.  With the patient’s consent, ask to take a picture or video to refer back to after treatment and that you can breakdown further for future appointments.  Sometimes the dysfunction may not be so obvious that you can see it.   To evaluate the patient effectively, put your hands on the patient and feel what is happening.  Is the patient sitting on his/her ischial tuberosities or sacrum?  Try to move the patient over his/her pelvic floor and feel what happens, or what doesn’t happen.  You should also use this time to show the patient what is limiting him/her from maintaining or moving efficiently.  This is a key component to getting the patient to really see that you care about what is important to them and to begin to educate them about their body.

2.  Treat the Pain in the Functional Position

            Do not waste time moving the patient back to the treatment table, treat the problem in that position.  Not only will this allow you to constantly re-assess mechanics and end-feels, but it will make your treatment that much more specific.  It might not just be a straight AP glide to the talus that is limiting efficient ankle dorsiflexion for sit-to-stand or squatting, the talus may also need to go slightly lateral, but you might not necessarily be able to feel that if you loaded the ankle while the patient laid supine on the table.  After treating one area, re-evaluate and then move to the next area that looks and feels limited.  Once the mechanical restrictions appear clear, you need to re-train the patient to use the new mobility in that position.  Using skeletons or diagrams, explain to the patient what he/she could not do before and how his/her mechanics have changed after treatment.  Then, using the same verbiage, have the patient perform a prolonged hold in the new range of motion to facilitate neuromuscular re-education to the appropriate muscles.

3.  Prescribe Exercises that Mimic Components of the Functional Positions/Activities

            So, you’ve improved mobility and re-trained the patient to activate and sequence the appropriate muscles to facilitate this movement.  Now, you need to give the patient exercises that reinforce the mobility, muscle coordination, and strength needed to maintain the gains.  Break down the posture or movement into its components to help you think about what those exercises may be.  Is the gastrocnemius or soleus tight and limiting ankle dorsiflexion range of motion?  Then the patient would benefit from a stretch of these tissues.  Does the femur tend to adduct and internally rotate when the patient descends into a squat?  Then giving the patient hip abduction and external rotation strengthening exercise, maybe even one that combines the two motions.  It is important that you can relate each exercise to the functional position or activity that you were working on, so that the patient understands why it is necessary to perform the exercises on a regular basis and promote compliance.

4.  Practice, Practice, Practice

            You may have to come back to this posture or activity a few times over the course of the patient’s case to re-assess for other areas of restrictions or to review efficient muscle sequencing to move into and out of the position.  If you suspect that the patient has not been compliant, ask the patient to take you through the steps to attain or correctly move through the activity.  Doing this will reveal areas that you may need to review or re-treat.  Stress to your patient the importance of practicing at home, work, or anywhere else they find themselves assuming the previously aggravating position.  The goal is to make the control of the new mobility and strength to be automatic, which can take several weeks.  Make sure that the patient understands this and that repetition is key to attain automaticity.

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