Painting the Full Patient Picture

[zcanova]

A few weeks ago I started working with a patient referred to me for bilateral quadriceps tendonitis. During the subjective examination, he noted that he had a lipoma removed from his lower back in 2021. After the surgery, he attempted to get back into the gym which he believed led to the onset of his symptoms. He had gone to physical therapy and experienced more pain than relief. In the subjective examination he stated that his pain would be so bad that sitting for too long would hurt and walking less than a mile would bring on his symptoms. Due to this, he had drastically limited his overall activity. He also stated that he was a lawyer and had transitioned to a remote job over the past few months. From the way he described his symptoms, I was expecting him to be a lot more irritable than he presented. His strength and flexibility were adequate, and I could not seem to find a comparable sign other than some mild tenderness in the distal quads. I was not quite sure where to go with the treatment so I decided to prescribe him a body-weight-focused exercise program emphasizing glut and quad strengthening.
When he returned to the next visit he noted that his symptoms had really flared up and even walking was difficult the next day after the visit. I had felt that the exercises were fairly light, but failed to consider the fact that this was the first workout he had done in over a year. After realizing this, we spent the next few visits working very lightly on quad strengthening and working more on proximal muscle strengthening. Even with the lighter exercises, he was still having complaints of significant soreness that was out of proportion to the way he was presenting. It took a few visits for me to get the full picture, but I finally found the reasoning behind his complaints.
What I realized was that I was not putting the patient’s full picture together. I finally realized that this patient was describing delayed onset muscle soreness as his pain and was not aware that soreness was a regular response to loading a muscle. Along with this misconception, he also did not realize that more movement was okay and would improve his recovery.
Furthermore, this patient had completely avoided any physical activity after failing to recover from his previous physical therapy. To add to the lack of physical activity, he had also switched to a remote job which led to an even more sedentary lifestyle. When I realized this, I spent some time educating the patient on the reasoning behind his misconceptions and worked with him to find ways to keep him accountable for increasing his regular activity levels.
My biggest takeaway from this experience was realizing the importance of the subjective examination and understanding the patient’s knowledge/understanding of their presentation. Looking back at the initial examination, I realized that I had failed to put together the full timeline of events and lifestyle changes that occurred leading up to the onset of the patient’s symptoms. I was able to successfully educate him on the importance of increasing his activity levels throughout the day and reassuring him that his level of soreness was a typical response to the exercises we were doing. He is now walking at least 30 minutes a day and performing a series of higher-level strengthening exercises 2-3 times a week with little to no soreness.

[AJ Lievre]

Zack
Considering his prior poor response to treatment, did you discuss his expectations and potential concerns about this bout of therapy? Might that have made a difference in your initial approach? Do you feel that your relationship with the patient was negatively impacted after that first visit when he came back flared up? If so, did you address that?
Thanks
AJ

[Farisshd]

As a personal trainer and group fitness instructor as well as a PT, I have seen a lot of this one! I try to be sure with patients and clients to program a bit more conservatively (at first) for those that are deconditioned, but I think the biggest benefit is the education on letting the first few sessions guide intensity and volume, and that a bit of DOMS is expected, but should not be so painful that they fear coming back.
I think its great that you used this example because it is something many PT’s might not think to explain to their patients. We won’t always get the dosage right on the money the first visit, but letting the patient history and activity levels guide it and being sure to educate the patient on acceptable levels of pain and/or soreness during and after sessions has really helped in my experience.

[Author]

Posts