“This doesn’t fit with anything I learned in school.”
We often encounter this uncomfortable situation in the physical therapy clinic. In school, we are trained to fit each patient into a neat diagnostic category; grade II ankle sprain, subacromial shoulder impingement, radicular low back pain. These diagnostic categories often work in acute situations with a clear mechanism of injury. However, we also see atypical presentations, that is, a mix of signs and symptoms that don’t match any single diagnosis.
We can think of this like a spectrum. On the one end are “textbook” injuries that neatly fit a diagnosis. On the other end are atypical presentations that make one say “Hmmm”, those ones that don’t match a single diagnosis.
For those atypical, “Hmmm” presentations each subsequent visit is a mini evaluation. We learn more about how the person responds to therapy. We learn about their pain triggers. We learn about their adherence to home exercise. For example, we assign a patient with chronic low back pain the “bird dog” exercise. On the next visit, they have more pain. So we adjust the exercise (such as the range of motion, volume, etc). Or we select a new exercise. Every visit gives us more information and we better adapt the program to that patient.
On the flip side, the evaluation for “textbook” injuries doesn’t end on day 1. Every patient responds differently to therapy. Every patient has different goals. Every patient has unique factors that impact their rehab (psycho-social, economic, etc). For example, consider two people post total hip replacement. One has a telework job with flexibility and a gym in their apartment building. The second works long shifts in a factory and has to drive an hour to get to therapy. Do these people neatly fit into a diagnostic category? Yes. But will they respond the same way to therapy? Probably not.
The process of evaluating is iterative-it is not something we “complete” on the first visit. The evaluation starts in that first hour with a patient, but continues at every following visit.