Clinical Integration - Part 1: Strategies to get familiar with new information more quickly

Use your existing skills - Don't stop them

The sub-classification model we use is designed to help you with clinical reasoning to better apply your existing skills

Background

The SMARTERehab sub-classification model is the most comprehensive model in musculoskeletal medicine. It provides a rehabilitation directive for almost all patients. Despite the completeness, the sub-grouping is very easy. After the patient is sub-classified, we have specific courses which detail appropriate treatment for individual subgroups.  If you don't have that skill set, or it is not within your scope of practice, you know where to refer on.

Each course presents cases and does demonstrations which highlight how you can use various manual and passive techniques. Clinicians are by nature very helpful and frequently want to use their hands. One of the biggest challenges is to know when not to do this (HINT: it isn't always with behavioral presentations).  We present very clear indications when this should not occur, but also give you other skills you can use to help manage the presentation using other strategies.

Some techniques are "semi-passive" in that although they are passive, they either directly facilitate better movement (e.g. taping) or involve active participation from the patient (e.g. sensory discrimination training).  This is how we encourage the use of traditional manual therapy. In mechanical pain presentations, they should be used to help improve movement and other aspects of motor control to allow the patient to better use their active strategies.

The point being, regardless of your background or current skills, the model provides enhanced clinical reasoning to allow you to better utilize your current skills. The "trial and error" methods that are generally used are now almost obsolete when you apply the model.

Reduced Stress and Burnout

What a time to be a new graduate (or someone in the midst of a career crisis)! You no longer have to struggle with not knowing what to do or people blaming you for their problems. You can confidently give patients clear rehabilitation options. You don't have to (or no longer have to) go through the painstaking trial and error methods that countless clinicians have done. IT'S NOW MUCH EASIER.

Obviously it is up to the patient to take this information and they are not always able to do that (Note: I will post the use of the transtheoretical model of behavior change in the near future). This involves a complex interactions of beliefs, expectations and other psychology.

Getting Familiar with Course Material

The information I am going to mention below applies to all courses, not just SMARTERehab courses.  You do weekend course and you show up to work - what to do? You'll likely remember some things from the course, but unlikely everything. It takes a bit of work to get familiar with the whole course manual. Below are some things I started doing as a student and new graduate. If you think of others, please let us know so that we can tell others.

• Favorite Patient

·        We have all had friendly patients. They tend to show up early, talk to staff and want to know everything about you. They would be more than willing to act as a model for you to try new things. Book off a little extra time (if possible) and bring your manual into the treatment room with you. Practice the relevant tests, techniques and rehab.

• Anything Can Happen Thursdays (or some other day during the week)

·        Read the manual the night before or morning before work. Pick a group of tests, techniques or rehab exercises to focus on. As much or as little as you can handle. Practice them on all relevant patients that come in on that day. The reading was meant to be so that you don't have to bring in the manual with you.

• What Happens in Vegas Stays in Vegas

·   For those of you that are not familiar with this, it means a "Non Judgmental Environment"

·         Not everyone like being assessed by our peers. For the next three strategies to work, there needs to be open dialogue with your co-workers where there is a commitment to learning rather than judging. Workplaces that have this, have workers that are much happier (which results in less turnover, more productivity) and facilitates a better therapeutic environment.

·       If there is a mistake, or if something could be done better, more than one set of eyes / ears is better than one so feedback can help self reflection.

• Case Study Presentation

·      This will encourage you to read your manual, and check your notes prior to presenting. Along with dialogue from your co-workers or peers, this facilitates self refection of the case and the material.

• Inservice Training

·       Pick a common patient presentation and look up the relevant tests, techniques and rehab related to this to perform an inservice for your coworkers. Along with the above, this facilitates self refection of the case and the material.

•  Mentoring Program

·        We have had several requests over the last couple of years about mentorship. This mostly by patients in remote areas or who work on their own. We are currently looking at the best way facilitate this and will have some options soon.

• Clinical Visit

·      We do offer clinic visits to see complex patients. Here, you can sit in on the assessment, treatment and plan making for a patient. There are a variety of formats this can be done in depending on what you, your staff and the patient want to get from it. Note: This is normally done as an end stage learning process rather than early in the learning process, but it can be done early.

What are some useful skills for a clinician?

We would hope that your school would have taught you how to screen for red flags and do a basic assessment of function. Good communications skills and the development of a healthy therapeutic relationship are needed and can be learned over time. Some people are naturally good at this, while others need more practice. We give you the skills to know about what to ask, how to ask it and how to relay answers back to the patient while considering their individual factors (see previous post on the sub-classification model). There are some very important common skills that can enhance the therapeutic relationship, which are enhanced or limited by the personality, presentation, beliefs and expectations of the clinician (e.g. clinician's individual and environmental factors).

After that it is useful for clinicians to be able to

• Address articular, myofascial and neurodynamic restrictions (in mechanical pain presentations). There are different schools of thought and techniques for these.
• Prescribe a functional and / or graded exercise program
• Teach pacing, and pain control strategies as well as how to deal with a flare up of symptoms
• Use taping, splinting etc as indicated
• Provide education to patients as indicated. There are many different forms of this (e.g. pain physiology education).
• Offer counseling skills and various behavioral interventions (e.g. Cognitive behavioral therapy), however these are frequently outside the scope of practice for many
• Refer on to another professional when they are unable to help. Ideally this would be done very quickly in the assessment - rehab process.

Once again, I need to stress the importance of not applying passive techniques inappropriately and out of context as well as giving information, or other passive supports (including rest) to patients which could negatively influence the outcome (e.g. instill fear or the need for inactivity).

We do demonstrate many of techniques and strategies on our courses to help show how you can integrate your skill set into your clinical practice, but what we do should not substitute for other full length continuing education courses. You should endeavor to continue to learn throughout your career. The SMARTERehab Concept can be used a template for clinical reasoning to help you apply your new learning more appropriately.

Sean GT Gibbons BSc (Hons) PT, MSc Ergonomics, PhD (c), MCPA