Are You Creating the Problems Yourself? Tips for Physical Therapists on Formulating Problem Lists

Hello.
This is Chiyone.

Identifying problems is extremely important when formulating a physical therapy program, but many new physical therapists struggle with this.

While you learn the basics during clinical training as a student, once you enter clinical practice, you are often troubled by a wide variety of patterns.

In my experience, I believe there are two main reasons why new physical therapists and rehabilitation therapists struggle with formulating problem lists.

In this article, I would like to examine why people struggle with identifying problems.

Identifying problems in physical therapy means putting the cause of a patient's distress into words.

For example, suppose a patient comes to the clinic with the complaint that they cannot walk for long periods because their knee hurts.

We physical therapists evaluate the patient based on the ICF (International Classification of Functioning, Disability and Health) and formulate a list of problems.

Rehabilitation consists of resolving those problems, but if you cannot identify the problems well, you will not be able to determine what kind of treatment to develop.

You need to proceed based on the flow of: what is the patient worried about? → what is the cause of that worry?

Whose problem is that?

At the beginning, I mentioned that there are two main reasons why new physical therapists struggle with identifying problems.

One is not being able to hear the patient's true problem.
The other is you, as the physical therapist, creating problems on your own.

These are the two points that can be considered.

Case 1: Not being able to hear the patient's true problem

I will give a common example.

For instance, let's say there is a patient who cannot squat.

Suppose that as a result of the physical therapist's evaluation, they considered the limitation in the knee joint's range of motion as the problem.

As a result of performing rehabilitation, the range of motion limitation improved, and the patient became able to squat.

When I ask patients if their daily life has changed, they often reply that it hasn't changed much.

Upon closer questioning, it turned out that the patient had no opportunity to squat at all.

Case 2: You, the physical therapist, are creating the problem

Don't you sometimes see rehab therapists like this?

Patient: "I don't have any problems anymore regarding the knee I had surgery on."

Physical Therapist: "But the muscles here are still weak! Let's train them!"

~A few days later~

Physical Therapist: "How is it? Has it improved?"

Patient: "Hmm, I don't think it has changed much."

Physical Therapist: "In that case, your training is still not enough!"

Is this muscle weakness really a problem?
This patient does not feel any particular problem, and just because their muscle strength has increased slightly does not mean anything will change.

In this case, it is possible that the physical therapist or rehab therapist is creating the problem on their own.

Problems change significantly depending on how you perceive them

Problems can be created indefinitely depending on how you look at them.

It is the difference between seeing a glass with half the water in it as "still half full!" or "only half full..." (Reframing effect).

In terms of rehabilitation, this can be applied to what you consider a problem regarding muscle weakness or limited joint range of motion.

For a patient with hip abduction MMT of 4, this would be sufficient if the goal is to acquire walking ability. However, it might be insufficient if the goal is to return to sports.

I believe it is important to provide sufficient explanation regarding how the patient and the physical therapist think about this.

Conclusion

To formulate problems, the perspectives of both parties must be aligned.

In Case 1 above, a lack of explanation by the physical therapist or rehabilitation therapist is likely, while in Case 2, a lack of understanding by the physical therapist or rehabilitation therapist is likely.

In such a state, identifying problems will not go well either.

I would like to communicate thoroughly and share what the goals are.

I am rooting for you.

Thank you for reading until the end.
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Let's do our best together.