Physical therapists are movement experts. We analyze movement dysfunction caused by pain, injury, or illness and then we formulate a plan of action to improve functional mobility and improve the quality of life of our patients.
The most important aspect of our job, in my opinion, is the clinical examination. We sit with our patients and ask appropriate questions to understand the problems that our patients face. We then select appropriate tests and measures that can help us understand the nature of our patients' movement dysfunction. From the information gathered during the clinical examination, we can then work with our patients to improve the impairments that may be causing the functional mobility loss.
Many patients ask me about the importance of looking at MRI and x-ray pictures. While these diagnostic studies can shed light on some problems, they really don't help me too much in my practice. In fact, it seems to me that when a patient has an MRI and then goes to see the doctor about the results, little or no time is spent on a clinical examination. All eyes go the magical picture of the MRI, and very little attention is given to the patient.
Here's a little (totally true) side story about the importance of the clinical exam:
Rewind to 2002. I am a physical therapist working in an outpatient clinic. I've been a P.T. for about a year now, and I am starting to feel pretty confident in my abilities. My boss has an aunt who had developed leg pain just below her calf. She is having a difficult time walking, so her doctor sends her to physical therapy. I am the one who preforms her initial evaluation.
My patient arrives and we start talking about her pain. She is about 70 years old and has had calf and foot pain for about a week now, and she can barely put pressure on her leg. This is limiting her ability to walk. She went to her doctor and an ultrasound was performed to rule out a deep vein thrombosis (DVT). A DVT is a dangerous thing. It is a blood clot that can travel to the lungs or heart and can cause sudden death as a result.
My patient reports that the ultrasound taken was negative for DVT. So here she sits in the physical therapy clinic with a diagnosis of non-specific leg pain. My clinical exam reveals swelling and redness from her mid calf down to her foot. There is extreme tenderness to touch in her calf, and squeezing her calf sends her through the roof in pain. (The calf squeeze is called Homan's sign, and exquisite pain as a result of the squeeze is a sign of a possible DVT.) Her range of motion and strength are normal in the leg. Just a bit painful.
All signs here are pointing to a DVT. But her ultrasound was negative. Something is not adding up. I telephone her doctor and inquire about the ultrasound. Her doctor assures me that the ultrasound was negative for DVT. He recommends that I try some heat on her calf to help.
I return to my patient who, as you may recall, is the aunt of my boss. I tell her that I suspect that she has a DVT and I would feel much better if she reported to the emergency room for a repeat ultrasound. She seems a bit confused, since she already had an ultrasound and it was negative. I told her that my clinical exam is telling me that she may have a DVT, and I would feel much better if she has a repeat ultrasound. Both my patient and my boss think I am a bit crazy at this point.
A few hours later the phone rings in the clinic. It is my patient. The ultrasound was done again. It shows that she has a DVT.
Now had I trusted in the first ultrasound and listened to her doctor and just put heat on her calf, her situation may have become really bad. But my clinical exam led me to believe that my patient had a DVT, and my training told me that physical therapy was not the correct treatment for this particular patient.
Don't get me wrong. I sometimes look at MRI or x-ray reports and pictures. They are fun to look at and patients like it when you take time to explain the things that you are seeing in the pictures. But diagnostic studies should never take the place of the clinical examination. I often tell my patients that MRIs are like a picture of a telephone: you cannot tell if it is ringing or not. Diagnostic studies do not tell me what to do to help my patients move better.
Your physical therapist is a movement expert. He or she is trained to help you feel better and improve your functional mobility. Make sure that you receive a thorough clinical examination when you see your therapist. It is the most important aspect of your rehabilitation, and it can help you return to normal mobility quickly and safely.
