By Jared Rumsey and Joe Gagliardo
Dr. Craig Liebenson
Dr. Craig Liebenson is a chiropractor, author, and expert in rehabilitation and sports medicine. He created the patient profile and assessment to provide clinicians with a systematic approach to understanding patients' needs and guiding their treatment. Dr. Liebenson emphasizes the importance of establishing patient goals, determining baselines, and addressing mechanical sensitivities to create tailored rehabilitation programs that promote optimal function and pain reduction. His approach aims to improve patient outcomes by identifying and addressing the underlying causes of musculoskeletal issues.
Dr. Kate Rozborski
Dr. Kate Rozborski is a chiropractor with expertise in rehabilitation and sports medicine. She has received training from Dr. Craig Liebenson, a prominent chiropractor and expert in musculoskeletal rehabilitation. Dr. Rozborski has participated in Dr. Liebenson's seminars and workshops, which focus on functional assessment, patient profiling, and evidence-based treatment strategies. Through this training, Dr. Rozborski has gained valuable insights into optimizing patient care and promoting functional recovery.
What is Patient Profiling?
Patient profiling is a system in which we build connections with patients and get to understand the underlying issues they have. When performing this profile as a practitioner you need to have manners, introduce yourself and make them feel comfortable. If a patient is nervous, help alleviate their nerves by connecting with them and reassuring them that you will help them get better. While doing this, you need to find an equilibrium between letting the patient talk freely and building a bond with them along with keeping them on track with the profile system. Speaking of keeping on track to the patient profile, let's get into its structure.
The 12 Steps of Patient Profiling
- Chief Complaint (CC)
- What brings you in today? Find out what has been bothering them and get a basic foundation, or baseline, of what is wrong.
- Onset
- When did this occur?
- The length of an injury is important because, as Dr. Rozborski iterated, “Pain is multifactorial: With injury time increasing we will see more factors come into play.” Some factors she said are associated with injury are: social stress, financial stress, poor sleep, poor hydration and nutrition, not exercising. These will all play a role in pain.
- Mechanism of Injury (MOI)
- How the injury occurred, most of the time patients won’t know how it happened, but if they do then this is very insightful into what may be going on with their injury.
- Imaging
- Imaging is a very useful tool to confirm what you have found through your assessment of the patient. But Dr. Rozborski recommends taking imaging “with a grain of salt” because if you imaged someone who isn’t experiencing pain, 9/10 times you will find something on imaging that is incorrect, such as a bulged disc. But if this abnormality isn’t causing pain, a painless dysfunction, then it shouldn’t be the main focus. More so, if they have pain in their shoulder, and not in their disc bulge in their spine, you should help them with the shoulder pain first and then work on the spine afterwards.
- Past Medical History
- The greatest predictor of injury is previous injury. By understanding their past injuries we can help connect the dots and figure out what is going on.
- Yellow Flags
- These are the patient's fears, worries and beliefs. Things that are driving pain are usually neural, and by eliminating these yellow flags; by increasing the amount of confidence a patient has that they can move without pain, the more likely they are to get better.
- Activity Intolerance
- The activities in a patient's daily lives that cause pain can give a great deal of information as to what is going on with the injury. Such as, pain when they walk over a block, pain when sitting, shooting pain down the leg when they go from sitting to standing, etc.
- These intolerances are also a great way to develop goals and show progress. If a patient can only walk a block and then develop pain when they start, then the goal is to be able to walk two blocks before the pain starts. When they can walk two blocks before they develop pain then they know that they are making progress.
- Past Treatments
- By understanding what treatments they’ve had in the past can help you in your treatment of them.
- If the past treatment they had didn’t help them, then you know to try a different approach to your treatment of them.
- By understanding what treatments they’ve had in the past can help you in your treatment of them.
- Medications and Supplements
- Knowing what medications your patients are on is essential. Both for setting baselines and to make sure you’re prescribing them the correct level or intensity of exercise.
- For baselines: When they start coming to you and are taking four ibuprofen a day, that is their baseline. But after a month with you they are only taking two ibuprofen a day. This shows the progression of pain decreasing.
- For exercise prescription: You as a practitioner have to know what medications they are taking. For example: if they are asthmatic you need to know that in case they have an asthma attack and need to have their inhaler on deck. Maybe they are on a beta-blocker, slowing the heart rate (HR). If you’re prescribing exercise intensity via HR, then you have to know that their HR is going to be lower than normal and you can’t calculate their intensity for a normal HR.
- Dr. Rozborski recommends that you take creatine and collagen.
- Creatine to help with energy levels, due to the creatine kinase reaction within the musculature, and many more reasons.
- Collagen to promote the healthy growth of muscles. It’s one of the many things needed to build muscle and acts as a building block for this process.
- Knowing what medications your patients are on is essential. Both for setting baselines and to make sure you’re prescribing them the correct level or intensity of exercise.
- Relevant Orthopedic History
- Does this patient have osteo- or rheumatoid arthritis, do they have a hot or bulged disc, are they experiencing any joint pain?
- These are all things that will affect how you prescribe exercise and individualize an exercise program.
- Does this patient have osteo- or rheumatoid arthritis, do they have a hot or bulged disc, are they experiencing any joint pain?
- Mechanical Sensitivities (MS)
- These are what we look for during the assessment portion.
- MS’s are things such as tightness, pain or asymmetries.
- These are what we look for during the assessment portion.
- Abnomral Motor Control or Painless Dysfunctions
- This is when an exercise movement form or alignment of a joint isn’t correct but doesn’t elicit pain.
When should you perform this test?
This evaluation of the patient should be performed for a couple reasons. You should do it as an intake evaluation, when the patient first comes to you, so you can develop a connection and a baseline for them. This allows you to develop a deeper understanding of what is going on with their injury, and how it affects them in their daily life. It should also be performed as a means of re-assessment if a patient's condition seems to be worsening, allowing you the chance to catch something you may have missed the first time, or see if the injury has changed in itself. By understanding and implementing the evaluation correctly you will be able to identify and correctly treat a patient's injury. After you have finished the Patient Profile portion of the examination, you should move into the assessment portion of the evaluation.
Assessment
Principles
There are a few principles of assessment, but they are essential to the success of the assessment and treatment. The first principle is reassuring the patient that hurt does not equate to harm. The movements will most likely be uncomfortable for them, but that is expected and is okay. This is very important; make sure to tell them that a pain level of anything lower than a 4/10 is okay, but if it’s ever a 4/10 or higher then they need to stop the movement and you will need to find a different exercise for them to perform. Make sure to reassure them that a little pain is okay and that it’s essential for development of strength. The second principle is to move well and then often. You need to help them correct their movement patterns before they start moving or exercising a lot. This will help prevent injury and promote muscular development in the correct musculature. The final principle is to add load. Once the patient has completed the first two principles then we can start to push them by adding load and making them stronger. It is essential that you address and implement the first two principles before you even think about the third principle.
Assessment Goals
Goals play a crucial role in rehabilitation, serving both the patient and the practitioner. Patient goals are instrumental in maintaining their commitment to the rehabilitation process, while the practitioner's goals during assessment are multifaceted: they aim to establish baselines, develop specific patient goals, and support the patient in achieving those goals.
Determining Patient Baselines
Establishing the patient’s baselines is pivotal for monitoring progress and setting achievable goals. These baselines serve as reference points for tracking improvements throughout the rehabilitation process. Key metrics include identifying instances of cramping during exercises and noting the specific repetitions where it occurs. Observing pelvic shifts during movements provides insight into alignment and stability issues. Assessing for neck pain or tightness helps gauge any discomfort in that region. Additionally, determining the patient's comfortable number of repetitions and identifying any strength deficits or imbalances, such as disparities between sides, further informs the treatment plan and facilitates targeted interventions for optimal outcomes.
Showing Baseline Improvements
Communicate improvements in baselines to the patient. For example, if a patient initially can only do 10 calf raises before experiencing cramping, but later can do 15 calf raises before cramping, it demonstrates progress. Thus as practitioners, we should convey this progress to the patient. As it will help motivate them to continue their efforts towards recovery or improvement and help reinforce the effectiveness of the treatment plan, empowering patients to stay committed to their goals.
Identifying Mechanical Sensitivities
Mechanical sensitivities encompass anything that irritates the patient physically or neurally. To establish these, assess where the patient currently is and where they want to be. With this information, create SMART goals (Specific, Measurable, Achievable, Relevant, Time-Bound). For instance, continuing the example from above, if calf raises are identified as a mechanical sensitivity, training in this area can help the patient reach their overall goal of walking a mile throughout the day within six months of starting their exercise program.
By accomplishing these goals, practitioners can effectively guide patients through rehabilitation, tailor treatment plans to their needs, and monitor their progress over time.
Flow
The assessment process adheres to a structured flow aimed at comprehensively evaluating the patient's condition. Initially, through observation, practitioners keenly scrutinize the patient's movements, noting any deviations in gait or discrepancies in hip and shoulder levels. Following Dr. Stuart McGill's recommendation, an additional method involves intentionally dropping an object to observe the patient's picking-up technique, providing valuable insights into their movement patterns. Subsequently, palpation allows for a hands-on examination to assess muscle tightness, warmth, swelling, or bruising, providing tangible indicators of potential injury. Moreover, assessing tissue temperature aids in identifying areas of inflammation or swelling, crucial for understanding the extent of the injury.
The assessment then progresses to evaluating the patient's range of motion (ROM), aiming to identify deficits in joint mobility and any accompanying pain, which offers valuable diagnostic clues. Manual muscle testing further delves into sensory and motor function, aiding in the detection of neurological deficits that may contribute to the patient's condition. Specific orthopedic or special tests, such as the Thomas test or straight leg raise, are then employed to pinpoint the precise issue. Transitioning to functional tests or movement preparation, practitioners identify the most challenging yet pain-free movements for the patient to practice at home, aligning with the concept of "movement snacks." These exercises target smaller issues to address larger problems, enhancing overall function and reducing pain. Additionally, focusing on movement preparation enhances general physical preparedness (GPP), preparing the body for more complex movements while strengthening specific areas like the core and grip strength. This systematic approach ensures a thorough evaluation and sets the groundwork for targeted rehabilitation and progress.
