Q&A Time!: Discharge Considerations | Modern Manual Therapy Blog

Q&A Time!: Discharge Considerations

I get this question from patients as much as I do other clinicians. When is an appropriate time for discharge and what do I instruct on the graduation day?

I like my patients to be at least Sx free in all ADLs for 1 week prior to me discharging them to home program. When they are initially Sx free for at least 48 hours, I will check to see if it is safe to start the Recovery of Function phase of MDT.

  • check the painful/limited motion of the DP
  • it should be full and painfree for all reps
  • check the opposite direction that would have re-deranged the first motion 10-15 times
  • re-check the DP, if it is still full and pain free, the derangement is stable
  • reintroduce the motion opposite the DP (often flexion) that the patient has most likely been avoiding for weeks
  • always follow these movements with the DP exercises
If I was not using an MDT approach, I'll run them through the SFMA to look for dysfunction and/or pain or the FMS to look for asymmetries. For the FMS you're looking to at least make the tests mostly 2's with hopefully a 3 or so. Not everyone has to be a 3 in all movements (perfect score).

For patients who ask, "So, what am I supposed to be doing now?" I think the answer to this is quite simple. Whatever I had told you to do in the past. Patients expect, and perhaps this is the fault of other well meaning clinicians, that you are going to inundate them with extra instructions/education/exercise on the final day. I told someone today, "If I give you extra exercises now, how will I monitor their effect on you if you this is your discharge day?" Whether it was MDT or corrective exercise, I just make sure they have their own self audit, a movement, test or functional activity that if limited, they would know they need to double down on the exercise or movement that corrects it. 

The last important discharge educational piece is when to call or schedule another visit.
  • I always internally market toward the end of a patient's visits by asking, "Is there anything else you would like us to help you with?
    • even though I always ask about "anything else medically that you need to be addressed that you're not necessarily here for?" on the first visit, this question still gets some patients to come back immediately to address their knee problem when they were originally referred for a cervical spine issue
  • I also educate them on the research stating that treating an acute cervical or lumbar problem is easier within the first two weeks
    • If your symptoms begin to return - are you still doing your ther ex (that you were supposed to be doing forever)
    • double down on your HEP
    • if your symptoms start to improve or motion increases, etc, you do not need to call
    • if your symptoms are not able to be controlled by your HEP, or they are not improving after 1 week, call immediately and we'll get you in
    • do not call your MD, go to emergent care, come straight to us without referral
    • many patients are still surprised at our direct access, use it if you have it!
Do some patients stay on for maintenance? Sure, they are often private pay and come in as needed. Most of them are marathoners/runners who need a tune up now and then and come once every 3-5 weeks depending on their training schedule. 

After a patient has an exacerbation, I fully expect if they come in during the acute phase, it should be a 2-4 visit outcome as long as they kept up with their HEP as the groundwork for correction and manual work was already done. This is of course as long as it was within a reasonable time frame from discharge. Hope this helps with some of your questions. What are some of your discharge guidelines?

1 comment:

  1. You make good points here E. I do too go without symptoms for a week as a general guidlenine. Pending their frequency from the start (due to work, financial issues with co pay, etc); I usually get them to try things on their own for at least a week too without me performing manual or even supervision and correction with exercises in the clinic.

    We also have a self pay wellness program that I don't necessarily push (mainly bc we are in a rural area and not a lot of money flow) but do give as an option down the road. No contracts, just come as needed. They seem to appreciate this more.

    And of course Direct Access. I push this heavily. I have seen high numbers over the years, always with good results.

    I provide a piece of paper (it's color, well written and informative) to give to them listing these 3 options (Direct access, wellness and simply return to our MD), as well as what to do now with HEP.