Subjective Subjective

In most, if not all, medical evaluation rubrics, it is taught that the subjective is the most important part of the evaluation.
Becoming ingratiated into the movement-based approach over the last several years, I have found this to be not nearly as true as some suggest.
In fact, I’ve come to think that at times it is the least important piece of the evaluation, or perhaps better to suggest the most misleading in terms of clinical decision making.
I mean how many times does the person with knee pain tell you that their hip is all jacked up but doesn’t hurt, and that’s where they need coaching?  Or I’m still waiting for the runner to come in and tell me their Superficial Back Line is linking their neck to their plantar fascia.
The subjective is a crucial portion of the evaluation, but not necessarily for me to decide how to help or train the individual.

One of the more legitimate and respected editorial pieces on Regional Interdependence in the literature.

Sometimes there are things other than the need for terminal knee extension in here.

Far more than the patient or client’s impression on their condition, which is honestly just based on their non-expert perception, I am much more interested in what they want out of the training exchange.  Training and rehab are in the service profession, so in the end, I see my role of the coach or clinician to provide what the person wants.  Some of us are more privileged to not have to deal with individuals that think they know how to get what they want, but in the end, I think it’s our job to provide results.  I have been lucky in my career that when someone tells me, “I know my body,” I also know that when it’s 4th and 8, the right move is to punt the individual right out the door.

I hate people that don't punt on 4th down, but I don't hate punting patients.

So herein lies the first question I ask every person I see for the first time.  I ask, “So, how can I help you?  What’s going on that I can help with?”
I have to know what they want in the end.  The details will sort themselves out, but we need to know where the end of the tunnel is before deciding on the best route to get to the tunnel, through the tunnel, and doing it all safely and efficiently.
This is the most important piece of the subjective for me.  I need the person to know that I care about what they want……….even if I really don’t care how they want to get there.

Obviously we are going to go through having the individual describe their pain, what makes it worse or better, how long it’s been going on, etc.  If it’s training, what have they done in the past, what they enjoy doing, is there a definable event or season we are training for.
The pain stuff is more in the common sense piece for the medical evaluation, and the definable event piece is more useful in terms of periodization for the most efficient route of training.
But whether it’s training or rehab, I will likely always ask the following questions…..
1.  So even if you think it’s totally unrelated to what we just talked about with your <painful segment or goals>, do have any (other) current injuries or aches and pains anywhere?
–We’ll run through the whole body, and they ask, it’s a simple response.  Everything’s connected, and everything matters.
If there is a history of a recurrent ankle sprains, is it a surprise that the person is looking for help with knee pain?  And do we not automatically need to also start thinking about intervening with the ipsilateral hip?  And if we’re training, are we not already expecting to see asymmetries in the FMS?
The goal here is to start to either open the curtain to a regionally interdependent approach where rehabilitation of a non-painful area may be the answer and/or that training isn’t chest and tri’s on the finest selectorized machines money can buy.
I think this also separates the clinician from others that the person has worked with.  I think people like “whole body.”  They like “holistic” maybe without saying that word.  They understand that the body compensates in other areas, even though particularly in rehab, most physicians, PTs, and chiros, both don’t know and don’t care about regional interdependence.

Don't talk to me about your low back pain and not talk about your head and t-spine entering the room 5 seconds before the rest of your body.

2.  Do you think you have good balance?
–We’re going after 2 things here.  If they say they have good balance, and they don’t, I’ve found it makes the client a little more deferred and open-minded to training in ways they haven’t done or seen before.
The other route is simply that folks that do admit they don’t have good balance are usually very receptive to understanding that mobility in distant areas is important.  Everybody seems to find balance of value.

3.  Do you think you have good flexibility?
–Same thing as balance.  In mentioning something that you know the person values, I think it further supports the “they know you care” value to the subjective evaluation.  If the person knows you care about them having things they don’t currently have, they will go to work for you.

Are you flexible? Do you have good balance? Do you train on machines or do crunches?

4.  Tell me how you train.  Practice.
–I want to know what I’m up against here.  How much undoing of garbage do we have to do, not just in the body, but in their mind.
I’ve said many times, I ain’t half bad at convincing other people I’m right.  But I am not very good at convincing other people they’re wrong.

5.  Do you have any medical situations that impact training hard?  Social/life situations?
–Certainly finding out about having to take insulin at certain times of the day before training would be a good thing.  But beyond the impactful medical stuff, respecting non-physical stressors is an enormous part of the training picture.

Ultimate Stress Analysis.

To bottom line it, the goals of the subjective for me are 1) the person has my confidence, 2) the person knows I care about them, and 3) the evaluation and training process may not be what they think.

  • November 28, 2011

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Brad Cole Reply

I’ve read some others discussing how the patient’s report only muddies the diagnostic waters, threatening to sidetrack a thorough kinetic chain assessment. But I was glad to read your post describing the importance of establishing rapport and goals before jumping into the assessment. In addition, the patient interview should answer the question “what hurts”. (Is it functional hip pain or infectious hip pain?) Confirm the working diagnosis with physical exam, then (if it’s functional pain) jump into a thorough kinetic chain assessment to answer, “why hurt?”
Great blog. Thanks for sharing your thoughts.

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