How/When to Discharge Patients?

Welcome back to our latest blog where we begin to ask the question:  Is the end > the beginning when it comes to rehabilitation of our patients?

There is no denying that the initial evaluation and assessment may be one of the most important things we do every day as healthcare professionals.  Understanding and empathizing with a person who is in pain is of utmost significance when determining how to treat that patient, what to treat, why is there pain in the first place, and if that person is even a candidate for our services.  But what about the discharge process?  Is it just as important to have a system to determine when that patient is actually ready to “leave” you?  Expanding on that notion, is it also important to measure "function" with more than manual muscle testing and range of motion numbers?

If you have read our earlier posts you have heard us reference the old discharge phrase, “How does it feel?”.  Those 4 words have guided (and still guide) most of our decision making process to determine when a patient is ready to progress, return to sport and/or discharge from rehabilitation.  When I was recently at a FMS (Functional Movement Systems) course they showed a computer generated graphic of a jump landing on a patient who had “finished” rehab.  The patient was a teenage girl who had undergone ACL reconstruction and was now returning to sport participation.  She was not only discharged by her treating therapist she was cleared by her MD, however, the results of the graphic were rather alarming.  Her surgical leg looked fairly solid - good control of ground reaction forces, no noted dynamic valgus or increased heel lift, etc.  The other side was startling.  Her “good” knee demonstrated significant valgus collapse, tibial rotation, and pronation/heel off with weight acceptance and loading after a simple 2 legged vertical jump in place.  To make this story even worse, she needed a second ACL reconstruction.  Can you guess which leg?  If you guessed the one that was ALREADY surgically reconstructed you would be 100% correct.  But how did we miss the significant deficits on her "good" leg?  As Mike Boyle states we cannot “prevent” injury, after all LIFE itself is a contact sport, but we can significantly reduce the likelihood of it occurring (or recurring).  So what can we do to catch these deficits?  Have a system!

At our clinic, prior to discharge, we attempt to run everyone through an FMS Screen.  Utilizing the screen we can determine asymmetries and/or noted significant deficits in global movements.  If the patient can achieve an acceptable score (>14), and more importantly does not demonstrate side to side differences (aka asymmetry) we can move on further to specific testing with a Star Balance Test for the Upper or Lower Extremity (depending on the treating diagnosis).   The old paradigm of restoring 80-85% of strength and power on an involved limb may be out of date.  Currently it seems that a minimum of at least 95-98% symmetry is the best way to protect against recurrent injury, this not only holds true for the STAR test but for jump and plyometric testing as well.  When that is evaluated and trained we can then assess and move on to “Sport Specific” Testing such as push up testing, timed agility and endurance assessments, planks (front/side/variations), and whatever you determine is a “sport specific” test.  The beauty of the sport specific testing is just that - they can be specific to the patient in front of you - regardless of what "sport" they participate in.  They can also be incorporated as functional tests and measures in any personal training program.   Here is a quick video of some easy functional discharge/performance tests you can use with your clients:  

In order they include:

  • Tall Kneeling Chest Pass:  Measure the distance between your client and the wall to monitor progression in UE Strength and Power Output
  • Plyometric Ball Chop:  Assess distance between R and L sides.  Can your client reach the wall on a "bounce" evenly on both sides?
  • Prone Reach/Endurance Taps:  Time client for 20 seconds (Can be done if varying positions including quadruped and plank)
  • Single Leg Depth Jump/Land:  Monitor for valgus and weight acceptance between R and L.  This test has directly been linked to recurrent ACL tears
  • Depth Land to Plyometric Jump:  Building off previous assessment can your patient now transfer ground reaction forces and react/create movement more closely linked to sport specific movements
  • Pistol Holds:  Global measure of LE mobility (Which as Dr. Andreo Spina would say is simply a combination of flexibility and strength)

So whether you're a firefighter, football player, muay thai fighter, track and field athlete or the weekend warrior we can not only develop an appropriate rehab strategy but an empowering discharge process to reduce the risk of injury and keep patients doing what they love!

Does your clinic have a discharge process?  What sport specific tests/screens have you found beneficial in determining injury risk and or asymmetry.    

Until next time, Happy Rehabbing!


References:

Bodden, J.G., Neddham, R.A. & Chockalingam, N. (2013) The effect of an Intervention Program on Functional Movement Screen Test Scores in Mixed Martial Arts Athletes. J Strength Cond Res.  

Butler RJ, Contreras M, Burton LC, Plisky PJ, Kiesel KB. Modifiable Risk Factors Predict injuries in Firefighters during Training Academies. Work. in press.

Cook G, Burton L, Hoogeboom B. Pre-Participation Screening: The Use of Fundamental Movements as an Assessment of Function – Part 1. N Am J Sports Phys Ther. 2006a; 1: 62–72.

Cook G, Burton L, Hoogeboom B. Pre-Participation Screening: The Use of Fundamental Movements as an Assessment of Function – Part 2. N Am J Sports Phys Ther. 2006b; 1: 132-139

Kiesel K, Plisky PJ, Voight M. Can serious injury in professional football be predicted by a preseason Functional Movement Screen? N Am J Sports Phys Ther. 2007; 2(3):76-81.