As a Physical Therapist, I enjoy having PT students with me in the clinic, but I’ve found that there’s one common mistake that almost everyone makes. In fact, it’s a mistake I made, too, when I was a student physical therapist.
If you’re in PT school and about to start your clinical rotations, avoid making this mistake by learning from my experience.
A Trip Down Memory Lane: Me as a Student Physical Therapist
Let’s rewind to the days of young Tim, a fresh PT student in clinical rotations. There I was, wide-eyed in my blue polo and khaki pants. I looked like a PT, sounded like a PT, and was ready for anything…or so I thought.
I quickly discovered that it’s one thing to simply stand next to the clinical instructor as they guide the patient. It’s quite another when they invite you to take over the patient’s treatment. I went from feeling like I had a good grasp of PT to feeling like I had been marooned on a desert island, especially when it came to choosing the right exercise at the right time.
To make matters worse, I wasn’t always sure how to properly grade the exercise. I erred on the side of caution and was really conservative with exercise progressions. Being cautious isn’t necessarily a bad thing, but too much caution may fail to challenge the patient during their appointment.
By contrast, since becoming a PT I’ve seen students make the same mistake in the opposite way. Unsure how to progress the patient appropriately, many students choose exercises that are way too aggressive or challenging for their patients.
If you identify with these scenarios, don’t feel bad. Grading exercises takes time and practice, and it’s something that I had to learn as well. To help you get a head start, here are 5 tips for progressing exercises in the clinic.
#1: Start Your Assessment Immediately
You don’t always have to wait for an interview to learn how your patient is feeling. Their body language will tell you, long before you’ve had a chance to greet them.
Early in my career I got into the habit of starting a patient’s assessment immediately. As soon as my patient enters the clinic, I take note of pain indications such as their gait pattern as they walk into the room or their shoulder mobility as they take off their coat.
Next, I always try to lead with a question that ties in a functional task, such as: “What kind of things this week were easier to do around the house?” Or, “What are you still struggling to do at home?”
If they answer with “Going up and down stairs” or “Getting in and out of the car,” then I already have a great start on my subjective notes. Plus, these responses will lead me right into the objective section of my notes, since now I know to focus on exercises that are directly related to those functional tasks. Not only does an immediate assessment kick-start the treatment session, it can also help you stay on top of your documentation. (For more tips on writing documentation faster, check out this article!)
As PTs, one of our most valuable soft skills is observation. If you notice something unusual in how your patient is carrying themselves, or if there is a clear indication of pain in their walk or stance, then you’re already a few steps ahead in getting them assessed, treated, and back to normal.
#2: Start Simple—Especially for the First Follow-Up
It’s tempting to jump into challenging therapy and think you’re boosting the patient’s progress. But if this is your patient’s first follow-up appointment, you may have better luck sticking with simpler exercises. You don’t want the patient to overdo it on their first visit, experience increased pain, and decide physical therapy isn’t worth the effort.
Let’s say I’m treating a patient for knee pain from arthritis. On their first visit after the initial evaluation, I may not know exactly how they’ll respond to a full treatment session. But I know I shouldn’t blow past the simple movements just because they seem easy.
Simple movements are the building blocks of PT. For example, a single-leg stance will help my patient work on balance and stability, while step-ups or side-stepping provide a scalable challenge that we’ll return to again and again. Ultimately, the balance and stability exercises will help my patient work on alignment and muscle activation early on in their treatment.
Simple movements are motivating!
Another reason to use “easy” exercises in the first follow-up is that they help boost a patient’s morale. Simple movements are generally more familiar and easier to grasp than advanced exercises, and the patient will feel more encouraged as they achieve a few small wins on their first full day.
Granted, the patient will ultimately need to be challenged in order to get stronger. But as the saying goes, Rome wasn’t built in a day, and the body doesn’t rehabilitate in one session. Start with the basics and build from there.
Finally, don’t make the mistake of assuming that, because a patient is young or athletic, you should jump to more advanced exercises right away. By doing so, you may miss out on the opportunity to identify small movement patterns or necessary corrections before moving on to advanced exercises.
But when you are ready to advance the exercises, keep in mind the next tip.
#3: Economize the Exercise
Imagine what it’s like to follow your own exercises, and whenever you prescribe one, try to think of 2 or 3 other exercises that you could seamlessly perform after it.
For example, if you’re working on a single-leg stance at a countertop or parallel bars, what other movements can you have your patient do there too? How about a tandem stance with reaches, or cone taps on the airex pad, or even step-ups to that airex pad?
Economizing the exercises helps the patient in a few ways. First, if movement is painful, they don’t want to be dragged around the clinic simply because you didn’t think ahead and program together movements that require the same equipment.
Secondly, it’s easier to remember exercises if they’re “chunked” in this way. Instead of 5 individual exercises, for example, it’s a balance series, or it’s an airex pad routine that the patient can do in one go. And thinking “around” the exercise will help you be more creative and flexible whenever one of the movements doesn’t work for your patient.
Side Tip: Use MedBridge to create your home exercise program
When you’re ready to assign exercises to your patient’s home exercise plan, a program like MedBridge Education will save you substantial time and energy.
With an exceptionally comprehensive library of treatments, MedBridge is my go-to resource whenever I need to create a home exercise program for my patients. It’s the best HEP builder I’ve ever used. Not only does it allow me to create HEPs on the fly at the clinic, it can also save past exercise routines for quick access through the program template tool. I love that I can upload my own custom exercises to MedBridge or request new ones to be made.
Best of all, MedBridge is delightfully user-friendly, especially among my patients. The MedBridge Go app allows patients to easily access their HEP on their mobile device at home or on the go. Plus, MedBridge gives each patient a special access code so they can watch videos of their exercises and make sure they’re doing them correctly.
Regardless of the HEP program your clinic uses, I recommend signing up for a personal MedBridge account when you graduate. With an annual subscription, you’ll have access to both their top-notch HEP builder and unlimited CEUs, which you’ll need for your license renewal. Use the discount code “PTProgress,” and you’ll save $150 on an annual subscription.
#4: Do Your Homework
Homework plays a vital role in the life of every student, so whenever I work with a student physical therapist, I give them the following assignment:
Write down a list of 15 different exercises you can do to treat 10 different situations, such as balance training, shoulder stability, or recovery from a total knee replacement or rotator cuff tear.
Certainly, there are hundreds of different exercises that could treat each ailment. But my challenge is to look around the clinic and build your list using the equipment and resources that are immediately available.
The point of this assignment is to develop quick problem-solving. When you’re with a patient in the clinic, you need to be able to quickly adjust or swap out an exercise whenever it becomes too painful, easy, or difficult for the patient. If you can improvise with alternative, effective exercises, you’ll become a much more confident and competent therapist.
Additionally, while reviewing this homework assignment with my students, I’ll often ask them how they would make each specific movement harder or easier. Knowing how to appropriately progress each exercise is an essential part of being a physical therapist.
#5: Get a Head Start by Using a Template
Hang around a physical therapy clinic long enough and you’ll start to see patterns in how we treat certain conditions. You don’t have to reinvent the wheel with every new patient, and many times you can use a template to guide which treatments you should start with.
Of course, every patient is different and deserves a customized treatment plan. I’m not saying there’s a cookie-cutter way of providing physical therapy—far from it! But there are instances when patterns arise. For example, if I’m treating a patient with a total knee replacement, I’ll probably use a very standard set of post-op exercises such as ankle pumps, heel slides, quad sets, straight leg raises, and mini squats.
You’ll learn these patterns over time as you encounter more patients more frequently. In the meantime, give yourself a head start by using a template. I created a set of Exercise Flowsheet Templates to help me generate treatment ideas and stay organized at the clinic. Feel free to download this flowsheet and use it for your next clinical. While you’re at it, check out the other templates I made to help improve documentation and expedite note-writing in the clinic.
Final Thoughts for the Clinical-bound Student Physical Therapist
PT school is no picnic, and neither is clinical work; there are some things only experience can teach. For me, experience yielded these five tips and helped me learn how to better grade exercises for each patient. With a few smart resources, such as the MedBridge HEP builder and my flowsheet templates, you’ll avoid making the same mistake I (and so many other PT students) have made and become a confident, autonomous PT in no time.
For more resources on navigating your budding PT career, check out the rest of the blog!
