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Toni Talks about PT Today

Very Acute Therapy

Published April 9, 2012 4:40 PM by Toni Patt

This week I found myself at an outpatient orthopedic clinic treating work-related injuries. The clinic was one of several in the area. They have agreements with many local industries to provide medical and therapy services to injured employees. The injured worker sees the doctor at the clinic, is given a script for therapy and starts as soon as possible.

The majority of patients I evaluated were between one and two days post-injury, with six visits ordered. There is still ample chemical pain around the injury that pain response is unreliable. The presence of acute chemical pain means nothing is going to significantly decrease the pain and everything is going to hurt. Most of the diagnoses included the word strain. That wasn't very helpful.

Most of these people were still working. After therapy they would often go right back to doing something that would make them hurt. Light duty for them didn't mean sitting at a desk or filing. It meant doing the same job with lifting or positional restrictions.

I was taught to rest acute injuries and use modalities for pain control. When I was learning the McKenzie method, we were told to wait at least a week before evaluating back injuries. The only exceptions were postural training and flexion avoidance when appropriate. The six visits were spread over two to three weeks. They would be halfway through therapy before a real assessment could be completed.

I don't know why there was such an emphasis on starting things so early. Obviously the employer doesn't want to lose valuable worker time to injury. Starting sooner would seem to imply being finished sooner. Movement heals but you don't want to move someone too early and cause an injury. I can see the point of gentle movements initially but continuing to work sort of defeats the purpose.

I've read some literature talking about having PTs in the emergency room. The purpose was for gait training, education and screening some patients for safe discharge home. That makes sense to me. Maybe I'm completely missing the boat on this one.


Early intervention is key!!  Sure, the focus is different is such acute cases.  I'm initially using modalities, stretching, soft tissue mobilization, etc just to get pain under control.  But, starting with pain control, proper alignment and mechanics sooner means you will be able to progress towards strengthening sooner.  If your patient is going to return to work the same day, that's a great opportunity to review proper lifting strategies, abdominal bracing, or other protection techniques.  

By the time I see a patient who was injured weeks ago they have already established altered movement patterns and that makes it harder for me to correct the underlying injury.  It's the same mentality of working with very acute stroke patients.  The earlier you can intervene, the more likely a patient can restore normal movement and strength.  

PTs in the ER do more than just screen for home safety.  There are many PTs who do acute manipulations, mobilizations, and other treatments for pain control.  It is really amazing how quickly a patient's pain can be reduced with a few quick treatment strategies.  

PTs in all settings need to educate providers on the benefits of early intervention.  

Lisa Mueller April 10, 2012 8:59 AM

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