Roni details the process of follow-up visits in her cash-based PT clinic. Roni explains her approach to patient greetings, subjective assessments, strength retesting, manual interventions, and targeted exercises. She stresses the importance of a test-treat-retest methodology and continuously reassessing a patient's condition. Roni also touches on the benefits of using AI for note-taking to enhance patient interaction. She concludes by encouraging listeners to provide feedback and emphasizing the importance of understanding the 'why' behind therapeutic exercises.

Welcome back to another episode

of the Rehab with Ronnie podcast.

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What's up guys?

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I'm Ronnie.

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I don't know.

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It's it's 4th of July weekend and

it's the end of it and I'm feeling.

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A little tired, but I have this

commitment that I made to myself

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to drop one episode per week for 52

weeks straight equaling a year of a

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podcast episode coming out weekly.

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And I'm not gonna, I'm not

gonna back down on that goal.

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So I'm here to deliver a solo episode,

and this is going to cover a subject

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that was requested by a follower,

and I thought it was really smart.

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In the past, I created an episode

called an initial evaluation at rehab

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with Ronnie, and I kind of walked

audience through what it looks like to.

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Be inside of an initial evaluation in a

cash-based PT setting, specifically in

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my cash-based PT setting, because I think

it can differ a little bit from your

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traditional outpatient clinic so I walked

you guys through that and she messaged

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me this follow in and said, Hey, I would

love to see what a follow up would look

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like in your clinic and what better time

to detail out that process than right now.

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I would like my disclaimer to be that

this is just the way I do things, and

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I think as you grow and figure out what

it means to be a physical therapist

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to you, your practice will change your

patterns, your tendencies, and right now.

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These are just what my

tendencies tend to be,

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I think there are certain things that

you definitely, absolutely should

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cover, but I'm excited to get into

the nitty gritty of what it looks

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like at my clinic, because over the

past year and a half, I've started

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to refine it a little bit and.

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I can just kinda give you guys all of

the, all the fun stuff that happens.

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So let's get into it.

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For the sake of continuity, let's

just say that I am seeing somebody.

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This is their first follow-up

visit after an initial evaluation.

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So let's say they came to me on a

Monday and we'll call this patient Mr.

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Joe.

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No, that's such a basic fill in name.

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We'll call this person Mr.

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Uh.

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Mr.

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Jerry.

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Okay.

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I know way less Jerry's than I do.

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Joe's and Jerry, he came to me

on Monday with a torn labrum.

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He was doing a squat snatch at CrossFit,

overextended through that right shoulder

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bar went backwards, chest went forwards.

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Kapow torn labrum.

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He's been to his doctor already.

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He got the MRI.

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They said, yes, you have a, a tear

in your right shoulder labrum, but.

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We think that you should try conservative

treatment first because this is a

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minor tear and we would like to see

what rehab with Ronnie can do for you.

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So I've already seen him on Monday, Mr.

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Jerry, for his shoulder pain.

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I gave him some things to

work on and now it's Friday

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afternoon and we're following up.

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I'll give you guys a little insider

scoop at my clinic specifically.

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It's in.

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A great part of town, but the

doors stay locked from the outside.

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So there's these double glass

doors where patients cannot get in.

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They can't just walk into the lobby.

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I have to be eyes on the

parking lot like a hawk.

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At all times to see when they

pull up and then watch them walk

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to the doors and then be there

greeting them when they get there.

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So first things first.

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I am greeting Mr.

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Jerry at the door.

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Hi Jerry.

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How's it going?

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Welcome in.

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Sorry, the door stay locked.

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It's just for Mac security.

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Um, but I'm always here

to open the door for you.

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What a, what?

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A welcoming first impression,

you know what I mean?

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Or I guess second impression,

because we've met before,

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but this Friday afternoon.

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I welcome Jeremy in.

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We bebo down through the lobby,

take a hard write, another hard

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write, and we're in my clinic.

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It's been a few days since I've seen

Jerry, so I'm asking him how have

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things been, how's work been this week?

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Um, did you go to the

baseball game on Thursday?

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You know, we're just, we're cutting up,

we're establishing some common ground and.

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Then he sits on the table, I sit on my

stool laptop open body turned towards

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Jerry because I don't know about you

guys, but I've been using AI to help me

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take my notes and no, this is not an ad

for ai note taking, apparatuses, apparat

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tie, but it really helps me be way more

present with my patient because I'm asking

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him all the things I would normally ask

while tip tapping away on the keyboard.

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But I don't actually have to

do that, so that's pretty cool.

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So I'm.

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Talking to him and we're catching up, and

then I wanna know how his shoulder's been.

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So let's get some good

subjective information.

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How are you feeling?

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Were you sore after your visit on Monday?

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I kind of expect him to be if

he's a labral tear, and then

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I gave him some exercises.

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Maybe there was some muscle fatigue,

maybe there was some soreness from

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the manual interventions that we did.

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So I'm gonna get a good

subjective in that way.

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And then I'm gonna ask him how

his exercises went, because

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nobody leaves my clinic.

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Rarely do they leave my clinic

without a little home program.

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Two, maybe three things that I want

them to be working on that are specific

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to what they have going on and.

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The frequency duration,

how many days a week?

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That totally depends on the patient.

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Like rarely am I having

someone do something.

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Seven days a week, multiple times a day.

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It's more so, Hey, implement this

into your gym warmup routine.

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Or, Hey, before you go for your

run or after your run, or whatever

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it is, do these exercises,

see if you feel a difference.

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Um.

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For Jerry, I wanna know

how did the exercises go?

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Were you compliant?

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Did you download the app?

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I see that you didn't track any progress.

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So I really hone in on that and

I'm, I'm really not a stickler for

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if people actually use the app.

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I just wanna make sure that

they're doing things correctly.

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So.

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We'll touch on that for sure.

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Let's just say for the sake of this

storytelling experience, Jerry's

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like, yeah, Ronnie, actually I was

feeling better by Wednesday, Thursday.

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I woke up with less pain and I didn't go

to CrossFit, but I did go to the Y and

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I was able to do, uh, not bench press,

but the machine press for shoulders

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because he loves to work his chest and

shoulders, and I didn't really have

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as many symptoms as I normally would.

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And I am like, great, Jerry,

this is fantastic news.

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I'm so happy to hear that you already have

some neurovascular adaptations happening

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in that shoulder in the joint itself.

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You are responding well to exercise.

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We didn't push it too hard on day one.

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Let's retest some things.

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He's like, you know what?

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Yeah.

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The only thing is I've noticed whenever

I'm reaching overhead, I still have

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this pain here, and he points to a part

of his shoulder and I say, well, why

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don't you rate that pain out of 10?

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Always ask for a rating, because

if I just write, patient has

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pain when reaching overhead.

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Then maybe we do some interventions

and then we retest it and he's

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like, yeah, it still hurts.

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But less hard to measure that

if we didn't ask prior to.

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So when they say, okay, let's say right

shoulder forward flexion, five outta

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10 pain, before we start anything,

just him sitting there, us catching up.

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At the end of the session,

I'm gonna ask the same thing.

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I'm gonna measure the same thing.

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He goes, now it's a two out of 10 pain.

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That's good.

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Objective kind of subjective information

to have to keeping the chart to see how

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the pain behaves over the course of time.

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So a lot of times on the first follow-up

visit and honestly many consecutive

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visits, I like to retest strength because

as some of you may know, as physical

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therapists, a lot of neuromuscular

changes can happen in the first few

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weeks of exercise when you haven't really

necessarily been exercising those muscles.

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And so patients will test.

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Quote unquote, stronger.

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You know, maybe within that same

visit once you give them some targeted

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exercises or a week or two later, and

they like to see that progress too.

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So.

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I'm, I'm retesting manual muscle

tests and I'm informing them of

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the changes that have taken place.

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So I'll say, Hey, you know, on

Monday, this right shoulder abduction

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was a four minus out of five.

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That's how we grade it

as physical therapists.

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And today you're a four

plus, or whatever it is.

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It's hard for patients to wrap

their heads around where they were

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day one, how far they've come.

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They don't remember all the, all

the things we're, you know, we're

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putting their shoulders and arms

into all these different positions

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and doing these special tests and

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we're palpating and doing joint

mobilizations and potentially soft

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tissue and taping and dry needling.

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So they're going to be hard pressed

to remember exactly what was what.

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And so having a good document

of what was what and then

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letting them know is just good.

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It, it establishes good rapport, right?

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I think it does.

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So let's say some things test better.

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Some things are still painful,

as we would expect, you know, one

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follow-up visit later from there.

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I kind of let him know my plan.

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So I'm like, I'm somebody that enjoys

knowing what's going to happen within

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the hour of whatever visit I'm going to.

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Like right now, I'm going to a lot of

OB visits and I like knowing I'm gonna,

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okay, I'm gonna meet with the doctor.

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I'm gonna pee in a cup, then they're

gonna take my blood, then I'm

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gonna go talk to the other doctor.

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I don't know.

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I just like knowing and.

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I think a lot of other people do

too, rather than them just guessing.

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I'm like, okay, first

you lay, okay, lay down.

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I'm gonna work on you.

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Alright, get up.

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We're gonna go exercise.

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I let them know.

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Let's say we talked about dry needling.

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The first visit, we didn't do it, but I

explained, I think this might help you.

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If we add a little bit of e-stim, it might

improve some neuromuscular recruitment

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of those rotator cuff muscles and address

the trigger point in your infraspinatus.

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Guys, I'm just literally throwing stuff at

the wall right now, but you get the point.

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Let's say I rationalize a

manual treatment, I'm gonna tell

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him, this is what I wanna do.

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Then we can retest that painful

motion that you were just describing.

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And from there, I wanna look at

how those home exercises are going.

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So I wanna do a few and just make sure

everything looks okay since we've only

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gone over them once before in person.

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And then I wanna progress some

things today to make sure that we can

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keep working towards your personal

goals and get you outta here, ASAP.

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For the sake of time and context, I'm not

going to delve into every single manual

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intervention that I would or could do.

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I wouldn't say I'm heavily

manual based, but I.

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I would say I'm a good mix.

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It really just depends on the patient

and what they are expecting out of

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a session and what I think they need

and what's appropriate at the time.

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So sometimes maybe I am dry needling,

sometimes I'm working on their neck.

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Sometimes we're taping.

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Or if they've expressed that

in the past, they like cupping,

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maybe I'll do that because they

believe that it has helped them.

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So.

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If that's up to your discretion.

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I'm not here to offer professional

advice about what's going to

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work or what's not going to work.

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I think a lot of physical therapists

understand that the research behind

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manual interventions is like,

eh, does it work, does it not?

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When combined with exercise, the exercise

populations always do better, so I'm

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always going to err on the side of, let's

make sure we're doing our exercises,

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but also let's make sure that this is.

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An enjoyable experience and they're

feeling better, and a lot of times

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that hands-on treatment feels better.

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As I'm recording this, I am

realizing that I talk kind of fast.

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I had a direct message a couple

weeks ago, and granted this person

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was from out of the country, and

they, they did ask me, hi Ronnie.

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I really appreciate your content.

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Do you mind talking a little

slower in your voiceovers?

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Because I can't understand

what you're saying.

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English is not my first language.

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Uh.

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And so I kind of think about

that now when I'm chatting.

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I am a little over analytical of my pacing

of my voice, so hopefully this isn't

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too fast for people that are listening.

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Let me, let me slow it down.

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Okay, so manual interventions

have come and gone.

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Jerry sits back up.

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I'm like, how you feeling Jerry?

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He's like, I'm doing good, Ron.

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I'm doing good.

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We retest his.

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Shoulder flexion.

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And he says, you know, that feels a

little bit better, but now it's sore.

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Like it's not a sharp pain,

but I'm feeling some soreness.

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And I go, oh yeah, well that could be from

the needling that we did in your shoulder.

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And he's like, that makes sense.

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So then I say, alright, let's walk

on over to the exercise room and.

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Reassess those exercises

I gave you on day one.

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So we mosey on over to the other room.

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My clinic is set up like I have my, I

call it exam room, but it has my high-low

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table, my plants, my comfy leather

chairs, my rolling desk, uh, some of my

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evaluation equipment, you know, like my

little rolling card of dry needling and.

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Um, tape and goniometers and blood

pressure cuffs, all that fun stuff.

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So that's where a lot

of the magic happens.

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But we do meander on over to the

exercise room pretty much every session.

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So we go over there and he shows me

his exercises and I check his form,

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make sure everything's looking good.

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If it's necessary, we'll progress them.

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Let's say one of the exercises, let's

say his, uh, his pushup plus is.

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He's like, I don't feel this anymore.

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And he was just doing it in Quadra path.

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He was doing it on all fours.

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I said, well, let's, let's get

into a high plank position.

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Oh, that's, that's still

not challenging enough.

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Let's actually add a little pushup.

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Um, so you're not just

getting that serus anterior.

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For those of you that don't specifically

know what I'm talking about, this

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is like a very much a PT term.

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Uh, so I apologize.

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I try to make this content

applicable to the masses, but.

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When I'm detailing out a

follow-up visit in a PT clinic,

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it's hard not to go real deep.

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Anyways, I wanna progress exercises.

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At this point, it's probably,

if his appointment was at

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8:00 AM it is 8 35, 8 40.

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Okay, so we've got about 15 minutes

to add a couple of exercises and then

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cap it off back in the exam room.

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My employee that I recently hired

had an interesting insight, and I

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wanna just bring this up because I

think it's relevant to my visits.

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She said it's interesting how with

your daily visits, your follow-ups,

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you only give them like four exercises.

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We might only do four exercises

over the course of an hour.

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Um, but she was saying they're so specific

and they're obviously so targeted to

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what that person needs at that time

that you're not throwing in a bunch

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of other fluff to fill up the space.

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And I agree with her on that.

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I think when I was working in an

outpatient clinic, I found myself often.

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Trying to hit a number, like let's

say for a total knee replacement.

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I was just trying to get them to

do eight exercises like in a row.

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And I think part of that was

just to maintain some time

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management and make sure that

everybody else was taken care of.

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And I wasn't just only paying attention

to one person, but when you have the

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opportunity to work in a cash-based

clinic like mine and be one-on-one with

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patients, you really can sit down and.

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Mull it over and really make the

exercise specific to exactly what

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they're trying to accomplish.

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And again, like that totally depends on

the person, because if Jerry is trying

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to get back to snatches at CrossFit

with his shoulder, there's going to be

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a nice, linear, hopefully progression

of the way the exercises will go.

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If Susan has.

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Just generalized pain from knee arthritis.

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It might be a little less specific,

but I think you guys get my point.

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Like it is nice to have autonomy and

creativity and the time to look at

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the patient in front of me and say,

this is what I think is gonna help.

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And then educate them on why.

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So I'm glad that I'm going down this

little rabbit hole here because I

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think the why is important for you as a

physical therapist, as a clinician to.

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Sort of double down and explain

to yourself out loud why

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you're choosing this exercise.

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And then the patient isn't

then sitting there just getting

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thrown exercises at them without.

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Understanding how it

applies to their recovery.

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So for Jerry, I'm gonna say,

okay, Jerry, we're gonna do

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this overhead kettlebell carry.

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I want you to walk and hold

this kettlebell overhead, and

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we're gonna go for 10 laps.

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And I want you to do that

because I don't want to get the

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shoulder used to stabilizing in

an overhead position because what

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do we have to do during a snatch?

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You guys?

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You guys get where I'm going with it?

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So.

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I don't do that for every exercise,

every time, but it is nice to

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clue people in a little bit on

what your thought process is.

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And although they probably aren't

gonna remember exactly why or what

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it is you're doing, it helps them, it

reaffirms that you know what you're

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doing and they feel confident in you.

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And it, it's, it's trust building.

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At the end of the day,

that's what we're doing.

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So the exercises have commenced.

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We're finished.

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Jerry's got, he's broken a little bit of

a sweat on this Friday morning and he's

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feeling kind of good, kind of pumped up.

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He's like, I think I could go to

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And I'm like, no, Jerry,

don't do that yet.

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We're not there.

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I know you're feeling

good, but let's talk about.

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Rest.

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Let's talk about controlled rest

and the appropriate way to load

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tissues over the course of time.

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And so maybe I throw in a little

bit of patient education there on

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the back end of the visit, and then

we head back over to the exam room.

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He sits down, I explain.

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What's happened during that session?

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Like, Hey, you, you tested stronger with

shoulder flexion after these exercises.

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Oh, let me, let me backtrack really quick.

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After manual interventions and often

after exercise, I am retesting.

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So the whole theme of my follow-up visits

is like test, treat, and then retest and.

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For Jerry, it is painful

shoulder flexion overhead.

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I'm gonna test that.

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I'm gonna treat it manually.

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I'm gonna retest maybe a two point

pain difference change, but let's just

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say range of motion's still limited.

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We're gonna address that

with some exercises.

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We're gonna test, we're

gonna treat it with exercise.

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We're gonna retest.

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Uh, and that again, to my

point earlier, shows them.

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What physical therapy intervention can

do in the short term, and then hopefully

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in the long term as we continue to

pile visits one on top of the other.

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If you're not testing, treating

and retesting, you also don't quite

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know what you're doing, right?

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Like if I just throw a bunch of things at

him and we do it, , and then he leaves.

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And then he comes back the next

week and says, yeah, I don't know.

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I'm, I'm kind of in more pain.

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I don't know.

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I don't know what it was.

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Could have been something I did.

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Could not have been.

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Maybe he comes back and he is feeling a

lot better and you're like, well shoot.

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Which one was it?

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So if you take anything away

from this episode, I would say.

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Test, treat, retest.

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Some people say, assess, treat,

reassess, whichever it is.

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However, you can weasel that into

your brain and keep it there.

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Sear it into your brain, whatever

verbiage you need, I think

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that's very, very important.

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If you don't do anything else

during the follow-up visit, do that.

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That's important.

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Jerry's going to be excited to see

changes that happen inside the clinic.

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So I digress.

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We have finished everything.

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We're back in the exam room.

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I'm like, okay, Jerry,

this is what we just did.

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This is what I plan on doing next.

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So I always include a plan

for the follow-up visit.

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Sometimes people are scheduled out.

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Maybe Jerry said, Hey, I

just want to go one by one.

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I don't, I don't wanna buy a package.

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I just wanna see how this thing goes.

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And I tell him, okay, you know, I wanna

see you two times next week and this

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is what I'm planning on working on

on Tuesday and Thursday of next week.

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That way, again, to reiterate, he has

a pretty comprehensive plan of what

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it's gonna look like for him when

he comes in and what he should be

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working on at home when he is not in.

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One thing I do that I think might be

a little bit different compared to

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outpatient clinics is I will update

their home exercises pretty regularly.

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I use an app, it's integrated

with Jane, which is my, um,

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billing documentation, EMR system.

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So, Jane.

404

Is my documentation and then

fizzy app or fizzy track?

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Um, I think fizzy app is for the patient

and fizzy track is for me to add.

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Either way.

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I go onto that app pretty

often and update things.

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Uh, one because I want them to gradually

be doing a little bit more and more.

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Two, because they get pretty used

to some of the ones that were maybe

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beginner level in the beginning.

411

And so I like to progress and I feel

like, I don't know, I feel when I was in.

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Big outpatient clinic.

413

I would kind of forget about their

home exercises ashamed to say it,

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but I would forget about them.

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They would forget about them, not

all the time, but sometimes it

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would be two weeks before I would

progress something or three or four.

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And I hate to admit that,

but that is the truth.

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So.

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Maybe with Jerry on this one follow up.

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I'm not, I'm not updating anything

yet, but I'll say, Hey, by the end

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of next week, I expect that we're

gonna progress this home program.

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So you're feeling good and

we're, we're moving right along.

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So just a little thing that I like to add

before he heads out the door to enjoy his

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nice weekend with his family on the boat.

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I'm just like making up

an entire life for Jerry.

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He has a pretty good, honestly,

he's a pretty fit guy.

427

He's got.

428

A boat, a pon.

429

A triune actually.

430

And he also likes to wakeboard.

431

So I told him, no wakeboarding this

weekend, but you can drive the boat.

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Oh, this is so random.

433

But anyways, before he leaves,

I always say, do you have

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any other questions for me?

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You know we covered a lot today.

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Any questions for me?

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And sometimes people do,

most of the time they don't.

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I mean, at this point, we've

spent a solid hour together.

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They're like, no, peace out.

440

Bye.

441

But people like Jerry, they're

really active and he wants to

442

know, yeah, hey, can I bench press

max with my buddies this Sunday?

443

And I say, no, you actually can't.

444

But here's some of the things that you

can do to get you back there eventually.

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So in closing, I think.

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Two main takeaways here

are, say it with me.

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Number one, test, treat, retest.

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Don't forget that, please.

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And number two, I haven't said this

one yet, but someone said this to

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me one time when I was in clinicals.

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She was another therapist

working at the clinic.

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She was not my ci, but she said, you know.

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I treat every follow-up visit as

an evaluation, like a reevaluation,

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and that stuck with me.

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That hit so hard.

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I was like, you know what, girl, you're

so right because maybe you thought it

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was one thing when they came in on day

one, and then they come in the next time

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presenting a little bit differently and

you need to sort of take a step back.

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Reassess.

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So keep that mentality.

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Obviously, you can't do an initial

evaluation every time somebody comes in.

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Like you kind of have to go with one

narrative and subscribe to that for a

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little bit and see how they respond.

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But it is nice to know that as a

PT you can change course and you

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can continue to question yourself

and retest things and be curious.

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That's the fun part about

the follow-up visits.

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It doesn't have to be set

in stone after day one.

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Like, okay, he's a labral tear.

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This is what we're gonna work on.

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Maybe there's some next

stuff going on too.

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And maybe we also need to work on his

rib cage mobility and thoracic mobility.

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There's a lot of other little components

that go into treatment that make

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it exciting and make it fun and.

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I think I know that that's much more

doable in a setting like mine, and this

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is not me out here bragging about how,

oh my gosh, cash-based one-on-one PT is

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so much better than everything else, but.

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I am able to talk about all

this in this lovely way because

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this is my experience now.

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It wasn't always, but regardless of where

you work or what setting you work in, I

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think there's definitely some takeaways

that you could glean from this episode.

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And so I hope you have, and as

always, I love when you guys write

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in and give me ideas to talk on,

because I love having guests on.

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But I also love just kind of getting

down and chatting with you one-on-one.

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So I don't know that I have tons to

offer, but when you gimme good ideas like

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this, it's, it's kind of fun in closing.

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Gimme a little five star review

if you're interested in that.

487

Maybe a little comment on the episode.

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If you wanna make my day, make sure

to, I don't know, like subscribe.

489

I don't even know if you can

do that on Spotify or Apple.

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Show me some love 'cause

it makes me happy.

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That is, that is the main reason

why, and I look forward to

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chatting to you guys next week.

493

Bye.