Episode 2: The importance of assessment in having confidence in your body

Michael Dermansky (00:01):

Hello, everyone. And welcome to the show that helps you become more confident in your body so you can keep doing the things that you love. My name’s Michael Dermansky, I’m senior physiotherapist and managing director of MD Health. And today I have a special guest. She’s Nicole Davis. She’s our branch manager at Templestowe and senior exercise physiologist.

Michael Dermansky (00:21):

And we’re going to be interviewing her in regards to the importance of assessment. So last week we talked about the whole process, what you need overall to build a confident body. And today, we’re drilling down a little bit further about the assessment part as well. So welcome, Nicole. Welcome to the show. Nice to have you.

Nicole Davis (00:40):

Thank you, Michael.

Michael Dermansky (00:41):

So briefly, just a brief introduction about yourself. Tell us your career, even in a few words, what you’ve done as a health professional?

Nicole Davis (00:54):

Previously, before I was an exercise physiologist, I was a myotherapist as well. So that led me to my exercise physiology journey. And it has been a very complementary service that I’ve been able to provide and do much less of the myotherapy now, with more and more that I’ve learnt about how the exercise physiology aspect takes the clients through their journey.

Michael Dermansky (01:19):

How do you find the exercise part allowed people to build their confident body?

Nicole Davis (01:27):

It creates varying independence. So they can fulfill their own goals, therefore their confident body.

Michael Dermansky (01:37):

Right. Well, today I really wanted to talk about assessment a bit more. From your point of view, why is it important? Why is it important that we assess people, not just go into an exercise program?

Nicole Davis (01:51):

For us, it gives us outcome measures. Outcome measures are very important for us to measure how a client’s going. So some of the measures that we use are: range of movement, strength testing and special tests. It also provides us the client goals. So it helps us connect what we’re trying to do for the client to what they’re trying to achieve.

Michael Dermansky (02:16):

Okay. So tell me a bit more about the client goals. Where does that fit into it too? Because you’re the professional. Shouldn’t you know what I should be doing?

Nicole Davis (02:25):

Yes. But if I tell the client what to do, that doesn’t mean they understand the purpose of doing it. So the client goal is very important to be able to relate any exercises or the pathway that we choose to the client. For example, if somebody wants to be able to get up and down off the floor to play with their grandchildren, that is why we are going to make them do a lot of hip stability work and strength through their legs.

Michael Dermansky (02:56):

Right. Is there a specific example of someone you work with that had a goal in mind that you directed their program with that you can think off the top of your head?

Nicole Davis (03:06):

For example, a client that had a lot of neck pain and headaches that wanted more passive treatment, so my therapy approach that I’m talking about. And being able to relate to their goal of being able to go through a day without a migraine, to needing to support their body with their muscle control and strength, made more sense to them than just managing the migraines. So to be able to relate to the client my outcomes that I’m trying to achieve to their goals that they have, will mean they’re much more likely to actually follow through with the program.

Michael Dermansky (03:50):

How does this person go?

Nicole Davis (03:54):

She manages her migraines. Unfortunately, they can be cyclic. But in terms of quality of life and independence of doing her own exercises now, much better.

Michael Dermansky (04:05):

Right. Fantastic. What happens if you don’t do an assessment? Actually, let me rephrase that. If you don’t have injuries, so you don’t have a specific pain like a migraine, why is assessing still important? Or is it important?

Nicole Davis (04:21):

It is important because it helps direct and guide our programs that we run because they are individualized. And it also helps identify what the body is physically doing that you might not be aware of. We don’t necessarily know about asymmetries, for example. And also, where there are areas where we could have more of the injury prevention aspect, if there is something new a client wants to go to do.

Michael Dermansky (04:51):

I know I’ve done quite a few assessments over the years. And people come in, they want to get fitter, they want to work on their muscle tone and so forth. And not until you go a bit deeper, they tell you what’s really going on. “Oh, yeah. I’ve got no problems. But 20 years ago or 10 years ago, I had a knee reconstruction 10 years ago.”

Michael Dermansky (05:13):

And you see the consequences of that knee strength just hasn’t fully come back. And as a result of that, they’ve changed their activity levels and they haven’t noticed it because it’s just the background noise of what they’ve done.

Michael Dermansky (05:26):

But it really has made a difference in their strength. So their ankle isn’t as strong, their knee isn’t as strong, their hip isn’t as strong. And they wondered why when they go for a run, it just doesn’t feel the same. And it’s because often, that rehabilitation hasn’t fully been done.

Michael Dermansky (05:39):

And they haven’t told you that at the start, but you find it out pretty fast once you start looking for it. Like, “Oh, okay, that’s not what it should be, and that’s not what it should be.” And that has to be incorporated into someone’s program.

Nicole Davis (05:51):

Correct. Yes. When we do our assessment, it’s not just about our outcome measures. It’s about subjective assessment too. So the client history is very important to build that picture because what they did 10, 20 years ago might not be relevant to them, but it will show on our assessment and it will guide what we can do for them.

Michael Dermansky (06:14):

So when you do do an assessment, Nicole, what would you focus on? Where would your mind or your assessment go?

Nicole Davis (06:22):

I would relate it to the client’s goals first. So yes, we have our protocol that we follow for our assessment, but there are areas that we could delve into a bit more based on what the goals the client wants to achieve.

Nicole Davis (06:37):

So if, for example, they are a swimmer and they have on my assessment very tight thoracic movement, therefore it’ll impact their breathing for their swimming. Then it is something that they might not be aware of the influence that we can actually have. Not just on their breathing, but then their shoulder range of movement, if we improve their thoracic mobility. So that’s, for example, when the assessment is crucial in connecting with the goals.

Michael Dermansky (07:08):

Okay. So from what I can hear, without knowing what their goals are and then doing the assessment, you really can’t relate the two. So if they want to be able to run a marathon or they want to be able to go skiing as well, that would be a great goal, but without having to look at it in more detail, there’s no way you can put the two pieces together.

Nicole Davis (07:28):

No, you wouldn’t get someone who has a knee injury doing any of the mobility or strength type drills that a skier would do. We would be missing vital steps and potentially creating injuries rather than preventing them if we don’t do an assessment to know where they actually start in the process.

Michael Dermansky (07:49):

Okay, fantastic. So you’ve done an assessment with somebody, you found out these are things that are right or wrong with them as well. What’s next? What happens after that?

Nicole Davis (07:59):

We focus on a treatment plan. So that’s where we prioritize what needs to be done to be able to achieve the client’s goals. So that treatment plan would include a letter to the client after the assessment we’ve done.

Nicole Davis (08:17):

So just their outcomes in a way the client will understand. Not just the terminology that we use, but also that treatment plan can then be implemented by any of our team because of the way we structure our assessment and our procedures. So we can guide then each session with the client based on that treatment plan, which comes from our assessment then.

Michael Dermansky (08:48):

So it sounds like there’s about three different steps. So firstly, there’s the client goals, what they want to achieve. Then you assess what’s going on under the surface.

Nicole Davis (08:59):

Yes.

Michael Dermansky (08:59):

And then the missing link after that is the treatment plan. So all right. What does all this assessment mean? And how do I put this into a useful program to match with what the client wants to achieve?

Nicole Davis (09:12):

And that’s where our experience and our clinical reasoning comes in. Yes.

Michael Dermansky (09:17):

So how does the clinical reasoning come in? You’ve done an assessment, you’ve done a plan. So where does experience come into it too? What’s the big deal?

Nicole Davis (09:28):

Helping the client see what’s actually important to achieve those goals. So if we’re doing minor movements, like hip hitches, the client doesn’t understand how that’s going to make them squat better. Whereas, for us, we know that hip control is what we need first to be able to build on hip strength to be able to squat better.

Nicole Davis (09:51):

So for our plan, we have to meet certain steps. So control first, and then we go onto strength. Everyone’s journey’s a little bit different based on their goals and where they physically are. So the assessment allows us to identify where they are in that journey and then how we can help with getting them to their goal. And there might be a few deficits there that they might not be aware of or they might be aware of. And then that will help tailor the treatment plan.

Nicole Davis (10:23):

And with the treatment plans, also they’re adaptable. If something isn’t changing in about seven weeks, we do a reassessment. And then that reassessment is where we also reevaluate the goals. And then we might take a little bit of a different direction with the next seven weeks, if they didn’t express something that was actually more important to them goal-wise.

Nicole Davis (10:49):

Because when you get to know a client, they do open up and talk to you a bit more, and then more things come out during a session than it would’ve just in an assessment. So that’s where we’re flexible in the sense of being able to make alterations to their treatment plan. And that’s where that clinical judgment needs to come in. As long as it still needs the goals and it’s within the plan and knowing the steps that they’re on to follow, to achieve their goals.

Michael Dermansky (11:15):

So what I can understand, from what you’re saying, is that basically you’ve got their goals, you’ve got the assessment, which tells you what’s it like at a point in time.

Nicole Davis (11:25):

Correct.

Michael Dermansky (11:26):

And how you’re going to get from this point in time and that point in time, is what you write up in the treatment plan.

Nicole Davis (11:30):

Yes.

Michael Dermansky (11:31):

And then you have a look at it again to: have you achieved those goals? Have you got there based on the plan you put in place?

Nicole Davis (11:38):

Mm-hmm.

Michael Dermansky (11:39):

And the other interesting thing that you said is that as you get to know people better, they don’t always tell you everything at the start. So they don’t have the full trust in you yet. So once trust builds up over time, there’s little bits of information that just mean the difference between a great outcome and so-so come out more over time.

Nicole Davis (12:00):

Correct, yes. And the assessment is just one aspect. When we’ve made that treatment plan, we have that first session, we do that follow-up with the client, making sure they felt okay after their first session. And then we also touch base with them in three weeks to make sure that we’re still on track and they’re feeling confident within us.

Nicole Davis (12:18):

Because within those three weeks we should have done two sessions a week. Therefore, the trust and the communication should have increased enormously by then. So that’s when we can adjust things if we need to. But the clients are more likely to actually follow through if we’ve kept up that communication after the assessment.

Michael Dermansky (12:38):

Right. Is there a reason why that happens? Is there anything that you can think of that I’ve kept the communication up and then they’re more likely to trust me if… What you just said: if you communicate more, that you’re more likely to get a better outcome. Why? Why does it make such a big difference?

Nicole Davis (13:01):

Clients feel heard then. And knowing that our programs, our treatment plans, you’re right, are very specific to them. So we expect certain outcomes after sessions, whether it be some muscle soreness, just some DOMS, or if we’ve tried a new treatment that they’ll feel a bit different.

Nicole Davis (13:25):

We want to check in to make sure that they’re trusting us to return because we know we have our plan that we have in place for the client, but the client doesn’t always know what we do for them. So that follow-up communication helps bridge some of those gaps so that the clients are comfortable coming back.

Nicole Davis (13:45):

And also comfortable telling us if they are sore after a session. They’re comfortable telling us that, “Oh, you pushed me too hard.” Or even the other way, “You didn’t push me hard enough. I didn’t have any DOMS like that last time you pushed me.” So it’s important so that they don’t plateau.

Michael Dermansky (14:00):

I know from my perspective as well, that the first three weeks is a large part of it is to reduce people’s fear and anxiety.

Nicole Davis (14:08):

Yes.

Michael Dermansky (14:08):

So this is new or scary or it’s hard and people feel sensations they’re not used to. Now we know, because we’ve seen this a thousand times, this is normal or this isn’t normal. But they don’t always know that. And so just having the time and communication to reduce people’s fears and reduce people’s anxieties is a huge part of the first three, four weeks.

Nicole Davis (14:31):

Yes. Vital. Yeah. Yeah.

Michael Dermansky (14:34):

What happens if something goes wrong in your assessment? So you’ve got a great assessment, you’ve got a great plan and you ring him up in three weeks, “I’m worse. I’m no better.” What happens?

Nicole Davis (14:49):

We have lots of options in that sense. For example, on a Thursday, we do a team meeting where we’d be feed-backing on clients. That’s particularly difficult clients or clients that have had a difficult time through their sessions. So we have an opportunity there for us to all brainstorm together, to see, review the assessment and the treatment plan if there was something missed, or if there is an alternative avenue that we can go down. For example, using referrals that we have.

Nicole Davis (15:24):

So with a sports doctor, if we need to. But by three weeks, if they’re worse, and I’ve had that conversation with them, I would ask them to come in and I’d rather spend a session trying to figure out why and what exactly is sore. But then I’d also be talking to the client about what they’ve been doing outside, if it’s solely what we’ve been doing, or if they’ve done something new as well.

Nicole Davis (15:46):

Because they have felt more confident because they’ve started something new. So it might not necessarily be what we’re doing on our own. It might be what the client’s doing outside. So we got to differentiate the two. But if a plan is not quite right, and the client is sore, that is another reason why we do the three-week calls and we’re checking in with them.

Nicole Davis (16:05):

Because they might not tell us on their session. They might just say, “Yes, I’m fine,” before they start the session when we do our check-ins as usual. So it’s important then for us to review either in feedback review, we can do a little reassessment with the client. Otherwise, we can also refer on to partners that we trust with our clients, like the sports doctors.

Michael Dermansky (16:28):

I had a case today where it was a little more longer term client too. And they came in with a new problem as well. And because they are feeling better, they’re doing more gardening. And so this new knee problem that didn’t used to be there has come about because they feel much more confident. So they’ve done more things, which is great, but it also means we have to adjust the plan.

Nicole Davis (16:50):

Correct. Yes. And as long as we’re keeping up communication, it’s easy enough to adjust the plan and to help manage flare-ups. Because flare-ups are normal, whether they’re caused externally or because the treatment plan wasn’t quite right. They’re all normal. But if we’re maintaining communication, then they don’t last that long and we can get back on track much quicker.

Michael Dermansky (17:13):

Right. Okay. All right. No worries. I’m not going to put you on the spot, but can you think of an example of somebody you’ve had recently or a while ago who was similar into that boat there that you’ve gone three weeks down the track and it’s no better? Or they’ve had a flare-up of something different as well, and how you’ve adjusted their plan with them as well, and the changing outcomes as a result?

Nicole Davis (17:38):

So for example, a client that didn’t respond in the three weeks and we were questioning on their treatment plan whether there was a bursitis in the shoulder. So we’ve been working on the rotator cuff, we’ve been working on that strength and stability side of things, but that bursitis was just not calming down.

Nicole Davis (18:00):

So that three-week mark, we talked to the client about it and go, “It might be worth getting a cortisone injection.” So for that client, we looked at that avenue too because we know for bursitis, it’s so inflammatory. As soon as we calm that down, we’ll actually make better progress with the tendon protocol.

Michael Dermansky (18:17):

Right. I see.

Nicole Davis (18:19):

And then with another client that had a knee, not necessarily flare-up after the three weeks, but not happy about it. It was probably more of an osteoarthritis type issue, that as much as we might do the strengthening side of things, it was probably just that little bit further down the line of needing to have some more intervention, like getting a second opinion about replacement.

Nicole Davis (18:50):

So the arthritis aspect was more prominent than we would be able to manage just with the strengthening. So with that client, we focused a bit more on prehab then to prepare that joint as much as we could before having the surgery. And then communicating with that client during their rehab, that initial rehab post. And then getting them straight back in as soon as we can.

Michael Dermansky (19:17):

So what happened? That client particularly, you said they were further down the track with their osteoarthritis and that they had a conversation more about surgery. How does the surgery… Isn’t that enough?

Nicole Davis (19:32):

No. That’s just one part of managing the problem. So that surgery might take away the arthritis. But because the body has adapted so long to managing with that arthritis, there were abnormalities in movement, restrictions in movement, there’d be limitations in strength.

Nicole Davis (19:51):

So once that has actually been addressed, it means that we can get back onto the treatment plan in terms of the mobility and the strength again, so that it comes all the way back around again, that 360, back to their goals.

Michael Dermansky (20:07):

It’s interesting. I’ve obviously seen this over the years too. But when people have an operation, like a knee replacement, there’s been a recent study that show that most people, after a knee replacement, hip replacement, don’t go to have any more active life than they had before they had the replacement done.

Michael Dermansky (20:24):

And that’s a shame because that’s not why they did it. And it’s because a lot of the time, the work isn’t done, the strength work isn’t done afterwards to the point where they actually have a better life. That stuff should be brilliant. They should have a fantastic life, they should be able to do all the things they want to be able to do.

Michael Dermansky (20:41):

That’s the whole point of it. But if they don’t do the work before and afterwards, particularly afterwards, it’s just going to be an operation that’s really not going to get the success it should.

Nicole Davis (20:51):

That it should. Correct. Yes.

Michael Dermansky (20:51):

And that can be used down the track.

Nicole Davis (20:52):

It might be pain management.

Michael Dermansky (20:53):

Yeah.

Nicole Davis (20:54):

But pain is one aspect.

Michael Dermansky (20:56):

One aspect. Absolutely.

Nicole Davis (20:57):

We know it’s only one aspect.

Michael Dermansky (20:58):

It’s not the biggest aspect stopping people living their lives. It’s usually lack of strength and control.

Nicole Davis (21:01):

Yes. And it’s our bread and butter.

Michael Dermansky (21:02):

Yes. I’ve seen it many times over many years now. How often do you review? So how often should these assessments be done and why? Why are these particular timeframes important?

Nicole Davis (21:17):

So I mentioned before that we do the seven-weekly assessment. So that’s when we just started making those neurological changes in the body. So the brain’s only just starting to understand and activate those muscles that we’re really trying to get working properly.

Nicole Davis (21:35):

And that makes sure that our treatment plan is on track around that seven weeks. And then it’s also obviously, an opportunity to make sure the client is staying motivated so they know their outcome measures are changing a little bit. They might not be dramatic changes, but change is still positive in the direction we’re trying to go.

Nicole Davis (21:53):

And then we review it again in that 13 weeks because that seven week to the 13 week, that’s when we should have made the biggest changes. So the body should have actually physically made some adaptations, the muscle should have grown and made some changes there. So we see some strength changes by that time too.

Nicole Davis (22:11):

And then we review seven weeks after that again. And repeat that process until the client has achieved goals, we need to change goals or they have progressed, for example, to our strength and conditioning side of things where it’s not just about injury management, it’s actually about that confident body and that lifestyle.

Nicole Davis (22:36):

And we focus a bit more on not necessarily injury prevention, but improving quality of life by improving strength with some simple things like a back squat or a front squat that is just going to increase bone density, muscle strength and control and also their confidence.

Nicole Davis (22:57):

A lot of the time, the clients that come in here don’t think they’d be lifting heavy weights. So it’s almost a goal that we might have for some clients that they don’t realize is a very fulfilling goal that we put on them to be able to weight-lift.

Michael Dermansky (23:11):

It is an amazing thing when you see that too. I’ve got a client at the moment too, where when she first came in, she just wanted to get some degree of tone and strength that she’d had ongoing hip problems. We’re now quite a bit down track with her, probably about a year now.

Michael Dermansky (23:27):

But in saying that too, she’s lifting actually quite a lot. And that was not even on her radar of things. And now it’s something natural for her, and she lives an active life because she’s got the basics under control, she’s got a good base of strength. And now she can take things at the next level. And it’s just wonderful to see that she can do what she wants to do out of her life. And that’s the way it should be.

Nicole Davis (23:53):

Yes, yes. So we wouldn’t be able to achieve some of the things if we don’t do an assessment. And the regular assessment helps us keep the treatment plan active. Because for our non-pathology clients, we can do treatment assessments six months and 12 months.

Nicole Davis (24:19):

So they don’t need to be done every seven weeks if they’re asymptomatic. But if they’re an existing client with us, we, at a minimum, do a yearly assessment so that we are on track of their goals.

Michael Dermansky (24:35):

So at the start, it sounds like it’s much more important to do more often. So at the start, you do every seven weeks, 13 weeks, 26. And then you start spreading it out after that. Is that right?

Nicole Davis (24:45):

Correct. Yes.

Michael Dermansky (24:47):

Okay. Fair enough. Finally, just one last question. What happens if you can’t find the answer? So you’ve done an assessment and you’ve done the reassessment, and it’s still not going in the right direction. What options would you put in place for that particular client?

Nicole Davis (25:01):

So it depends on what we’re unable to assess with the client. So sometimes there might be a pain management aspect. So we can refer them to pain specialists rather. So they work a little bit more with how to manage with pain. And that’s an avenue that we work quite closely with, with some more exercise physiologists that specialize in that area.

Nicole Davis (25:34):

And if we don’t have the answers, that is where we refer on. We would have that feedback looking at that first, if there’s anything in our team feedback that anyone else can come up with because we work as a team already. So a lot of eyes would’ve seen the treatment plan. But we’d always have that feedback and have a look again if there’s anything else that we can do.

Nicole Davis (26:07):

And I think if we can’t find the answers for that client, then that is where we do our best to create the referral network and making sure that we’re not giving up on the client, but we’re referring them to someone that would be more appropriate for them. And we would maintain and continue communication with the client, but also with the therapist that we’d refer them to.

Michael Dermansky (26:30):

Yeah, yeah. I know quite a few times we’ve seen people with things like frozen shoulders where we’re suspecting it, but we’re not sure. And then we refer onwards. And we know the right approach at that time is to get on early with things like specific injections.

Michael Dermansky (26:46):

And when we get on top of that early, it’s a great outcome for the client. But we know we can’t do that ourselves. This is a great opportunity to talk to our referral networks and get them to do the right thing for the client.

Nicole Davis (26:58):

Yeah.

Michael Dermansky (26:59):

Anything else you wanted to finish off? Anything you want to tell the people listening to the show that you want them to know about the assessment process or what to do to build a confident body in general?

Nicole Davis (27:11):

I think with the assessment, it can be varied quite a bit. So it’s not just about gender and age group; it’s also sport-specific. So we can do functional assessments too, we can focus on specific sports assessments. So the initial might be a full body assessment, is what we call it.

Nicole Davis (27:34):

But we can actually be a little bit more specific in terms of the goals and what we want to achieve. But in terms of achieving that confident body, we want to put you in the driver’s seat to be able to do that. And we’re here to help you get there.

Michael Dermansky (27:51):

Yeah. Which is what we talked about, the goals and why the goals were so important. The goals of the assessment is what drives the assessment and what drives the treatment plan because of the outcomes we want for them.

Nicole Davis (28:05):

We want for them. Yes.

Michael Dermansky (28:08):

Well, thank you very much, Nicole. Next week, we’re going to go explore a lot more through where does the clinical exercise, the clinical Pilates fit and treatment? And so our senior osteopath, Dean Daskalou, at our Carlton branch will go through that in more details. So I look forward to speaking to him and talking to you guys then. Thank you very much.