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20 Minute Biomechanical assessment

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Blue123, Mar 6, 2013.

  1. Blue123

    Blue123 Active Member

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    I have recently done some work in a Clinic that has 20 minute appointments only and on my arrival I discovered the first three patients were New patient Bios...

    Now I usually allow 40mins for a Bio, I have been practising for 5years and feel this is about right...can any more experienced Bio practitioners or sports injury specialists advise me on how they would perform a 20 minute bio and what to include as standard??

  2. Griff

    Griff Moderator

    A detailed assessment in this time frame is impossible in my opinion. Taking a good history can take 20 minutes alone. My advice would be to tell the clinic to change the appointment times.
  3. OK, devil's advocate... if it walks like a duck and it quacks, how much time do you need to spend on an assessment to prove that it is a duck before you can conclude that it is indeed a duck and instigate the appropriate treatment protocol to turn it into a swan? Most of the time you spend is making sure it's not a coot disguised as a duck- right? I reckon I could assess the vast majority of patients in 20 minutes if I had to.
  4. blinda

    blinda MVP

    20 mins is the standard NHS time for biomech appts; Which tissue(s) hurt? Why do they hurt? (think functional anatomy) How do I reduce that stress/strain on those tissues? = tx plan. Job done, according to NHS guidelines.

    NB, Just re-read your post. I`m not an `experienced Bio practitioner or sports injury specialist`, just a lowly podiatrist.
  5. NHS guidelines advocate a tissue stress approach then?
  6. blinda

    blinda MVP

    I didn`t say that. NHS guidelines want a tx plan to work with, is what I said. The Trust I worked for prost-grad did use a tissue stress approach as it happens.
  7. Are you sure?;)
  8. blinda

    blinda MVP

    Well, I can't see anyone else smiling in here....
  9. Griff

    Griff Moderator

    Point taken and agreed with that 20 mins probably enough (for a man of your calibre) to come to a decision regarding a duck/diagnosis.

    Not that I'm telling you anything you don't already know, or probably agree with, but for me an initial assessment in the private setting should be very different from the NHS. It is more than just quickly assessing and coming to a diagnosis. It is about building a rapport with the patient (which in turn leads to trust and ultimately compliance one hopes). It is about conveying the fact that you have the time to sit there and listen to them. It is about not rushing a history taking. It is about performing the appropriate tests to confirm/refute your provisional thoughts and theories. It may be about performing more specialist tests (video gait analysis/pressure plate analysis) to both solidify your thought process and also use as a priceless educational tool for the patient. It is about fully explaining your proposed management plan and the rationale behind it (and ensuring the patient understands this and is on board). It is about having time at the end to ask "any questions?" instead of them feeling they are being ushered out of the door. It is about taking them along the corridor to meet the Physio/Osteo/Sports Physician who you are referring them to and introducing them to them with a short handover. It is about them paying the receptionist on the way out and thinking "that was one of the best investments I may have made with regards to getting on top of this chronic problem once and for all".

    So yeah probably 25 mins would do it ;)
  10. Bang on, which is why I allow an hour and don't work for the NHS.
  11. Griff

    Griff Moderator

    Likewise sir.

    Which brings us back to the original post and a question for Blue - why is a private clinic only offering 20 minute initial consultations??
  12. It's an old fashioned thing we used to call: "customer service", but I guess if you can still fill the books with 20 minute slots and keep 'em coming back for more...

    Common as muck, me.
  13. blinda

    blinda MVP

    Which is what i was kinda driving at. Nevermind.
  14. blinda

    blinda MVP

  15. Run along and make us a cup of tea then.
  16. markjohconley

    markjohconley Well-Known Member

    Takes me 5 minutes to get them in the chair! .... and then 5 minutes the other way
  17. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Most physicians and specialists I know and work with would laugh that it takes a "foot expert" more than 20mins to do a history and physical assessment of (just) the lower limbs, and develop a treatment plan.

    The physicians I have spent time with will do a history and physical assessment of multiple systems, organise referrals, write prescriptions, write notes and do half of their dictation in this time.

    Sometimes you need to see the forest for the trees....

  18. The length of the exam needed generally depends greatly on practitioner experience. Depending on the patient, I already have decided what the treatment plan is for the patient within 1-2 minutes, but I will generally spend a longer amount of time letting the patient tell me all their "important information" for another 2-3 minutes to make them feel they are getting their money's worth. Of course, I've been doing this podiatry thing for nearly 30 years so I've already seen hundreds, if not thousands, of cases of most foot pathologies before. Clinical experience, good observational skills and good clinical skills are the key to this.
  19. davidh

    davidh Podiatry Arena Veteran

    30 minutes for me. This includes explaining to the patient what I believe is wrong, and how we may help to put it right - so they understand.

    If I can't do it in 30 minutes I organise another appointment for them. That is a very infrequent occurrence.
  20. Griff

    Griff Moderator

    If these physicians can do all of that in this time then so be it and good luck to them. I wonder what the patient's experience of this interaction is though?
  21. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Almost universally grateful.

    I would recommend all podiatrists do rotations with experienced physicians and surgeons to see how comprehensive and efficient health care is delivered in arguably more complex areas than the foot and lower limb. I'm not talking '6 minute' medicine for a moment either...

  22. Griff

    Griff Moderator

    Forgive me if I remain sceptical. Must be due to the thousands of individuals I've seen who have not retained a single piece of information from their consultation with their Doctor. Appearing grateful on leaving the exam room is not the full picture.

    In any case we are a little far removed from where we started here - we are taking about a biomechanical analysis performed in the private setting in the UK.
  23. Blue123

    Blue123 Active Member

    Thanks Ian, yes in my opinion in a private setting charging £45-£65 for Biomechanical assessments I would feel a little short changed with a 20 minute appointment. This is the point but if this is the protocol (that needs changing) then I believe even an experienced practitioner would struggle to please a private customer...my question was what assessments are vital and which can be omitted from the standard functional assessment?

    Granted, 'if it walks like a duck and quacks like a duck'..very clever thats an ideal world but what if it doesnt? Can you still spend 2-3 minutes coming up with a plan because I cant?
  24. Blue123

    Blue123 Active Member

    so in 5 minutes you can justify approx £50 to a private customer?
  25. Takes me 5 minutes to generally have a diagnosis and have a treatment plan in mind. Explaining this all to the patient definitely is what takes the most time so this will take an extra 5-10 minutes. If a full biomechanical examination is needed this takes an extra 10 minutes. If I am adjusting or modifying an insole, this will take extra time also. Podiatry practice, especially a biomechanically-focused podiatry practice , is very different than practicing medicine, so I don't believe the two can be easily compared. My podiatric practice is very much "arts and crafts", where much of my time is spent modifying insoles and adjusting foot orthoses which, by its nature, takes more time than simply coming up with a diagnosis.

    Finally, I don't worry about the cost vs time too much. If you are good at what you do and get results, patients won't mind paying the money and will keep coming back. It's all about perceived worth of your service. I currently have a three week wait to get a new patient appointment with me, so I guess my patients don't mind how little time (or how much time) I spend with them.:cool:
  26. BEN-HUR

    BEN-HUR Well-Known Member

    40 min. should be adequate time for a Bio. (& there will be times where that is pushing it). I personally don't feel 20 min. is quite sufficient, based on not only diagnosis but also education of the patient... then if needed, obtaining a 3D model of the foot if orthotic therapy is required. Maybe it's just me, but I spend most my time educating the patient as to why something is hurting & the link between their body structure / movement patterns in association to their pain. Then there is the writing up of notes to record this process in the patient's file for future reference. The other thing is that some people take more time than others to assess i.e. some ask a lot of questions (i.e. runners) & there are times where I need to instil confidence / trust in the patient as the result of a not-so-good experience with another Podiatrist. You just cannot do all what is sometimes required sufficiently in 20 min. Hey, maybe I'm slow - or just have different intentions / treatment regime than others - that's not to say those who do their Bio. faster than me are less effective - there have been very experienced & wise practitioners above state their views. Anyway, with that aside, as we have had varying opinions on the time frame aspect. What about the crux of the question asked (as I see it) - what essential tests are required to perform the 20 min. Bio? Well, it could go something like the following:

    - Obtain area of pain.
    - How long has it been there?
    - What event they feel caused it.
    - Previous injury history.
    - Look at their lower limb posture standing (i.e. contours of lower limb & foot).
    - Then ask them to walk; then if required, ask then to run.
    - With the above in mind, then assess non-weight bearing structure/alignment.
    - Link your findings to their pain & inform the patient of this.
    - Discuss what's needed to resolve the pain i.e. lifestyle changes, exercises (strengthening &/or stretching), footwear, strapping (which can take me at least 5 min. alone), external support/guidance (i.e. via orthotic therapy).
    - If needed, do what is required to obtain sufficient model of foot for custom device (some may disagree here), if not using “off-shelf device”. I know there are some who allocate this last point to another appointment.

    Now, the above should be adequate - some no doubt may have different views. Yet, I suppose it is possible to do the above in 20 min. but it will be a push with some (if not many) patients (whilst at the same time instilling trust & confidence in you, as well as value for money).

    BTW, I allocate an hour for my Bio. assessments (in appointment book)... & sometimes I need the whole hour. I just like to get everything addressed in the one appointment (& treatment to start as soon as they leave the consult) than have to reschedule someone to come back to effectively finish the process (but that's just me).

    Have you considered discussing with your employer that 30 min. would be more appropriate... & that this form of assessment takes longer than a G.T (of cutting nails & calluses)?
  27. Trevor Prior

    Trevor Prior Active Member

    So, now you know, I keep a sneaky eye on the arena despite not posting regularly - this one I could not resist.

    I have 20 min slots in the NHS and 30 min slots privately. My case load is generally surgery and MSK.

    The direct question was what to do for the bio in a 20 min appointment - not sure it made it clear whether this was a new patient or referred for just bio assessment. Mine are new pt.s

    I will take a full history, exam the foot / ankle etc. for provisional diagnosis and perform a bio exam. the extent of the exam is, to an extent dependant upon the nature of the problem.

    However, for a more complex MSK or sports patient I would assess:
    Hip rotation
    Hamstrings / calves
    rearfoot motion, forefoot alignment
    1st ray position / MTPJ function
    Standing relaxed and corrected positions, pelvic alignment
    Visual walking gait.

    I would stimate that I can do up to walking in 2-3 minutes if necessary, and more if I quantify LLD. 1-2 mins max walking.

    If neuro problems then I will slump etc.

    1st case to-day was hip / glutal pain with core stability issues, increased left pronation and forefoot equinus. Had orthoses so explained why they were a problem, needed shoe advice and management plan.

    If patient needs x-ray, requested and they come back and we discuss.

    Do I run over time at times, sure, part of the swings and roundabouts of a balanced practice. Do I do detailed notes, definately, often done at end of clinic.

    Not a lot differently privately, just allow slightly longer.

    if patients require gait analysis (video / pressure analysis), this is booked seperately - many do not need it so not booked as standard. If they need custom devices, booked appointment.

    The main difference NHS - private is my private sec can brief the patients well and schedule a range of options at one hit. We (that is us collectively) cannot afford the cost to provide this on the NHS when it is more difficult to justify given the diverse nature of the presenting conditions and the relative cost / benefit analysis.

    I work closely with colleagues who provide orthotics services etc. and I always allow myself a rue smile at the length of time allowed to assess patients on the NHS.

    Hope all of you I know are well.

  28. akenne30

    akenne30 Active Member

    Just thought id put my Tuppence in as the NHS is taking a bit of a hammering here. I agree Private practice is more about the specialist treatments and investigations such as the scans and also about the customer service/ rapport gained with patients.

    Bio clinics in South Beds NHS is a 40 minute assessment with 20 minute review or follow ups which i thought was standard as this was the same with Bio clinics I seen in Glasgow


    Alan Kennedy
  29. Griff

    Griff Moderator

    This discussion has reminded me of an interesting chat I had with a colleague of mine after she had attended a presentation given by Beverley Bolton [Physiotherapist] on communication skills. This may even be worthy of a thread of its own but it kinda fits with the way this conversation here has gone.

    Whether you are in the NHS or private, newly qualified or 25 years qualified, offer 20 minute or 60 minute consults; I think there is something here for everyone. [N.B references to follow]

    • Good communication has been shown to improve patient understanding, recall and satisfaction
    • The average number of concerns a patient presents with is 1.2 - 3.9
    • The order of presentation of these problems may not be related to their order of importance
    • The earlier the patient is interrupted, the less likely it is that they will reveal all concerns [patients opening statements take on average 60-150 seconds / clinicians interrupt on average at 18 seconds]
    • History taking is likely to become dysfunctional if the main reason for the patients attendance is not discovered
    • Use of jargon acts as a barrier; only 15% of patients will admit they do not understand
    • Anxiety affects how the patient understands information
    • Only 50-60% of information given is recalled later
    • When giving patients information asking them to recall this information in their own words improves retention by 30%
    • Other helpful tips include use of diagrams, written info, repetition and giving summaries
    • Patient satisfaction is directly related to the amount of information they perceive they have received [Tailor your explanation to fit with their perspective]
  30. David Smith

    David Smith Well-Known Member

    I would say as a rule of thumb that if you take 20 mins or less to do a Bmech assess then you haven't done it properly. :eek:
    On the other hand I've had people come into my clinic, without an appointment, in a rush and a tizz because they have excruciating foot pain and they've gone out 10 minutes later pretty much pain free. E.G. they have PTTD and a max pronated foot, I nip out to the workshop, grab an old orthotic with a medial skive that's about the right size, try it out for comfort, maybe add a soft top cover to smooth out the fact that it wasn't made for their foot and Robert's your mother's brother.
    So horses for courses


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