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I remember him vividly.
He was a cantankerous old farmer. You know the type. Rough and rugged exterior but would do anything for anyone at the drop of a hat. At 72, he was still working on the farm daily.
He’d had a total hip replacement (THR) and was resistant to physical therapy from the beginning. In spite of this, we’d developed a good relationship, and he progressed well. As we got closer to his regular work activities, I knew what should come next. But even though I knew what I needed to do, I couldn’t bring myself to do it.
It was time for his discharge testing.
I had been using the Selective Functional Movement Assessment (SFMA) throughout his rehabilitation, and his top tier was completely pain-free with the only dysfunctional pattern being his squat. He now needed a Functional Movement Screen and Y Balance Test. But I didn’t want to do it.
I have spent my career trying to inspire rehabilitation providers to complete systematic and rigorous discharge testing on their patients. I feel that this is how we improve rehabilitation and impact the lives of the people we treat. Yet this particular time, I was having trouble doing the very thing I champion.
Discharge Testing Avoidance
I am not the only one who didn’t perform adequate discharge testing. I was one of the researchers in a study of 469 soldiers who were injured and then missed time due to that injury. Once they were released to return to full duty, we tested them. We tested them on everything from simple movement patterns of the top tier movements of the SFMA to hop testing and 75 percent body weight carries. We then followed the soldiers for a year to see who got injured and used the data to develop the tests and standards for safe return to duty. While I believe the final results of this study will be impactful, the research team was stunned by some of our initial analyses.
When performing the simple movements of the top tier SFMA, 43 percent of soldiers had pain with at least one movement.
Let me say that again: Almost half of the soldiers who returned to duty had pain from simply turning their head, moving their shoulders, touching their toes, bending backward, or squatting.
Something is very wrong with this picture!
This problem of not testing at discharge is not limited to the military. Just in the past month, I have seen athletes who had ACL reconstructions, meniscectomies, and ankle sprains that were still lacking everything from simple ankle dorsiflexion ROM and bodyweight squatting ability through higher level hop testing. When asked about return-to-sport or discharge testing, they all said their physician, athletic trainer, or physical therapist performed minimal to no testing.
We can do better.
Why Aren’t We Testing?
All of this has caused me to reflect on why I didn’t do discharge testing. It turns out that three main issues were holding me back.
1. It can be time-consuming.
While it’s true that discharge testing can be time consuming, the reality is that it is no longer than a typical rehabilitation visit. Just like manual therapy skills, you get more efficient at discharge testing the more you perform it. Also, while high-quality discharge testing can include a comprehensive list of tests, you don’t (and probably shouldn’t) save them for the last day.
In my MedBridge course series on discharge and return-to-sport testing, I discuss how discharge testing should start early in rehab with ROM and strength. Performing testing consistently throughout rehabilitation helps direct care and gives patients clarity on their progress.
2. I wasn’t sure what I would do with poor outcomes.
This is a tough one because it’s so common for us to feel some sort of inadequacy as rehabilitation providers. I think the number one way to deal with this is to progressively test throughout rehabilitation. If some type of high-quality discharge testing is performed each week in rehab, the patient gets very used to you tailoring what you are doing based on the test results. And if the patient is doing well, you can celebrate the progress together and look forward to the next level of testing.
The bottom line is that discharge testing should be a continual process in rehabilitation and not saved for the last day before discharge. The results should never be a surprise—and in fact they can actually be used to guide meaningful conversations with your patient, including discussions about how their recovery might not match their insurance benefits and what their options are. Or the testing might lead to an excellent discussion of the neuroscience of pain and injury and help instill confidence as the patient returns to normal life.
3. Most patients aren’t appropriate.
Honestly, I was trying to give myself a pass even though I knew better. The patient had had a total hip replacement, right? The Y Balance Test might be contraindicated, right? Researchers would disagree.
For example, this recent study examined Y Balance Test Lower Quarter (YBT-LQ) performance in 94 adults after THR. One of the screening procedures used was a 10-second single-limb stance (SLS) test. If a patient can stand on one foot for 10 seconds, then they can do a YBT-LQ. What is amazing to me is that 25 percent of the participants couldn’t even pass the SLS test. This is similar to the findings of a 2015 study that used 10-second SLS as a screening procedure before the YBT-LQ, in which they found that 37 percent could not pass the 10-second SLS test.
There are multiple studies that use the YBT-LQ in people over 65—and even one by Shin and An that performed the YBT-LQ on older females with poor visual acuity with a mean age of 78.6 ± 5.2 years!
A New Commitment to Discharge Testing
I realize that there can be barriers to comprehensive discharge testing, but I truly believe it is the single most important action we can take to improve our profession and—more importantly—our patients’ lives.
Since that farmer with the total hip replacement, I firmly believe that all of my patients deserve comprehensive and systematic discharge testing. I also have to keep myself accountable and improve patient expectations. I go through a discharge testing checklist with my patients early in rehabilitation.
Ready to dive deeper into discharge and return-to-sport testing? Check out these MedBridge courses:
- Hosseini, S. (2011). The effect of aquatic and mental trainings on balance in elderly males. Middle-East Journal of Scientific Research, 7(3), 296–302.
- Lee, D., Kang, M., Lee, T., & Oh, J. (2015). Relationships among the Y balance test, Berg Balance Scale, and lower limb strength in middle-aged and older females. Brazilian Journal of Physical Therapy, 19(3), 227–234. doi:10.1590/Bjpt-rbf.2014.0096
- Lee, D., Kim, G., Ha, S., & Oh, J. (2014). Correlation of the Y-balance test with lower-limb strength of adult women. Journal of Physical Therapy Science, 26, 641–643. doi:10.1589/jpts.26.641
- Shin, S., & An, D. (2015). Comparison of energy expenditure during the Y-balance test in older adults with different visual acuities. Journal of Physical Therapy Science, 27, 697–699. doi:10.1589/jpts.27.697