Standardised Care ≠ Cookie-Cutter Care

As clinicians, our ultimate goal is to provide the best care possible for our patients, and work to help them overcome the problems/address the concerns they are seeking our services for.

Not one musculoskeletal injury will be exactly the same as another.

Every person with their clinical presentation will have their own unique combination of; physiology, contributing risk factors, psychosocial elements, levels of tissue tolerance, physical activity histories, functional goals, health literacy, beliefs and so on...

The uniqueness of every patient's presentation calls for treatment approaches that reflect this diversity.

** Remember, as we're exploring this topic -
it's through the lens of musculoskeletal pathology management **

Traditionally "cookie-cutter" treatment protocols have been widely adopted due to their simplicity & ease of application. However, these "one-size-fits-all" strategies often fail to consider the individual patient.

Whilst there are many who still adopt and implement these "cookie-cutter" approaches, with the goal of saving time & to deliver "standardised care", there is a distinct difference between the two.

Today we'll be discussing the differences between "cookie-cutter" & standardised approaches, as there can often be a misunderstanding of the differences between the two & their application. We'll also look at what we can standardise and what we need to individualise.

You CAN provide high-quality standardised care that is unique & adaptable to the needs of your clients, without falling back on a "cookie-cutter" approach.

Cookie-Cutter Protocols vs Standardised Care

When we're referring to CCPs vs SC, it pays to understand the differences, so we can reflect & refine our treatment practices. A problem exists where the understanding of what standardised care & cookie-cutter protocols are are often conflated.

CCPs typically follow a set of pre-defined steps, running with the assumption (or hope) that every patient responds similarly.

What do I mean by "cookie-cutter"?

Think rigid scripts, consultation actions, pre-printed exercise sheets issued en masse.

This rigidity fails to consider the complexity & individuality of human health & the human experience.

Standardised care, on the other hand, allows for flexibility & adaptability within its approach. Appreciating the distinction between the two is crucial; standardised care should be about providing consistently high-quality care, NOT identical care.

Limitations of Cookie-Cutter Protocols

Fixed approaches &/or procedures used for treating a particular condition, regardless of the individual patient's circumstances, may sometimes have a role within healthcare. However, they often overlook a critical aspect of patient care: individualisation.

As we covered earlier, the unique combination of factors contributing to an individual's presentation will often require an individualised approach.

When we reflect on many of the clients we see with chronic &/or complex musculoskeletal pathologies, their clinical history often reflects seeing multiple practitioners and growing levels of frustration, not to mention possibly ever-increasing entrenchment of psychobehavioural barriers.

Whilst I can appreciate that not every clinician or clinic has the desire to treat chronic & complex musculoskeletal pathologies. I am of the belief however, that if we are comfortable with taking a client's money & we care about the responsibility we have of providing patient care, we should be treating clients as the unique individuals that they are.

Often the cookie-cutter approach is adopted with the thought of saving time & money. However, when we reflect on the responses many clients have in response to this approach, it may actually lead to the opposite (ie: cost more time & money).

The Power of Treatment Frameworks

If you care about achieving successful treatment outcomes, then treatment frameworks are arguably the way to go.

Unlike rigid protocols, frameworks provide a structure for care BUT allow for adaptation of an individual's unique presentation & circumstance. As they guide decision-making without restricting a clinician's ability to adjust the treatment strategy in response to a patient's ever-evolving needs.

Framework-based care also promotes equity in healthcare, as it ensures that every patient's unique needs are explored & considered. This stands in start contrast to cookie-cutter protocols, which may overlook individual differences & perpetuate health disparities.

Extending beyond equity we have the ethical implications. When we adopt an individualised, personalised approach, this allows out treatment to align with the principles of patient autonomy, and recognition of patients as individuals with their own specific needs, values and goals.

Individualisation & Treatment Outcomes

A treatment is only as effective as the level of engagement or adherence exhibited by the individual.

It is well-known that when patient's individual circumstances are considered (type of injury, lifestyle, social factors, occupational factors, goals etc), and they are given the opportunity to have an input into their care, they are more likely to adhere to the implemented program.

When we move away from the cookie-cutter protocols and the assumption our clients need to comply with this management approach, and more towards individualisation, we are promoting patient engagement, and in turn, improved treatment adherence. Ultimately leading to improved treatment outcomes.

Creating Effective Frameworks

Creating an effective treatment framework requires striking a balance between standardisation & individualisation.

Practical Tips for Developing Individualised Care Frameworks

Utilisation of Current Best-Practice Guidelines

Best Practice Guidelines are a great starting point for developing your treatment frameworks, as they are typically a synthesis of current available literature & expert recommendations, covering the assessments, diagnosis & evidence-based treatment pathways.

For example;

Ankle Sprains (2018)

Plantar Heel Pain (2021)

Achilles Tendinopathy (2021)

It is important to remember that guidelines are exactly that, guidelines. That is, a general recommendation of how to proceed, not to be blindly followed - as by doing this essentially creates the problem we're attempting to move away from.

To expand on this point, I refer to the exercise progression outlined in the Dutch Multidisciplinary Guideline on Achilles Tendinopathy (2021).

Whilst the guideline can be useful in helping clinicians understand what a progressive loading program may look like. It does pose the risk of either overdosing or underdosing a person's exercise rehabilitation.

This was something I discussed with Podiatrists who attended my recent 2 day rehabilitation programming workshop at Charles Sturt University (Albury-Wodonga) last week.

I was asked by a delegate why I was explaining a lot of different functional tests and tests to determine the load tolerating capacity of the Achilles, and running through a dozen or so similar exercises and the 9 dosage variables we can use to modify an exercise (more on that here), when there's the protocol that already exists in the Guideline??? (paraphrasing here).

Well...

What isotonic exercises should you start with?

What will you do if 4 x 15 flares?

What isometric exercises should you regress to?

What will you do if the individual can't tolerate 5 x 45s isometric holds?

etc etc etc...

In order to individualise our management we need to understand how to prescribe exercises and their subsequent dosages, relative to the client's presenting functional/load-tolerating capacity, and with their goal capacity/desired activities in mind (shameless plug of the online courses & workshops we provide to teach clinicians how to prescribe individualised exercise rehabilitation programs).

So whilst Dutch Multidisciplinary Guideline on Achilles Tendinopathy (2021) may present a very workable guideline on progression, individualisation can't be neglected if we are to meet the varied needs of our patients.

Similar can be said in relation to the Best Practice Guide for Plantar Heel Pain (here). For some patients, the core approach may not be appropriate, for others it may be perfectly suited.

The take-home message here is that best practice guidelines can help you reflect on your current practice, introduce new approaches that may have robust evidence, move away from approaches that may have demonstrated little-to-no efficacy and use this to guide what options you may consider when developing your individualised management program for your client.

Communication & Collaboration

Open communication & adopting a collaborative approach with clients about their needs & goals typically results in higher rates of engagement and adherence.

It also create opportunities for our management programs to be responsive to the person as a whole, not just focusing on their physical symptoms. That is, considering their psychological factors, lifestyle habits, personal history, personal preferences and so on.

Regularly Review, Revise & Revisit

This applies to the individual patient and their management, in addition to your clinical frameworks.

Evidence is continually evolving, as should we.

In regards to our patient management plans, having an established macro goal, and breaking it down (when required) into micro goals, to continually review progress and allow for prompt adjustment of the plan if required, ensures that our care is continually patient-centred.

In regards to our clinical frameworks, evidence is continually evolving. New treatments become available, new evidence regarding existing treatments changes, existing guidelines are revised, all to provide clarity and assist clinicians in delivering the best in patient care. By ensuring that as new guidelines become available we review & adjust our clinical frameworks, this can ensure that we are able to build evidence-based frameworks that can deliver the best in patient care.

What Can Be Standardised vs Individualised?

Standardised Elements

- Management Frameworks

- Diagnostic Criteria & Treatment Triggers

- Procedural Protocols

- Documentation & Record Keeping

- Patient Onboarding

- Clinical Safety Measures

- Healthcare Ethics & Behavioural Principles

Individualised Elements

- Treatment Plans

- Exercise Prescription

- Patient Education Elements

- Patient Goals & Priorities

As always, I hope this article has provided some insights and practical tips to help you in your clinical practice.

I love your feedback, so feel free to drop a comment or message me if you'd like to talk shop.

If you'd like a FREE rehab resource designed to help develop a framework of individualised exercise prescription, click here