It looks like it’s that time again. Time to summarize what my 4th year of practice has taught me. It’s been another busy year, but also a transformational year for my practice. I’ve settled into my clinic in Toronto, adjusted a few paradigms and am happy to report I still love what I do everyday. Being a physiotherapist is truly the best choice I have ever made.
So without further adieu, here are a few select things I learned in my 4th year as a physiotherapist:
1) Paralysis by analysis: reading too many blogs can be a bad thing: This might sound weird coming from a blog, but I have slowed down how many blogs I read (I say that every year, but this year was especially true). Reading 100 different opinions on any given topic can make you nuts. There have been times this year when assessing a patient I have a blog post from Reinold, Lehman, or Erson in my head and although I learn so much from all of them, it can still screw you up with the patient in front of you. Have a system and stick to it!
2) Quick clinical point that has really been great for me this year: Rhythmic stabilizations and reactive neuromuscular training is better that pure strength training for shoulder rehab. I have got MUCH better and quicker results by teaching the shoulder to resist movement by centrating it in the glenoid than I ever did with good old fashion side lying external rotations. Patient has pain at 120 degrees abduction before treatment, do 2 minutes of theraband assisted rhythmic stabilizations , and their pain is usually gone or at least better in most instances (not all, but always worth a shot). I will get a video up showing you what I do for this.
3) You can cherry pick research to justify pretty much anything in rehab. Anyone can use google scholar to find anything that validates just about everything…I’ve seen articles that validate some pretty wacky things. As a clinician, you have to take it upon yourself to have a cursory understanding of research methodology, statistical analysis, and levels of evidence. This helps you see through the bullshit.
4) Research has advantages over real life practice in that a patient in front of you in pain is not pre-screened using specific inclusion and exclusion criteria. It’s up to you to piece it together to help who comes to your door. As much as I love research and use it as much as possible, I have also come to learn that real patients don’t all fit into nice little boxes where we can do treatment ‘A’ and expect a certain result. Not everyone fits into a clinical prediction rule and we must treat the patient and not the condition.
5) Don’t feel bad for using treatments that many say don’t work. If I decided to stop doing all the treatments that such websites as sciencedbasedmedicine.org and saveyourslef.ca said are ineffective there would be very little I would be able to do as a physiotherapist. I really enjoy these sites and read them often, but I have come to learn that if something is of low risk and has some possibility of helping, it’s worth a shot. I’ve bashed craniosacral therapy before for its biological implausibility and lack of any research for its use. However, I also know there are subsets of patients who really enjoy it and respond well to it. I don’t for a second think the therapist is actually moving skull bones around or normalizing the flow of CSF, but I do think they are providing some great therapeutic touch, which we know down regulates the CNS, which can alter the sensitivity of the nervous system. The risk is small so I say live and let be when it comes to stuff like that. Just don’t say it can cure cancer okay? :P
6) As much as I hate this, I have realized that my goals for patients don’t matter because it’s what the patient wants that ultimately dictates treatment progression. For example, if I see a patient with reoccurring low back pain and my goal is to teach them strategies for decreasing the rate of recurrence, I will do an SFMA and work on their DN’s which may include some serious strength training. However, the patient may just want pain relief from this specific episode and not care about prevention strategies. I will always try and explain that they need to do x,y and z to get better and stay better, but if they choose not to listen I have to respect that and just help them with pain relief. I sometimes believe this involves economic factors that I have no control over as well. In summery, if a patient just wants pain relief then that’s all I’ll give them. Can’t want to help someone more then they want to help them self.
7) Patients need to know you have a plan for them and seeing patients more often is better for their outcomes. I used to think that patients respected you more when you wanted to see them less (and I still think that is true to a degree). However, to really integrate proper exercise into daily life or to calm down nervous system output in the form of manual therapy, a patient needs to be seen a little more frequently at the onset. I now see new patients at least once a week for 3-4 weeks, sometimes twice depending on the nature of the condition.
8) I don’t think we can make permanent changes to people’s static posture and I’m okay with that. I am WAY less posture oriented this year then I ever was before. I don’t completely exclude it as a source of pain, but I don’t think I am able to correct a kyphotic thoracic spine to any appreciable degree…and I don’t think it even matters that much anyway. I now teach the mantra “motion is lotion” when clients ask me the ideal posture…the best posture is the next posture!
9) Lastly, we need to have a framework to treat patients. There has to be a standardized method used to assess and treat and it needs to be patient centred. This has proven challenging for me as many of the “frameworks” from which I was taught to view the human body have proven wrong in the world of evidenced based practice. For example, I was taught tests for SI joint movement and stability (gellet etc) and then was told to treat based off those assessment findings. This kind of structuralism methodology formed the bases of my physiotherapy education and much of my post-grad education. Now, a few years into practice I can safely say that I have almost had to relearn what I do for a living due to fact that I can’t ignore the massive amounts of research showing we can’t palpate multifidus, detect movement at the SI joint or ascribe the cause of back pain to a leg length discrepancy (these are just examples off the top of my head). Integrating pain science into my practice was and continues to be a challenge… Patients really want you tell them they have a fixable structural problem. They almost need it to help them feel like they got a thorough assessment. Changing patient’s expectations in this area is a work in progress to say the least.
Are we really doing what we think we are doing?
So there you have it. An inside look into what has been going through my mind this year. Hope you enjoyed it!