What 3 years has taught me

Posted: September 21, 2013 in Uncategorized

Over a year ago I wrote a post about what 2 years as a physiotherapist has taught me and it was well received. Entering my 3rd year as a clinician I think it would be fun and educational for new PT’s to see what I’ve learned over the course of my 3rd year in practice. This has been a challenging year both personally and professionally. On a personal note, I have moved my home and ended a significant relationship and on a professional note I left my old clinic to start out at a new facility in the big city of Toronto. Thus far, moving clinics has been an absolutely amazing decision for me and it’s provided me with so many more opportunities that I didn’t even know existed. I have never been happier professionally than I am right now.
I accomplished a few nice things this year in the physio world that I am proud of. I was a member of the blog team that was selected to go to Quebec City to write about the IFOMPT conference. I got to work with a physiotherapist I respect and am proud to call a friend, The Manual Therapist himself Erson Religioso. He is truly an encyclopaedia and very eclectic in his approach to assessment and treatment. I got to meet and talk shop with Gray Cook, Diane and LJ Lee, Peter O’sullivan, and David Butler. Later on in the year I received my intermediate diploma of manual and manipulative therapy from the Canadian Physiotherapy Association, I became a Titelist Golf Fitness Professional, and I dabbled in teaching clinical labs at a local PT school in Ontario along with lecturing to teenagers about fitness at a fantastic gym in Toronto. Later on this year I will be taking the SFMA course and my level 4’s through the CPA…always more to do!

No such thing!

So without further adieu, here are a few select things I learned in my 3rd year as a physiotherapist:

1) No single method or philosophy will work on every patient that walks in my door. I left my old clinic in part because I felt pressured to adhere to a style of practice I didn’t agree with. It was a philosophy on how the body should be assessed and treated that stopped making sense to me once I got enough experience to question what I was being taught. Did that style of practice work on some patients? Sure it did! Would rubbing their painful back and telling them they will be just fine also have worked? Probably to some extent.

Someone with low back pain from getting hit playing a sport, a sedentary lifestyle, or 20 years of chronic pain should all be treated very differently. In other words, following such things as clinical prediction rules, the pain science biopsychosocial model, or straight biomehcanics will yield different treatments based on the TYPE of patient I am seeing.

This leads me to point #2…and it’s a good one!

2) NO ONE KNOWS IT ALL!! There, I said it. The internet is full of gurus spouting how their method is the missing link to abolishing the world’s pain. I’ll be honest, there have been times I have read testimonials from someone who claims to know how to fix whatever pain and I’ve felt like I must learn what they know…ironically enough, more often than not they were selling a course just so you could learn how to do what they do. How convenient! Look, this is not to say that people who sell courses are just out to make a buck. In fact, I know that is not the case. But I have learned that if you question their methods and their main reply ultimately leads back to them trying to sell you their course than I think they just may be full of it. Prove me wrong…please! I will make special mention of a friend, Dr. Andreo Spina of Funcationalanatomyseminars.com. I have probably asked him over 30 questions on his blog posts and methods and he has personally responded to each and every one of them. He has even private messaged me just to make sure I understood what he was talking about…and I have NEVER taken one of his courses nor has he even tried to sell me one. For that, I plan on doing a bunch of his stuff in the near future. Also because I love what he has to say in the field of sports medicine and functional anatomy…but I digress.

Moral of point #2: Do your own research and don’t believe everything you read. The best people to learn from are those who are willing to admit they don’t know it all but use evidence to back up what they do know. Someone who says “you won’t get it unless you take my course” is full of shit in my opinion…bring on the hate mail!

3) Interdisciplinary facilities are the way to go! I work in a clinic now that has Physio (kick ass ones), Chiro (an awesome one), Sports med docs, Physiatrists, Massage therapists, Chiropodist, Psychologist, Pilates instructors etc. I have been able to sit in with my physiatry boss as he teaches  residents advanced neuro and medical assessment skills…so fun! If you know me you know that I will never give up a chance to learn something and working with such a stellar team of professionals is such an advantage. For example, the physiatrists I work with can come into a treatment session with me and look at something that seems “weird” such as a potential red flag. They have a different and more specialized skill set than myself so having that access is so refreshing. If I worked in a clinic with just physio I would only get physio input, which is not bad at all. Just great to have so many people to bounce ideas off of as well.

My clinic (shameless plug)

4) We are not as specific as we think are being: As someone going through the syllabus system in Canada to become an FCAMPT I am hesitant to write this. On a side note, I have had FCAMPT PT’s get upset with me over some of the stuff I have written on my blog…so I hope this doesn’t piss anyone off. I have read study after study that stipulates in black and white that we really have no clue what segment we are on when we are mobilizing and manipulating the joints of the body. Even better, research now clearly shows that it doesn’t even matter! Just look at the manip used in the CPR guideline for low back pain. It’s a wind ‘em up and crack em approach and magically clients still get better. Can we really determine the exact level of instability with our stress tests? Can we even isolate the joint itself with our stress tests? Do PIVM assessments matter? This time last year I would probably have said YES, of course they do! But as my sceptical brain kept digging, I realized over the course of the year that maybe it’s not as important as we once thought it was… I will leave it at that for now. More hate mail coming my way for sure! Haha

Take a guess at what they found
“The immediate changes in pain intensity and pressure pain threshold after a single high-velocity manipulation do not differ by region-specific versus non-region-specific manipulation techniques in patients with chronic low back pain.”

5) It’s not my job to fix anyone: I no longer think I have magic hands or know exactly what button to press to make someone feel better. Do you know why? Because there ain’t one!! I used to pressure myself into getting everyone 100% better within a 30 minute visit and if they weren’t all better by then than I failed as a physio. This left me going home frustrated and upset many a night. I now know that clients HAVE to be active participants in their recovery. It can not be just me working on them. I said this last year in my 2 year post and I am repeating it again because I keep forgetting it…I don’t fix people, I provide the tools, education and assurance for the clients I see so they can fix themselves. Some may not like that but I don’t really care. Do the odd hands on techniques help someone’s pain? Absolutely they do! And if we’re lucky, that pain stays a way for a while. But if the patient assumes that it was my manip, mob, soft tissue technique (whatever) that cured their pain than I have done a bad job as their therapist. This breads dependency and that’s a one way road to failing. This is HARD guys…really hard! Who doesn’t want to think they have magic hands? Or that they can cure someone’s pain with just their amazing manual therapy skills. It feels amazing when a client hops off my table and thanks me for fixing them…it does! But I know that they will be sore in a matter of days if they go back to doing what ever it was that brought them to me in the first place.

6) It doesn’t have to be complicated: In my 2 year post I wrote about the regional interdependence model and how much I liked and believed in it. I still do! However, I have learned that neck pain can just be neck pain. And ankle pain can just be ankle pain. I don’t need a movement screen to help be tease out the non-painful dysfunction to help me figure out someone has loose ankles or suboccipital tightness due to forward head posture…You may disagree and that’s cool! But I have done quite well treating locally when I feel it is warranted and have had some good results too. Along the same lines as point #4, I don’t think I have ever diagnosed someone neck pain by saying their right C0-1 posterior glide is tight combined with left C2-3 facet hypermobility and a fixated C4-5 IMP glide on the left…yet I have heard other manual therapists make these type of diagnosis’s all the time. Maybe they are just better at me at detecting these things, but I for one don’t know how they can rest their hats on something their colleague next door would not likely find (inter-rater reliability sucks for that stuff). Again, I will concede that maybe there are truly therapists with better hands than me that can feel these tiny nuances and then make a corresponding diagnosis based off of them. I for one think it doesn’t really matter all that much.

There are probably hundreds of little facts I have learned this year as well that are too boring to write about on this blog. These are some of the more holistic ideas that I have adopted in my 3rd year of practice. I’m lucky to report that I love my job and continue to be passionate about it. I really couldn’t imagine doing anything else. I get to help people move and feel better all day…what could be better than that?! I hope in 3 years time I will have learned all new stuff andI will laugh at what I wrote in this blog post. This blog is like a career time capsule in that sense. I am documenting my journey for all to see and enjoy. Let the professional growth never stop!

Till next time!

Jesse

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Comments
  1. Fraser says:

    Excellent blog, Jesse! I love how you question what you have learned, but then are still open to the possibility that what you have learned actually does have value. With respect to whether we can feel joints moving, etc.: sure, there is evidence that shows poor inter-rater reliability – for example when naming exactly what joint is stiff. That is why Ortho Div has taken the approach that using ONLY assessment of PIVMs and PAVMs as the way to come up with a hypothesis is insufficient. These tests are meant as only one in a series of assessment techniques – the results of all of the different assessment techniques are analyzed as a group to come up with a hypothesis. When I do lumbar PIVMs and I feel a stiff segment, can I accurately know exactly what level I am mobilizing? Probably not. Is there evidence that I can feel it? Probably not. However, if we think beyond the obsession that the medical world currently has with the need for evidence before we do anything: what if something can’t be measured? does that mean that it does not exist? (I really, really want to highlight those two questions!) What I use as evidence is my patient’s ability to feel the difference. I make sure that they can FEEL the difference in movement between segments or sides when I first assess it. Then, after treatment, I re-test, and patients can FEEL that movement has been restored. That is proof enough for me!
    Excellent blog, Jesse….keep going!

  2. Hey Jesse,
    Great post man! Glad you’re enjoying treating, as I do. I feel blessed to know that what I do day to day, I get a great deal of feedback from others but myself as well. Not many people can say that about their job.

    I do agree with your assessment of yourself and the treatments. I have actually used less manual in the last 2 years than I did for the first 2….even though I have had more training. I have learned to step back and look at the big picture instead of continue pounding on a specific area until that person was “fixed”. I am more happy now and no difference in outcomes, nor referrals. I am actually able to explain what I do to students better, which is rewarding to me.

    Keep up the good work!

  3. Tora says:

    Really brilliant advice for manual therapists! I especially loved #1 and #5. Well, I agreed with them all, actually. Thanks for putting into words, advice we all need to be reminded of!!

  4. Jesse,

    Enjoyed reading this last year, and even more so this year. Glad you’re taking another look at PIVM, something that is really liberating to give up on most patients. And yes, SFMA and regional interdependence is very fancy, and I love it, but many times, it is hard to argue with an approach like MDT that gets a shoulder better, or a neck better by only treating the neck. Great job, and I envy all the resources and approaches you’ve been exposed to in a short amount of time. You are a much wiser and I am sure better clinician than I was 3 years in. Then I thought I fixed everyone and had magic hands. i didn’t use MDT either so my HEPs were probably terrible.

  5. julie says:

    I agree with you wholeheartedly. I am a PT who floats between home health, acute care, and an outpatient clinic. I see all the therapists work. I am amazed at the specificity some claim in their notes and wonder what is wrong that I just can’t be that SURE to document it. I have long since given up on helping everyone. Provide the tools and do your best. Thanks for your words and posts – love reading them…

  6. jessephysio says:

    Thanks for all the kind words regarding the blog post. I think the key with me is that I’m honest. I’m in the trenches working with people in pain everyday. I have also seen a lot in my short 3 years career and before that as my dad is a chiro of 32 years. I will not say I have an handle on everything yet, but I know what the prevailing thoughts are in physio world when it comes to pain and rehab. It’s a very subjective field and most people will proclaim there methods are best. I personally don’t even have a method. I assess and treat 100% based on the client in front of me…I take into account the level of pain, their beliefs around their pain and therapy, what they want, and what I think needs to be done. I can assess 2 clients with back pain and come out with 2 very different plans of action. Does that mean there is other ways to treat these people. 100%!

    More to come friends!

  7. vsphysio says:

    Great post Jesse, I’m 3 years in as well and agreed with all of your points. We have come a long way and still lots to learn, that is part of what makes our job so awesome! Thanks for sharing your reflection on the past year 🙂

  8. Also you should mention, you learnt how to blog a lot in your first 3 years. 🙂

    I think the first few you got it solid! No one know’s nothing, and those that claim know less, and are shut off to the ever rapidly changing evidence base. And that goes with the first, no philosophy fixes all patients, so many physio’s gone down the wrong track (particularly here in China, and also in USA), with these certified such and such therapist. Ive even seen a single leg squat trademarked in FMS in USA. Please no ticking boxes, individual clinical reasoning with backing of proper science is all we need.

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