This edition of Top 5 Fridays comes from Dennis Treubig, PT, DPT, SCS, SFMA, CSCS
Over my years of practicing, there have been many thoughts,
ideas, principles, etc. that I have adopted which have made me a better
clinician. These changes have helped to
make my treatments more effective and efficient and thus, improve patient
outcomes. My only wish is that I had
learned these things in school (or at least earlier on in my career).
In PT school, I was primarily taught a pathoanatomical,
evidence-based approach to diagnosing and treating patients (which suited my
scientific, analytical mind well). While
I feel this approach is comprehensive and probably the best route to go for
educating students on the vast amount of material to cover, I also think it is
incomplete. But don’t get me wrong, I’m
not knocking my schooling. In fact, I am
extremely grateful for the solid foundation of knowledge and clinical skills I
received at the University of Delaware (and I always highly recommend their
program). This solid foundation has
allowed me to readily further develop my knowledge and clinical “toolbox.” I just wish they had educated/exposed us to
some of the following ideas that have made me a more effective clinician (and
if you read this blog regularly, I’m probably preaching to the choir).
1. Your treatments are not that specific and not that
deforming
Not being that specific refers
primarily to treatments regarding the spine.
Research says that when locating a specific spinal segment, inter-rater
reliability is ±1 level. So basically, 3
clinicians can try to palpate “T5” and all end up on different segments. And there is just no way that your joint
mobilizations/manipulations are moving only 1 segment at a time (the body isn’t
that “disconnected”), rather they are moving a bunch of segments together. So put this all together and you realize we
are just treating general regions of the spine – and that’s fine…and
effective…and less stressful/time-consuming to you!
By not that deforming I mean we
aren’t “stretching” or “lengthening” soft tissue like we think we do. If soft tissue “stretched” that easily, we
would all be super-flexible and probably collapse to the ground like a wet
noodle. Typical example: a clinician
“stretches” a patient’s hamstring and after doing five 10-second holds, the patient
achieves more hip flexion. Did we just
lengthen the patient’s hamstrings!? Of
course not, rather we just elicited a neurophysiological response and altered
the tone (the premise of contract-relax “stretching”). One research article found that it took
hundreds and hundreds or pounds of force to change the length of fascia 1% and
even that was transient. Let’s look at
another typical scenario: performing a massage or doing joint mobilizations to
break up scar tissue. Think about how a
surgeon gets rid of scar tissue – they open you up and cut it with a
scalpel. I’m not saying that it is
impossible for the body to break up scar tissue, rather our fingers are
unlikely to do it; repetitive/frequent movement by the patient will lead to
mobility improvements. If you make any
significant changes in mobility within a treatment session, it is due to
neurophysiological changes.
2. Develop or adopt a
movement assessment system (adopting one is a lot easier)
In school, we looked at how people
moved and the quality of their movement at times, but more often than not we
were taking goniometric measurements, manual muscle testing, and performing
special tests. When I go back and think
about those days, I realize that for some patients I had lots of objective measurements,
but I really didn’t have an idea of how they actually moved. We did not follow any system or have
standardized terminology, so assessment varied from clinician to
clinician. The concept of regional
interdependence was taught to us in school, but I don’t think I truly
understood its vast implications and significance until I started assessing
movement patterns. The system I have
come to like is the SFMA (and I’m not saying you have to use this system, just
letting you know what I use). It seems
complicated when you first get exposed to it, but it is actually rather simple,
I really like the terminology it uses, and it is easily reproducible/reportable
between clinicians. Using the SFMA has
definitely made my treatments more effective and efficient (and no, I don’t use
it on every patient and I don’t necessarily go through the entire assessment on
a patient, but I do use big chunks of it all the time).
3. Understand the
modern science of pain
The recent science behind how we
perceive/feel pain has developed greatly and subsequently debunked older
views. Understanding how pain is a
multi-factorial output from the brain (and I’m really summarizing this) will make you a better clinician by
improving the way you interact with and educate your patients - both on how/why
they are in pain and what your treatments are actually doing. I don’t want to go into much detail here
because it could be an entire article on its own and I also don’t think I would
do it justice. I highly recommend you
either read Therapeutic Neuroscience Education by Adriaan Louw or take a
course from him (there are other clinicians out there who teach courses on it,
I just found Adriaan easy to listen to).
4. How to better pick
CEU courses
I wish someone had told me to prioritize
courses that teach you a skill, rather than purely didactic courses. Early on in my career I attended a bunch of
lecture-based courses and, in addition to being expensive (registration fees,
travel expenses, etc.), I didn’t find myself getting that much out of
them. Many of them felt like a review
course for what I had learned in school.
And with the improvements in technology, why go to a didactic course
when you can just view it online from the comforts of your own home and on your
own time. If there is a didactic course
that you would like to take, see if it is offered online or via webcam. I personally use Medbridge for those types of
courses – they have a slew of courses on all different topics. Courses that teach you a skill give you more
tools to put in your clinical toolbox and actually use on patients – these
types of courses should take priority over anything else.
5. Diagnostic imaging
is essentially clinically irrelevant
As physical therapists, we treat
people and what they complain of and how they move, not MRIs. I tell this to patients all the time and it
amazes me how most of them still look at me with a puzzled look when I say
this. This is especially true for spinal
imaging/tests – I have never had a patient who feels better after getting a
spinal MRI or EMG. They always show
something and all it seems to do is increase patients’ anxiety and put more
fear in them. They also tend to “rule in” more invasive (and possibly
unnecessary) procedures – whether it be injections, surgery, etc. Numerous studies have shown high percentages
of MRI “abnormalities” in asymptomatic people (i.e. disc pathologies,
rotator-cuff pathologies, arthritis). This
isn’t to say that I think diagnostic imaging is useless; just that they are
grossly overused and you shouldn’t make your diagnosis and develop your
treatment plan based on imaging results.
edit - Amen, Dennis, echoes many of the messages I impart in my blog and courses. What can drive this change? Newer grads/current students are very fortunate with all of the amazing resources out there available to you. You do not have to make the same mistakes and learn the hard way like Dennis and I did.
Keeping it Eclectic....
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