Monday 11 June 2018

Advice I Would Give A New Physiotherapist Or Physiotherapy Student

            Before we get started I am going to be writing for Travis Mash’s website in addition to continuing to post content here. My content for Travis’s website will be more strength training focused whereas this site will be more rehab focused.

One of my favourite podcasts is Karen Litzy’s Healthy, Wealthy, Smart podcast. At the end of each episode she asks her guests “what would you tell your younger self” (or something of a similar nature). It made me think –  almost three years out of PT school – what would I tell my younger self.
                With that in mind, in no particular order, here are some things that I wish I would have known in PT school and when I started….

1) You probably know enough in your exercise & manual therapy knowledge to help a lot of your patients no problem. So be confident when assessing them and interacting with them.

Which brings me to….

2) There are a lot of things you should learn that aren’t taught in school so take the time to do continuing education and take the time to critically reflect on your practice & what needs to be improved.

3) Learn a system of rehabilitation such as Maitland, McKenzie, Mulligan, McGill (why do these all start with M?). You don’t need to be a strict Maitland, McKenzie etc therapist but I believe in the importance of having a base system to work with and to consolidate the info you know. I see too many therapists that are overwhelmed with information, have a hard time consolidating it, and end up throwing crap against the wall to see what sticks.

 4) Understand that you’re never going to be able to cure everyone. Sometimes patients won’t do their exercises or sometimes can’t modify exacerbating activities. Sometimes the patient needs surgery or medical management. Sometimes there are other health issues or psychosocial factors. Sometimes it’s a chronic issue that may not get that much better. Sometimes it’s not the right match of patient & therapist and sometimes, no matter how evidence-based it is, it’s just not the right input to reduce threat.

5) In physio school they teach that every exercise should be painfree. I believe you should do the best you can to make exercises painfree but in some situations (e.g. chronic pain, post-surgical) that may not always be possible. In those cases you need to educate patients that hurt doesn’t always equal and to do exercises in a way that may slightly increase symptoms but achieves their goals and doesn’t worsen them in the long term

Which brings me to….

6) One trick I learned from listening to Greg Lehman is to do “less more often” when working with people with signs of a central sensitization/more widespread pain. I anecdotally find 1-2 low dose exercises done frequently through the day more advantageous than the traditional 3x10 or 3x15 for helping these clients achieve their goals without as high of a risk of flareup.

7) Following on the heels on #5 – pain science education is great but it does need to be tailored to the individual in terms of
- Whether you do it or not and
- How much information you provide

Some will want to know all the details and some patients will be put off by it. A fellow therapist said it best – ask the patient if they want to learn more about pain. If not, no harm no foul.

8) One mistake that I made was subconsciously being in a hurry with my assessments. It’s tough to do this after being put through rigorous, time crunched exams but its important to really slow down your assessment in order to build better rapport with your patients. You may very well be the first one person in the healthcare system that’s actually listened to them.

Also – many objective physiotherapy assessments lack reliability, validity, sensitivity and/or specificity. Towards that end you can really hack down your objective assessment to what’s essential.

9) Take the time to learn how to progress, regress, coach and modify exercises. I learned most of what I know about exercise coaching, cueing, progressions & regressions from strength & conditioning coaches.

 10) When it comes to managing athletic/training injuries I believe workload management is the most important thing. Tim Gabbett’s research has shown that the “sweet spot” for increasing workload lies at about 10-25% at a time. I tend to stick to the “10% rule” of increasing workload in a week as a start and then go from there.

11) Understand that a patient’s recovery (or lack thereof) from pain or disease can be influenced by a multitude of factors including non-specific effects (I hate the word placebo), natural recovery, and other factors in addition to the treatments provided.

The last two points will be familiar if you’ve read my work….

12) Probably the most important point: use positive words with your coaching, cueing & communication. If you tell your client they got 20 things wrong with them, need you to fix them, and will hurt themselves with everything than that may set them up for chronic issues.

Sometimes yes – if you have a client that’s repeatedly doing activities that worsen the issue (despite advice to modify those activities) than you may have to come down heavy – but that should be a last resort. Read on the magnitude of the nocebo effect and the impact of clinician words.

13) If you’re reading this site you probably value continuing education and improving yourself (and others) as a therapist. My big advice – take it slow and don’t rush it. I poured myself into long weeks during and after school with writing, curriculum work, and other side ventures … and burned myself out more than once. Understand that you’re only as good as what you can recover from. Know that line and stick with it.

If you’re a new therapist or a student I hope this provides you with some useful tips. As always – thanks for reading.


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