[headline style=”1″ align=”center” headline_tag=”h2″]The Mistakes I’ve Made
It seems just like yesterday I graduated from PT school.
It was during this time I thought I knew everything.
I knew a ton of information, I learned from some of the best clinicians in the world, I had a systematic approach of assessing & treating patients, and even had pragmatic experience as a strength coach training olympic, professional, and collegiate athletes prior to PT school.
I was going to the world’s best physio …..
If a mistake has been done, I probably did it over the past few years…
Even if my intentions were great. This should count for something, right?
Regardless of the mistakes that I’ve made, I put down some random thoughts, opinions, and things that I have learned over the years. You can take them for what they are worth.
I don’t claim to know everything but what I can say is that a take a no BS approach….
I try to teach my followers stuff that works.
Without further ado here they are….
[headline style=”1″ align=”center” headline_tag=”h2″]Clinically What I’ve Learned
Always be thorough on your examination, never assume, and never skip steps.
Patient interaction in some cases surpasses clinical knowledge.
It is a fine line between optimal loading, under loading, and overloading your patients
Limit eccentric portion of an exercise initially with most patients ( they will think you hurt them when they have DOMS )
Doing a thorough examination acts like a placebo (your the expert)
Rarely is an up-glide lacking in the mid-cervical spine, usually it is a down glide
Manual therapy works but it is often done improperly or in the wrong context
- many have not had the appropriate training…
Never trust a MD diagnosis… Always assess with an open mind
- I once had a patient diagnosed with “sciatica” but had a groin pull
Less is more
Being fellowship trained doesn’t mean anything unless you apply that knowledge
Nutrition is rarely considered but should be more
- I think this should be part of our scope of practice and we need to address this
- Your cells become what you eat … literally
If we could do imaging we would put surgeons and others out of business (maybe not out of business 🙂 )
- Not that imaging matters but in some instances it does
- For instance, it is the public’ perception that they need this to validate what is wrong with them
- You have to meet patients where they are at
There is a lot of BS treatments out there….
I’m still not sure if trigger points exist…
You must master and apply the basics.
Robin McKenzie’s subjective examination is a game changer for discerning where to go with your eval and clinical diagnosis
Pain science is great with patients who have abnormal views on why they are in pain or are afraid to move, nothing more.
You can’t help everyone
Majority of patients will get better if you change their outlook and mindset (those who think they will get better…do)
Know how to manipulate the spine …. (if your not manipulating, you’re missing out)
Functional exercise has its place, its not everything
- Sometimes you need isolate in the acute, sub-acute, or with tendopathy
Biomechanics are important but not all the time…
- For instance, if your patient only has pain sitting, don’t start stating or thinking they have a hypomobile STJ and it is causing their LBP when sitting
- You need to fix the way they sit or get them out of the chair
It’s OK to do modalities at times when tissue reactivity is high
Taking a thorough subjective history may be the most overlooked part of an exam
Always be upfront with your patients
Doing just exercise only works with some patients, still need to put your hands on them (at least initially in POC)
- If you only do exercise, your patient won’t come back in (at least that is my experience)
- Most patients haven’t exercised or moved in years and 30 minutes of light exercise is too much for them.
Most physios don’t know how to treat and assess the spine (this is a gold mine $$$)
OCS and SCS is overrated but it may help getting you the job you want
- Most higher level positions require this.
- Looks great on paper but rarely translates into better clinicians
Getting an accurate diagnosis is important for patient “buy-in” and optimal loading to target tissue
Your spine loves and needs rotation ( even your lumbar)
Your annulus heals with rotation (see Grimsby’s work)
Know how specific tissues heal
- For instance, how does ligament heal?
Plantar fascitis and PFPS are easy to treat when you know how the foot/ankle and hip (hint- you may have to treat the other leg)
- stop doing VMO exercises …..
Most PT’s have no clue on how to assess the foot
Some patients do need an orthotic to fix knee and other kinetic chain issues
- I think orthotics are poorly prescribed because many don’t know how to assess the foot properly. Sorry.
Clinical management may be the most under appreciated part of clinical care
We should charge more for our services as a profession
Research isn’t the end-all be-all
- More and more I go back to understanding anatomy, biomechanics, psychology, proper loading of tissues, and how a joint or muscle works in “function”
- We tend to over complicate things and need research to back everything we do
- I think this is a mistake
- I’m not saying we don’t need research, btw 🙂 We can extrapolate great stuff from research.
Special tests are garbage in most instances
You need to read between the BS when evaluating a patient
- Many patients can’t describe their s/s properly or have abnormal views
- You need to be able to discern what is BS and what is real
- For instance, I had a patient complaining of lower back pain but had hip tendonopathy
Always back your treatments with objective data
- does that patient actually have tight pectoral muscles or are you assuming
- We tend to become biased because the majority of patients have “XYZ” impairments
- Be sure your objective tests confirm this ( do they have a positive MLT?)
Never talk about pain
Always start at the feet, hips, and thoracic spine
Gary Gray was right about a lot of stuff before his time and still is
Most physios don’t use manual therapy correctly
- I’m not saying it is the end-all be-all
- It is a tool but is often done incorrectly
Proper breathing is great with patients that have high stress and neck conditions
- I am not sure if it translates from clinic to sub-conscious everyday breathing
- If you have the answer on this DM me 🙂
Pain science is not the end-all be-all like many seem to think… it doesn’t cure cancer ( sarcasm )
- I use it only with certain patients ( those who have abnormal views of why they are in pain or are afraid to move)
3D biomechanics should be taught in PT school
Documentation is the worst thing about health care
Only work on one impairment at a time with laser like focus
SI joint pathology is REAL
- When I came out of PT school many “experts” were disregarding SI joint pathology …
- Don’t make this mistake
- Still need to discern why the SI joint is irritated though
- Are they hypermobile? Is the hip moving? Lumbar spine? Foot?
Jim Rivard and Ola Grimsby’s work has changed the way I dose my exercise
Brian Mulligan’s stuff works great
Dr. Paris was right …
- If you know your anatomy and biomechanics you can make sense of anything
- I would also add patient psychology though …
Shoulders are very hypersensitive after injury or post-op
- Don’t move the shoulder directly in this instance,… move the scapula instead
KT Taping works somehow ( I was skeptical aft first too)
- I use the swelling techniques more than anything
Teaching people how to bend properly is a $1,000,000 exercise
Patient outcomes rule
- Doesn’t matter what the research says about XYZ topic. Results rule. Period…
MRI is still the best test to discern ACL tear
- I had a patient that was negative to all special tests and could sprint, change direction, etc
- He had an ACL tear still
You have two types of disc patients (Thanks, Jim Viti)
- Traction and Positional Distraction
Inner and outer range MMT can be used to help discern tissue involvement
MMT’s are not indicative of strength levels in most cases
- You should use repeated motions or functional exercises
- For quad strength I do anterior step downs or single leg squats…
Sciatica & Neural Tension is easy to treat when you apply Michael Shacklock’s work
Blood Flow Restriction Training (BFR) in the outpatient setting could change the way we treat forever…
Table assessments can be elusive at times
- For instance, a patient may lack motion on the table but not functionally or….
- Have normal motion on table, but functionally lack this motion
- This is important with the hips, btw.
Keep it simple ( you can always get more complex later)
It’s OK to not know everything after eval…
- The more you treat the more things become more apparent
Always evaluate, treat, and re-assess every session (Thanks, Dr. Viti)
No one camp or train of thought has all the answers…. take pieces from everyone
[headline style=”1″ align=”center” headline_tag=”h2″]Personally What I’ve Learned
Training your sub-conscious mind is very, very, very, important
What you think about most of the time you will become
Good friends are hard to come by
90% of people are all bullshit
Family, relationships, and your health should come first
Have a plan on where you want to go
Don’t be afraid to ask other people for help
The more people you help, the better your life will be
- Zig Ziglar said something along these lines
Time will pass you by if you don’t take action
Haters are going to hate.
If you haven’t pissed someone off…. you don’t stand for anything
Everything usually takes about twice as much time and twice as much money
The APTA still annoys me at times
- I would like them to promote direct access at a national level
- We complain about not having money to do stuff… figure it out on how to get more membership (don’t complain about it)
- Here is a thought… Why don’t you buy out FSBPT and control your own board exam? Make membership mandatory…
- I don’t have the answers to this and if you do please DM me.
You will never know it all…
[headline style=”1″ align=”center” headline_tag=”h2″]What I Want To Learn More Of
I am shifting my focus away from course content, books, and other reading as of now.
If you have a firm understanding of anatomy, physiology, loading, biomechanics, and psychology you are on the right track.
I think the best way to learn is to travel and visit or interview other clinicians.
This is great because….
A) It’s cheaper
B) You see treatment with real patients
C) One-on-one attention and focus (classes have 30+ participants)
[headline style=”1″ align=”center” headline_tag=”h2″]Concluding Thoughts
The more knowledge I gain and the more clinicians I interact with the more I go back to the basics of understanding anatomy, physiology, psychology, and how our body moves “functionally” .
I don’t like this last word but…
At the end of the day that is what we are striving to enhance, right?
There are a gazillion and one courses you can take which I think is a good if you don’t have tools in your tool box.
I think many clinicians make the mistake of continually adding more tools but don’t develop the clinical reasoning or critical thinking behind patient care.
For instance, you can have all the tools in the tool box but if you don’t use the right tool at the right time, your not a better therapist.
One more thing….
Perception is everything.