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By: Erson Religioso III
Not anything and everything is taught in school. It is only when we are exposed to the outside world when we realize a lot of things. There are many facets of being a health care provider that they do not cover in physical therapy school or even when taking up the best courses.
Here are five important things I did not learn in school or courses:
Provocation Tests Actually "Provoke"
We are taught to use tests like Neer's, Patellar Grind, etc. It's sad that physical therapy students are still required to know a battery of tests that even the texts say have little sensitivity and/or specificity. They have to know them for the licensure exam and to communicate with clinical instructors and other clinicians who insist on getting information from something like cervical compression.
With what we know about modern pain science, we should try our best not to provoke our patient's complaints as much as possible. These patients are already anxious and possibly close to being centrally sensitized. I saw a young black belt who had excellent outcomes with his shoulder. He returned a year later for acute lumbar pain with a lateral shift. Upon explaining possible causes, being as vague as possible, his eyes widened, he became anxious and asked to be referred to all kinds of specialists. He even volunteered at our clinic for several months and knew how we emphasized conservative Tx, HEP, etc. These cases are specific to individuals and different areas on the same individual. Our choice of words may provoke, much less sensitizing movements or tests.
One of the biggest parts of MDT, the repeated motion exam can do this. If a patient tells me that bending, sitting, and squatting hurts them, it's probably not a great idea to test flexion in standing and lying repeatedly. I try and just check the motions that more than likely are going to be their directional preference.
Patients are Consumers
You may be the expert but you're also a salesperson for you, your therapy practice, your profession, and the approach you are using. The interaction from the first phone call, to the website, and with everyone in the clinic will make a difference on a patient’s outcomes and whether or not they are likely to refer you their family and friends.
We have an unwritten rule in our practice: say hello to everyone, especially if they are not your patients, and it's the same thing with good bye. When a patient tells me “thank you” at the end of the visit, I tell them "Thank you!" not "You're welcome."
Patient Positive Expectation of a Treatment is Important
One of my favorite recent research articles to be published recently is the Cervical Thrust CPR by @aussielouie. It is very simple and takes into account patient's positive expectation of a treatment. As an MDT practitioner, I do try to talk patients out of repeated passive treatments like maintenance adjustments. However, if they are hell-bent on getting a manipulation, and think they're going to benefit from it, I do a thrust manip. I then teach them cause and effect, loading and unloading strategies based on their DP and make them responsible for their symptoms.
The HEP is Everything
You think of the home exercise programs in physical therapy school as simple stretches or strengthening exercises. In reality, because of the transient nature of the treatment we perform in the clinic, the HEP is what helps lock in part of those changes. Making cortical changes in movement tolerance, pain thresholds, decreasing perceived threat, and redefining smudged virtual somatic representations takes both time and repetition. The time we spend in the clinic with our patients is so little compared to them being on their own. Even seeing a patient daily would not be enough. This message is one of the most important you can tell a patient from day one and shortly into evaluation and treatment.
The Only Rule is That There are No Rules!
Bonus points for those who can identify that cheesy quote from one of my favorite 90s martial arts movies without Googling it!
What works for one patient may not work for another with exactly the same subjective complaints and objective measures. My most personal example is not being able to treat myself or respond to treatment by my business partner for my own DeQuervain's-like issues. What worked on most thumb and radial neurodynamic dysfunction only worsened my complaints. I ended up coming up with a novel and easy strategy of repeated wrist flexion with radial deviation since that has also helped a patient I thought only had radiating cervical issues into her wrist.
What are some of the things you wish they had taught in physical therapy school? Share them with us!
Visit Dr. Religioso at www.themanualtherapist.com.
Click here for more information on Dr. Erson Religioso III.
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