Changing conventional thought
My first real post on here was originally going to be reserved for pain or maybe motor control and inhibition/compensation seen in runners/athletes of all types since I have seen a few more of those patients recently. But, now I just want to talk about being a physical therapist for a moment.
Over the previous 6 months my treatment principles have undergone a major transformation. You tend to realize the things that you don’t know or don’t have a good answer for when you have a student. Wanting to educate the student and really increase their level of understanding comes first from your understanding what is going on. This extends to the treatment of the patient. The why questions pop up a lot and I hate not having a good answer for them or at least a possible reason. I always had a lot of questions and attempted to answer them for myself but something about being partially responsible for a future physical therapist really motivates me.
This week a new student started with me. Today we talked a lot about pain and the the difference between motor control and strength/core stability. Going through the explanations of everything made me really think back to this whole changing a young therapists mindset and how much different it is to think along these lines vs what you are taught in school. I just graduated about a year and a half ago and for the most part the information being taught hasn’t changed much. ROM/MMT/flexibility and biomechanical changes in joint positioning. These were the things that were heavily stressed to be important. What wasn’t stressed was how meaningless all these are. Humor me for a second.
ROM: Yes, A/PROM is very important but it is amazing at how little so many therapists take into account active vs passive ROM in the spine. Just because lumbar flexion is limited in standing doesn’t mean that the hamstrings are tight or there is a joint that is out of place. You have to check passive as well in an unloaded position. What is worse is the cervical region. Limitation in ROM sitting does NOT mean that there is a closing/opening restriction. You have to check PROM in NWB. Most times this motion is actually perfectly fine and it is not something you need to start closing down or manipulating telling the patient that they have something out of place. All this does is raise their pain avoidance levels.
MMT: Please don’t rate someone a 4/5 via MMT of hip extension if they can’t complete AROM of hip extension without hamstring compensation. That 4/5 in glutes quickly turns into a 4/5 in hamstring strength and less than a 3/5 in glutes. Also, strength, most times means nothing if they can’t use it properly.
Flexibility: Tight hamstrings? The cause of Pain? Really? Come on. Just ask yourself this question. Why does something get tight? It a protective reflex from the CNS. You have the find the cause/movement dysfunction that is causing this massive compensation.
Manipulation changes joint mechanics: Where have you ever read that palpation skills are good? Have you ever seen a cadaver? If you manipulate something that isn’t out of place do you make it out of place? So how is it that manipulating something returns it back into place? Most research shows that it is impossible to target a specific joint without getting residual movement in surrounding areas so how can you really say that you are only manipulating the SI/C6/L4 etc.? Yes, manipulate and mobe but know why you are doing it so that you don’t scare the patient into believing that they will fall apart if they rotate slightly.
I know that I took the above to the extremes and there are always exceptions but for the majority the above is very much true.
This got completely off track quickly.
I faced the above reality when I stopped thinking about conventional PT treatments (cough, any doctor TV show, cough) and began to look at the body like we should. This includes less about strength/ROM and more about movement patterns and inhibition. Less about core stability and more about what pain is and what it isn’t. It is difficult to reboot much of what you have learned and takes time to really get back into a comfortable treatment approach incorporating all the new information you learned especially with major changes being made.
With a new student, I realized that I am still learning how to incorporate these new philosophies into my evaluation and treatment processes. It isn’t engrained into my thinking patterns yet but, like motor control/inhibition, practice will help write that new book.
Signed…the always honest TJ