A letter to a freshly graduated therapist (part 2 – Classification models)

Now that you know the basics, we can get slightly more specific with classification models. These are classifications used in physiotherapy. Keep in mind that whatever classification you use, it should help you refer when needed. We have to understand that we can not treat everything.

I am biased. I believe that classifying patients leads to better outcome and that it is the future of physiotherapy. Hopefully, I will convince you to think the same way.

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In university, I was taught to direct my treatment based on the physiotherapy diagnosis. It felt incredible to believe that I was able to diagnose! It felt incredible to think that I was able to differentiate between a bursitis, a rotator cuff tear, a herniated disc, a hypomobile joint and an instability! Each diagnosis had a slightly different treatment! A herniated disc likes traction. A bursitis benefits from ultrasound. A rotator cuff you check motor control of the scapula and drop some deep tendon friction to realign the fibers. A hypomobile joint you give ROM and throw some massage. It felt great! Too bad a few weeks after my graduation, I realized that physiotherapists weren’t reliable at giving a pathonanatomical diagnostic. This leads to poor evidence regarding effectiveness of physiotherapy. It frustrated me. Take for example low back pain. Even after thousands of randomized control trials, there is still no consensus on the best diagnosis and/or treatment!

Let me explain. The tools we use to diagnose aren’t reliable:

Let’s push it further. Let us assume that those tests were reliable… Let us assume that somehow we were able to identify that someone has a disc herniation or an instability. How do we even make sure that it is the cause of their pain? To what do we compare them to? MRI? X-Rays? We can’t.

Here is the reason why:

VOMIT Poster 2014 SAMPLE

Most asymptomatic people (never even had pain in their life) present with abnormalities! This leads to the question: “Is their pain really due to the herniated disc? Or was the herniated disc already present?”

So… Most of the time, we can’t give a patho-anatomical diagnosis, it does not guide our treatment, and it can even lead to wrong treatment approaches.

This is why many researchers got interested in classification models.

Preliminary researches show that classifying patients leads to better outcome (and yes, I cherry pick my studies and I am biased. Make your own opinion):

Mechanical Diagnosis and Therapy (Low back, knee)

Jeremy Lewis (shoulder)

O’Sullivan classification (low back)

Treatment based classification (neck, low back)

Mechanism-based classification (just theoretically)

Theory: http://www.manualtherapyjournal.com/article/S1356-689X(12)00081-1/abstract  . And theoretical treatment matched to the centrally sensitized subgroup: Pain education helps

I believe that more research is needed but that we have enough evidence to start classifying our patients into homogenous subgroups based on their clinical presentation. Each of them would benefit from a specific treatment…We also have enough evidence to stop worrying as much as before about pathoanatomy.

I believe that classifying patients before we treat them will lead to better outcome. This will then (finally) result in more conclusive researches supporting physiotherapy treatments.

I hope this helps.

Olivier Lam

A letter to a freshly graduated therapist (part 1) – The Basics

This post if for young therapists that freshly graduated and other interested therapists.

First of all, congratulations, you just graduated. Enjoy this moment, you have worked hard and probably deserve it.

Now there is a few things I want to tell you…

First of all, physiotherapy is the most amazing profession! You get to learn and help people on a daily basis. People trust you and love you for what you do and you can’t help but feel rewarded… This reward, however, comes with a price. It comes with responsibility.

You have the responsibility to go out there, spend time to read, learn and especially UNLEARN. If I have one thing to tell you, it’s to stay humble and skeptical. We are still in the dark ages of physiotherapy… very little is known. Don’t take what you have learned so far for granted…Quotefancy-3331-3840x2160.jpg

For example, allow me to expose a few lies you might have learned from physio school (with awesome blogs that you should follow. The real reference are via those blogs. Don’t take it for granted and go read the actual research until you trust the authors..)

  • You can’t stretch a fascia. Here are 2 great blog posts that completely changed the way I treat patients.

http://www.greglehman.ca/2012/10/26/fascia-science-stretching-the-relevance-of-the-gluteus-maximus-and-latissimus-dorsi-sling/

https://www.painscience.com/articles/does-fascia-matter.php

  • Palpation is rarely reliable… and often, when you use it, it can lead to a misdiagnose and a wrong treatment. When I learned that, I felt relieved. I didn’t need 20 years of experience to be able to accurately palpate… no one can (although some still think they can).

https://thesportsphysio.wordpress.com/2014/05/05/diagnostic-palpation-is-it-a-skill-an-art-or-an-illusion/

  • Most of your treatments don’t change the mechanics, the anatomy nor replace anything… You can’t break down scar tissues… Manual therapy probably only has a neurophysiological effect

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775050/

 

There are many more weird things in physiotherapy like: ultrasound, muscle energy techniques, dry needling, etc… which might be clinically useful but which all have outdated/ wrong theories on why they work.

There are a lot of approaches out there and I encourage you to understand a bit of all of them and to keep an open but critical mind… However, whichever approach you use, stick to the basics, and keep it simple stupid.

Know the basics. Start with that. Many systems share the same principles. Whether they call it “Quantification of mechanical stress” from Blaise Dubois courses on running injuries, “gradual exposure”, “Reset, reinforce, reload” from Gray Cook’s SFMA and FMS courses, or “postural correction + avoidance” from the McKenzie approach, it’s all the same thing.

My favorite way of describing it goes to Greg Lehman (http://www.greglehman.ca/):

Calm Shit Down, Build Shit Back Up. 

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Calm shit down by:

  • Reassurance
  • Use symptoms modifications whether it’s:
    • McKenzie’s directional preference
    • Mulligan technique
    • Jeremy Lewis algorithm for shoulder
    • Relaxation for patients with sensitized nervous system
  • Calm shit down often

Build shit back up with:

  • Creativity, variety, exercise
  • Functional meaningful exercise for your patient

I hope that this post helps some of you freshly graduated physiotherapists. Future posts will focus on what continuing education I think is worth taking and why I believe classification systems are the futur of physiotherapy.

Olivier Lam

 

Teaching ignorance

In physio, there are so many gurus that know it all! There are so many theories that explains everything… When we graduate, we have the belief that we can treat anything…

For example, when a doctor tells us “this patient has a lumbar sprain”, we laugh at it because we have the strong belief, based on our education, that this patient has a L5 Right Z-joint hypomobility in extension because of his lack of strength in the right gluts…

The physio education (at least the one that I received) spends too much time giving far-fetched answers rather than questioning and challenging our own biases.

Ignorance is what drives me… It is the thing that made me fall in love with physiotherapy… and there is nothing wrong about it….

Don’t trust everything those guru say. Don’t join the dark side.

Stay alert, stay skeptical. Whatever treatment or system you use… THINK.

There is no one-size-fits-all…

yfoo8

Ignorance creates questions… and questions are the answer to ignorance…