Another year is coming to a close. With every year that passes, I think it is beneficial to reflect on what I’ve learned over the previous year. Here are the 5 clinical things the I learned in 2017.
Communication is powerful
I always thought that the treatment delivered by a healthcare professional was more important than the dialogue between a doctor and patient. If a healthcare provider had excellent diagnostic skills and the matching physical skillset to treat the problem, they could solve every problem that walked into the clinic. But several cases this year taught me the therapeutic value of words.
Some patients were told that pain means tissue damage and therefore should avoid any movements that cause pain. This meant giving up activities that they enjoyed to do, like running and yoga. Others were told that their spine was broken and damaged. They would then avoid movements in fear of permanently worsening their condition.Being able to communicate with patient’s about their beliefs (more on this in point #3) and how they may not accurately represent pain can allow patients to overcome limiting barriers.
The patients in these cases had been to other healthcare providers who had performed various physical therapies with no or limited improvement. Their aliments did not need more soft tissue therapy or more joint mobilizations. Sometimes patients will need someone explaining what is happening to them and giving them permission to move again overcome their issues.
Becoming a health educator instead of a healthcare provider
There is a plethora of health and fitness information available on the internet, not all of which is accurate and helpful. If core exercises or rotator cuff strengthening were the answer to all low back and shoulder complaints, a simple search in Google or YouTube would solve it. But without a background in anatomy or physiology, it can be difficult to decipher what is good and what is bad health information.
As I began to see myself more as a health educator than a healthcare provider, my emphasis on treatment shifted. Instead of simply manipulating joints, massaging tissues, or taping body parts, I began to use my time to empower patients to help them overcome their aliments. Whether that was figuring out an exercise that would help reduce their pain or educating them about their pain or injury, the focus was to empower them to overcome their aliment and to increase their confidence with movement
Patient beliefs matter
I will admit when I used to hear misinformation, I would be quick to disabuse the thought or belief. Disc herniation as the cause of non-radicular low back pain? NOPE! Disc herniations are common in asymptomatic populations, and are more closely associated with age than pain. Foot pain while running because of pronation? NOT A CHANCE! There is no association between foot pronation and injuries suffered during running.
While I still think it is important for people to receive accurate health information (refer to point #1), context is important. For those with a fixed mindset or who were diagnosed by a trusted healthcare professional, the belief typically cannot be bluntly confronted because it is either outdated or inaccurate. Instead, treatment can follow a different path even when the belief has not been changed. For example, we can say that we are increasing the strength of the foot muscles to limit pronation or we need to do core exercises to take pressure off of the disc even though foot pronation or the disc may not be the cause of pain. As long as the belief isn’t a nocebo which is limiting the patient from recovering, it may not be important to specifically address the patient’s belief during treatment for a successful outcome. Of course, once trust has been established, then the beliefs of what is occurring can be discussed if necessary.
The robust, not delicate body
It is understood that people typically visiting a doctor are seeking a diagnosis to figure out what is wrong with them. But not all of these diagnoses are particularly helpful in explaining pain. While intentions are generally good, healthcare professionals are very good at medicalizing trivial deviations from “normal.” This can leave patients feeling delicate and vulnerable, which is especially true in the musculoskeletal field.
For example, the squat assessment is a common test used by doctors and therapists to evaluate movement. Most squat assessments look for foot positioning, inward/outward knee tracking, hip alignment, spine positioning, weight shifting, and head positioning to name a few. In majority of cases, the doctor or therapist will find some sort of movement flaw or dysfunctional movement which needs correcting to avoid a future injury.
There is nothing wrong with using the squat as a movement assessment but the body is not as delicate as many of us are led to believe. Movement deviations away from normal may lead to an injury, but there needs to be a tolerance of what acceptable movement is. Not all deviations away from normal are pathologic or predispose someone to an injury. Many of these deviations from normal might actually be normal movement variations, especially when viewed based on the individual. The human body is more robust and adaptable to movement than what we give it credit for.
Loading is a necessary part of recovery
The conventional wisdom is to gradually load the tissues after an injury and to avoid loading when painful. When I first graduated, whenever someone experienced pain during a movement it meant that that was the end of that particular exercise. The idea was that pain during movement meant tissue damage which would prolong recovery.
Now, I’m definitely not saying that rehab should consist of lifting like a bro. The rehab program should consist of a gradual, progressive loading program so that the tissues can adequately adapt to the load. But the loading program doesn’t necessarily have to be pain-free. In fact, painful loading has been associated with a small but significant benefit compared to pain-free loading in the short term and no difference was observed in the long term.
The tissues of the body need load to stimulate adaptation, which is especially true for tendinopathies. Sometimes the loading will cause short term discomfort but will lead to longer term benefit. The key is to prescribe the proper amount of loading, not too much but not too little.
Thank you so much for reading. Wishing you a healthy and happy 2018!
What did you learn in 2017? Leave a comment below!