Clinical Pearls and Advice: An Update Part 1
Dec 30, 2019
Exactly 4 years ago this very week I wrote a blog article titled “Clinical Pearls and Advice from a Young PT to Even Younger PTs”. Feeling nostalgic this weekend I decided to take a gander through some of my old writings in order to peer into where my thoughts were and compare them to where they are now. This is the beauty of writing thoughts down, the writing doesn’t change even when you do and your belief change blindness doesn’t allow you to see it.
At the beginning of the article I made reference to the Dunning-Kruger effect…and oh how right I was to peg myself squarely on the steep yellow line. Now that 4 more years have gone by, you may be wondering where I would place myself on this colorful representation of knowledge to humility. Well, that’s an impossible task, as I’ve come to learn that the Dunning-Kruger effect isn’t quite as clear cut or strong as the often oversimplified graphics and partisan articles tend to make it appear.
All I know these days is that I’m not even sure if the universe actually exists, or if we just interact within an oversimplified user interface that only exists when we observe it and that we’ve come to perceive over eons of evolution in order to keep our tiny ability to comprehend the limitless data around us from crippling us with overwhelming complexity. Yeah, I probably need to stop reading so much philosophy and quantum theory…
Ok, enough with all of that. Let’s move on to those clinical pearls 4 years ago me came up with and evaluate them.
- “Learn AS MUCH AS YOU CAN about pain science and the biopsychosocial model AS FAST AS YOU CAN!”
- I’m going to go ahead and say 4 year ago me had this one right. However, my understanding of pain science and the BPS model have dramatically changed since I wrote this. 4 years ago me felt strongly that pain science was an intervention and viewed patients as falling into the silos of either B, P, or S rather than understanding pain science is simply everything we know about pain and that every experience every person ever has is 100% B, P, and S. I also viewed the BPS model as unidirectional. Meaning that I felt you had to address BPS factors to affect pain, rather than understanding that yes BPS factors to impact experience, but experience also works back on the BPS domains of one’s life. It was Ben Cormack who helped me to see the multidirectional nature of this.
- “Listen closely and carefully to your patient and they might just tell you exactly what is wrong and even how to fix it. Stop thinking about every test you should do and every movement you should evaluate while the patient is telling you their story. Earnestly listen to them because you are often the first person that has. 80-90% of your diagnosis comes from the history you take.”
- I think 4 years ago me was on the right track with this as well. I didn’t understand the operator vs interactor mindset at the point of writing this, and had certainly not been exposed to the ideas of the inter-subjective third space. However, I knew from listening to smarter people than myself that we as medical providers on average aren’t nearly as good at listening to people and trying to learn their full story as we could be. I don’t so much believe any more that patient’s will tell you “exactly what is wrong and even how to fix it”, but I do believe more than ever it is important we recognize that we are becoming part of a person’s experience and sharing a consciousness with them and directly impacting their experiences when we sit down and interact with their story. We as medical providers are evokers of great meaning response.
- “STOP cranking on and cramming your patient’s total knee replacement right after surgery. They certainly aren’t limited in ROM due to massive amounts of scar tissue a few weeks after a surgery. They are in pain and have muscle guarding as well as fluid in the knee restricting movement. Honey will catch the fly in this case. Try gentle ROM, Contract relax, grade 1-2 joint mobs (not 3-4), light IASTM to the quads. If their knee really is burdened with scar tissue doesn’t it make more sense to have them exercise and move anyway? They can mostly likely put a lot more force through their knee into new ROMs that you can with your hands.”
- I’m seeing a consistent theme that 4 years ago me had some decent ideas but the level understanding and the why wasn’t quite so deep. I again still currently echo the idea that we should not aggressively perform manual therapies in order to force joints and ranges of motion. However, today I wouldn’t differentiate between different grades of mobilizations or specify that IASTM be done to the quads and only the quads. Grading of joint mobilizations is an arbitrary layer of complexity to manual contact that developed out of theoretical ideas that we had the power to directly affect joint tissues and arthrokinematics in a meaningful way with our hands. Today, I would recommend doing whatever form and intensity of manual contact the patient reported to be most comfortable and helpful. I would recognize that when we put our hands on a person’s body we are also putting our hands or their brain… and more importantly their concept of themselves as cognition is embodied and not separated from the body in a ghost in the machine duality.
- “Stop basing everything you do and the way you think off of a patient’s x-ray or MRI. We now know and have a plethora of evidence that tissue damage often does not correlate to pain presentation at all. Imaging is important, but we need to talk patients off of the I have DDD/DJD cliff and onto the you don’t have to be in pain because of you imaging ride.”
- Well 4 years ago me, this one still rings true and there has been quite a bit more evidence added to the bank showing the poor relationship between pain and imaging. However, 4 years ago me loved to look people right in the eye unsolicited and say “well you know there’s a whole lot of research to show that a lot of people with DDD/DJD/disc herniations/RTC tears/etc don’t have pain. I did this because I thought it was “pain science”, and I thought I was “pain sciencing” that person out of pain. Today in my practice, there is a lot more asking permission to educate and creating behavioral experiments in clinic that show people they are capable of more than they thought, challenging them with their ability, and asking reflective questions that get them to the point they want to know why XYZ doesn’t hurt if they are so broken inside.
- “Use manual therapy and modalities if you must as a means to get a patient to do MORE active therapy, not become passive and falsely reliant on your magic sound wand or massage.”
- Yet again, I still agree with 4 years ago me to some degree here. However, instead of a means to an end, I see manual therapy falling much more into the realm of nonverbal communication these days. Manual therapy can be used as a form of communication with purposefully placed contact to facilitate movement, forms of physical interaction that convey subliminal meaning – a form of communicating without speaking, a way by which we can show people their pain is modifiable, an avenue to talk more about their nervous system and the complexity of pain, and a way to provide proprioceptive cueing to a person who may have lost awareness and good communication with the embodiment of their pain.
Five out of sixteen “clinical pearls” down. I would love to hear your feedback and even more so love to hear your own reflections on your changes in thought process over the years! Stay tuned over the next few weeks for parts 2 and 3 of my current day reflections on 4 years ago me.