Every day on social media I see many different views and opinions on how we should be managing our patients. I see some saying how we need to apply various manual therapy treatments. I see others explaining how we need to find diverse and novel ways for our patients to move. And then I see others discussing how we should explore the psychological and emotional issues our patients may have. However, I wonder just how many of these suggestions are actually used in the real world, and how many just talk a good game online.
Now I don’t know about you but my time is ALWAYS of an essence, and ALWAYS a limitation. For example, in my NHS role as an ESP in an extremely busy orthopaedic outpatient clinic I see on average around 20-25 patients a day. I get about 20 minutes sceduled for a new patient and 10 minutes for a follow up. In private practice I see a few less around 15-20 patients a day with about 40 minutes for a new patient and 25 minutes for a follow up.
In the usual 9-10 hour day I am often seeing patients back to back with rarely any gaps, apart from the odd cancellation or DNA, or for a 30 minute ‘comfort’ break which is usually just long enough catch my breath, have a bite to eat, and take a pee. And lets not forget the notes, reports, and emails that need to be done during the day. So it’s fair to say that most days I’m busy as hell…
Now I’m not complaining or moaning as this has been my routine more or less for 15 years as a musculo-skeletal physio, and its a fairly common workload across the profession, and there are other healthcare professionals who have even less time and even more patients, like many of my busy GP colleagues.
Priority’s
But what this work schedule does mean is that I have to be realistic in what I can do and say to my patients on a day to day basis. Basically I have to prioritise everything, and to put it bluntly most of these online suggestions on how I should be managing and treating my patients I find are nothing more than pie in the sky, delusional, wishful thinking, by those with no real world clinical experience.
For example, in the average new appointment I have to make introductions, take a detailed and thorough history, ensuring I give time for the patient to speak, as well as ensuring I ask all the questions I need to, whilst also attempting to build rapport and a therapeutic relationship. I then have to do a physical exam checking movement, neuro-vascular status, and pain provocation signs and symptoms. I then have to give my opinion and advice on the diagnosis, answer any questions the patient may have, offer reassurance, correct any misunderstandings and address any concerns or fears. Finally, I am then able to offer some advice and guidance on ways to treat and manage the said issue.
So I don’t know about you, but I find myself with extremely limited time to do any thing with a patient. OK in follow up appointments there is more time to do things, but with the average number of follow up sessions being between 3-6 visits, due to restrictions from both the NHS and private medical insurers, it means time is short to get anything meaningful done.
Delusional
So to think that I can spend time with my patients on treatments such as massage, mobilisations, manipulations or any other manual therapy, and still have the time to give good sound advice and plan a suitable, comprehensive and individualised self management program that a patient can do easily and effectively is delusional.
To think I can spend the time with my patients in the gym in their yoga pants exploring interesting, novel, and unique ways to move, encouraging tri-planar vectors with over head rotational arm drivers is just applied functional fiction.
And finally to think I can spend the time to sitt quitely and listen effectively for long enough to develop a patient trust so that they tell me their deepest, darkest fears about a condition or painful issue, and then have the time to explore the barriers and ways and means to challenge and confront these is just psychobabble.
Keep it simple
Now that’s not to say I do not attempt to do ANY of these things before you all go and jump on the accusational band wagon, rather I just find myself having to do modified p, simplified versions of the above. Limited time also means I have to stop doing things that don’t help me or my patients that much. To be frank I can’t justify spending time on the 1%er’s at the sake of the 10-30%er’s
So this often means that after I have assessed a patient, ruled out anything sinister, got a diagnosis, I follow my three simple golden rules…
- Give good advice and education
- Encourage movement
- Load it
This means I rarely find any time or any benefit for ANY passive treatments such as manual therapy, electrotherapy, or taping, and is one of the reasons why I question and challenge therapists so much who do use them. I simply can not work out how any good therapist in this day and age can spend their time and limited resources on these kind of treatments and still find the time to talk and listen to patients, as well as plan, advise and demonstrate an exercise and self management program effectively. For me advice and movement is, and always will be, the first intervention, and will always be priortised as such.
I also find that rarely do I have the time to explore with my patients all their psycho-social factors, finding out about all their fears and concerns. This doesn’t mean I don’t explore some of them and find some ways to challenge and overcome them, just not as much or as in depth as some online experts advocate.
I also find that rarely do I have time to work out a kick arse periodised rehab program that covers all the aspects of strength and condition that I want to. Instead I often tend to pick just one or two exercises that work the area in question hard using simple large compound based movements such as squats, dead lifts, over head presses etc, and these are usually done with the basic principles of, do as many of these as you can, as often as you can, with a load that you find challenging but acceptable.
Criticised
Now I often get criticised and challenged for this simplistic approach, which is fine. But what pisses me off is many think because I keep things simple I don’t recongnise or understand the complexity or nuances of strength training, or pain science, or psychological interventions, or the individuality of patients.
Well I do, so shut the hell up.
I am merely trying to be open honest in an online world where so many seem to talk a good game and I’m sure don’t do half of what they say they do! I am trying to be realistic in recognising that I and many other healthcare professionals simply can not offer in depth, individualised, detailed management to 15-25 patients a day.
So, yes I do find myself giving very simplistic exercise programs of one exercise done as much as they can. I do find myself explaining pain very simplistically using explanations such as faulty or sensitive alarm systems, with occasionally some pathoanatomical explanations, such as inflammation, weak muscles and lack of capacity. And you know what, I find it helps many of my patients. Not all, it’s not a perfect model, far from it, but it’s all that I can do.
So when I see more and more ‘online experts’ complaining about the simple approach in physiotherapy, criticising it for its lack of individuality, and thinking simple approaches mean a lack of knowledge or understanding, it annoys me immensely. In fact it fucks me off completely.
As a strong advocate of simplicity I can tell you that to do something simply really well is hard fucking work.
Also do not let others fool you into thinking that complex approaches are more effective or more skilled. Do not let others fool you into thinking simple approaches mean you know less, work less, or get less results. Do no let these knobheads take us back to the days where we focused too much on the details and missed the bigger picture.
So I will finish by asking if we could all please try and be a little bit more honest and realistic in our explanations about what we do with patients. Lets remember that ALL therapists and patients have limited time and resources to get anything done. Lets stop talking a good game about what we SHOULD do, and start talking about what we ACTUALLY do do.
As always thanks for reading
Adam
PS I never though I would end a blog with ‘do do’
Adam, possibly before you were born or not far off, some 45years ago I retired as a Medical Pathologist & entered full time Research..I am impressed by and fully recognise what you say about limited time and provision of fuller professional advice and guidance. Knowing nothing much about Physiotherapy I recently (post-MRI) learned of a tear to the supraspinatus of my right shoulder and, thinking I’d also torn a muscle in my left groin, I was diagnosed with OA of my left hip. The young lady given my Rot.Cuff job was unable to agree with your article on challenging the discomfort/pain barrier and as far as I was concerned, treated my elderly shoulder too delicately, even though I’m only in my 84th year, by giving me 3 simple pieces of homework; a bigger stronger (rugby playing ) gentleman did likewise with my hip; I sympathise with you All but do agree with your notion of (when appropriate), discussing the benefits of different approaches and, especially of (when appropriate) a more rigorous and wider/ fuller range of physio. guided homework and, performed as frequently as though preparing for an Olympic Event. Fuller/more comprehensive handouts can be useful if the patient is thought capable but, you guys/dolls do need to be given greater flexibility to know the patient for psycho, physio and motivational suitability. I gave up after 4 visits and have followed your’s and other of your clleague’s advice on the Web. The tear is now 10months old and both are -albeit – very slowly improving. I thought your 10 Commandments were good. Very Best Regards, Tony (GA Phillips)
Hi Tony
Thanks for the comments and I’m sorry to hear of your experiences and issues with your shoulder. I’m glad however that things are slowly improving. Keep at it and it will continue to do so.
All the best
Adam
Hit the nail on the head again, Adam. I believe that we often over-complicate, over-document and over-explain simple things, mostly in an effort to engender the respect of our patients and our colleagues.
absolutely, simplicity scares the shit of ‘professionals’ makes them appear basic and not special and no one wants that…
I share your pain Adam. Increasingly I’m seeing more and more middle aged, overweight patients in poor physical health complaining of low back pain. They’re desperately keen for some convoluted, highly scientific explanation perhaps about their foot pronation followed by some clever taping technique or something ‘put back in place’ like an Action Man doll ; that will evaporate their problems.
Someone’s got to tell them haven’t they ? My discussions these days are far more about getting fitter, toughening up, being more robust and resilient… and reducing the load going through the spine (read as lose weight if they don’t get the hint).
As Basil Fawlty would say ‘Gary Martin from Flitwick : Specialist subject – pointing out the bleeding obvious’ …,.nice post Adam….it’s therapy for me.
Cheers Gary and you’re from Flitwick… I went to school in Bedford not a million miles away, small world hey!
Another great blog Adam. I’m a physiotherapist and ex army commando so you can imagine my mind set when people come in with pain for several years and doing no physical activity in their life. Lots of education and at times banging my head against the wall!
Day in day out I have to listen to the ‘nonsense’ that patients tell me about how bad there pain is.
Now I am speaking openly and this by no means every patient I see. I do know that working in MSK we are never going to have the perfect patient every day who does there rehab and gets better all the time, it does not work like that.
However we need to be more assertive we our patients and driving self management and progressive exercise cause simply this is what helps. I use manual therapy but as I continue to learn more I am becoming much more of an advisor and exercise prescriber which is what Physiotherapy is about.
Keep up the great work mate.
Thanks Ryan, keep fighting the good and noble fight. I feel your pain and know it’s tough trying to stop a tidal wave of bull shit, but as an ex commando I’m sure you have crawled your way throu much much worse fella…
Per Mare, Per Terram
Adam if you had more time with a patient say hour evaluations and half hour follow ups, would you change the way you practice?
Hi Scott
That’s a very good question, but my answer is no. I would merely have more time to ensure I reinforced and re emphasised the importance of movement and loading, as well as having more time to develop robustness and resilience in my patients
Hey Adam, from a patient’s perspective I love your approach. And I imagine you’re doing more exploration of the psychosocial factors influencing your patient’s pain than you’re giving yourself credit for, and more than ‘couch’ time could perhaps get to.
As a patient with a few years of unsuccessful PT under my belt I can say what that the good advice and education part was more emphasized in my own care (I think I had 7 different PTs in that time). I wish the explanations for my pain weren’t solely biomedical in nature and that someone had told me that pain with movement didn’t mean I was damaging my hip more or fucking up my surgery (I had hip surgery after 13 months of pain, I thought the surgery would fix it. It didn’t).
I was an all-start mover, I pushed hard, I loaded. But it hurt, and nobody ever told me that hurt didn’t mean damage. Ever. And my pain got worse, no wonder, because when it hurt I had all these erroneous beliefs (and visualizations) that I was destroying my hip. That led to more worry, more fear, more unnatural movement which led to later PTs telling me my ongoing pain was about my posture and dysfunctional movement, which I took to mean I was sitting wrong, moving wrong, existing wrong.
Damage. Destruction. Fucking up my surgery. Reinjury. That’s where my fears stemmed from, that’s what I worried about. And most patients I talk to worry about the same thing, that the pain means damage and that pain with movement means more damage and eventually more pain. And most patients I talk to are never challenged in that thinking by their PTs, just as I wasn’t. They’re left thinking they are damaged goods: broken, frail, weak, unstable, asymmetrical, out of alignment, dysfunctional, whatever. They’re left believing someone is always going to have to fix their brokenness or set them to rights.
What doesn’t seem to happen often enough, what I wish would happen more, is patients leaving feeling strong, capable, adaptable, resilient, and robust. And good advice and education would surely help and can surely be done whilst one is moving, which seems to me would only serve to reinforce the message. When one is being told they’re not damaged goods, that they’re strong and capable and able to do all these things WHILE they’re doing them, and they’re encouraged to do them more, that’s gotta be more likely to stick.
Sorry for soap boxing. This is all simpler and more complex than most people seem to realize. Simple isn’t easier, as you said, it’s much harder because it has to be done well and the message has to be concise, accurate, and helpful. It has to empower the patient to go forward and live their lives. After all, in the best case scenario a patient may go see a PT twice a week, that’s maybe an hour of time a week in actual contact with the PT (probably less)? Maybe two hours in the clinic? These folks are on their own, with their particular narrative about their pain and their abilities, the other 166-167 hours a week. And PT only lasts for a few weeks, right? So for the other roughly 8754 hours in the year they’re on their own.
Thanks for your comments and insights Joletta, and agree we need to ensure people know how they can help themselves more.
Also it really doesn’t take long to instil confidence robustness and confidence in people despite what others may say, a few minutes of reassuring advice followed by some exploring or challenging movements and we are already starting in the right direction.
Wish more would see this rather than spend time rubbing people thinking that this will get them better!
Thanks Adam. Always entertaining, whether I agree with you at times or not.
Thank you – I have always stood by a “keep it simple” approach and I would hope that your post will help others to do so with more confidence. I sometimes feel there are too many egos in our profession. Effective doesn’t always seem or need to be impressive.
Thanks Jeanine and I agree way to many ego’s… Mine included! ?
My bjj instructor once told me: If it’s not simple, it Simply doesn’t work!
Awesome post! I always think this way when o hear about the many experts going on and on about what we “should” be doing with patients. We often hear things like “if you don’t pay attention to the _______” then you aren’t doing anything! For me I always preach that taking a simpler approach is more effective. Does it really matter that C5 lacks end range rotation on C6? Or can you even feel that (I don’t think so)? To me, I the end we just have to get people moving more and that often takes care of th majority of their MSK problems. Movement with a purpose and education have always worked well for me. I believe that often the “experts” don’t actually treat people day to day and instead just do research and tell everyone what they should be doing. Also, I think that PT is one of the only professions where we all seem to be hard on one another about how we practice. Everyone feels their way is the right way and if someone has a different approach they must be wrong. Instead we should celebrate the diversity of the scope of our profession and work wth each other by teaching and discussing instead of belittling different approaches.
Always good to remember something an old hand told me years ago: the rule of thirds. 1/3(probably more) of your patients will get better no matter what you do. 1/3 won’t get better no matter what you do and the final third may be assisted by your ministrations. So first decide which group your patient is in and above all get over yourself, you’re not that important at least 2/3’s of the time.
Very true Kevin, and it’s good to be reminded of this!
As a new grad in PT I find this approach refreshing as the majority of our program taught us how to “fix” people using passive treatment. I have always been a firm believer in taking accountability for your own actions and in the world of PT this means taking accountability for one’s pain. I love the looks I get when I tell people, “how can you expect change (reducing pain or c/o) if you don’t change what got you here in the first place?”. It usually consists of what does this newby know or I came here for you to fix me. I have found that the simple approach to be far more empowering for not only the people I see but also myself and hearing it from an experienced PT only helps foster that belief that this is the road I need to take as I continue to grow as a clinician. In a world of a passive, fix me I’m broken approaches this helps give me confidence in the uphill battle that is active-based rehab in a passive world. So thank you for your voice!…however controversial it may be some times haha
Thanks for you’re comments and I hate the notion that therapists think they can ‘fix’ people… It’s such a narcissistic view to think that they can fix other people!
Hi Adam,
Surely you could fit a Masters Programme into your schedule, maybe a manips based programme (joke).
I see the NHS has not changed a bit, 20-minutes for a new patient, you have got to be kidding. I feel more for the patients, what are they exactly getting from a 20-minute consult – do they feel empowered, more resilient or is it just a whirlwind.
Good on you Adam for keeping things specific and simple – but personally, if I was offering 20-minutes for an initial consult I feel I would be doing the patient a disservice.
Keep up the good work
Thanks Carl, and yes it’s a challenge to ensure that patients feel valued and listened to in 20 mins… Sometimes it works, sometimes it doesn’t, would more time help yes, but then waiting lists would be longer and issues harder to address, the perpetual catch 22!
Hello Adam,
this is not completely addressed this topic (which I like btw!!)
i am a danish physio working in the public area, not hospital but sort of clinic. im 26 years old and have 2 years of exp. We are a few colleges who follow you alot and would like to upgrade our expertise in muscoloskeletal in generel. im starting at osteophaty and my college starts at sportsphysio because he started reading your wordpress! he tended to start at osteophaty but you changed his mind..
what do you think about osteophaty when you share this (your) approach on physio?
is it possible to combinate theese mindsets?
i know osteo is a manuel direction but dont you think that you can use the techniques as symptom modification?
thank you!
Hi Lasse, as you may know I am not a fan of offer wrong short term solutions to long term problems! Yes things like osteopathy and other manual therapy can help ease symptoms but they never solve the problem in my opinion and often can actually make matters worse with loss of patient self efficacy and dependance on these short term aids and ‘supports’
As I said in the blog self management is king and always should be prioritised as such!
Cheers
Adam
Dear Adam,
As a physio of almost 20 years and victim of the prolonged and expensive manual therapy certification process, I wish I would have come across someone like you earlier in my career. I truly appreciate your straight-forward, no BS approach and look forward to reading your comments. I became so burnt out (mentally and physically) with the manual therapy “I can fix you” approach that a change was necessary. Major wrist surgery also helped with that change. Your honest approach and postings are a breath of fresh air and often put a smile on my face in the midst of a busy day. Cheers! Keep it up. Any plans of coming to Canada (Ontario) in the future?
Regards,
Aaron
Hi Aaron
Thanks for your kind comments. I’m in Vancouver in April 2017 to try and talk about simple honest management in physio… Should be interesting!
Hello Adam,
I have been following you for quite a while. I always find your way of thinking very interesting and I agree with many of the topics you write about. I do think that we tend to think (or want to think) that we know more than we actually know. It seems that making things complicated and using different gadgets make us better. I do think that many of us are marketing and pretending “machines” and many times patients like that. Few years ago and even now, in many places back home (Spain), patients look for the clinic where they can find more machines and strange techniques (they do improve, we all know how powerful Mr Placebo is). This means money for CPD organisers, money for physios and all a big lie. EDUCATION is what patients need and less “selling smoke”.
Also, I do understand that physios in the NHS have less time, but physios in the private sector should have longer sessions (yes, I know, it might mean less money), as no one likes to be treated in a rush and we all know how important reassurance and interaction are.
Many thanks for your always interesting blog posts and for making people think (thinking, which we tend to forget far to often),
Jorge
Thanks Jorge
great article. Thanks
Hi Adam, just read this. As usual, you are on point. Thank you for your tireless efforts in the face of such a demanding work-life. I look forward to shaking your hand and buying you a beer in Vancouver next April. BTW, you do realise you are entering the hotbed of black-belt manual therapy focussed PTs, always armed with needles to IMS the pain away? If I wrote a blog, my first post would be: ‘Is the Physiotherapy profession in need of rehabilitation?’. Here in Canada, I believe so.
Keep fighting (writing) the good fight. All the best, Duncan Aspinall.
Hey Duncan, many thanks for the kind comments. Looking forward to a taste of Canadian beer, and I have been warned about the Jedi Masters of manual therapy over in Canada before… I will come prepared with my light sabre!
And if you ever wanted to write that blog (awesome title BTW) let me know and I would gladly post it for you, I’m always on the look out for guest bloggers.
Stay well, and see you in 2017
Cheers
Adam
Cheers Adam, I might take you up on that offer!
Also, be sure to pack that light sabre; I’ll dig mine out for back-up.