The 10 Commandments of Physiotherapy

A commandment is a decree given by a higher power, a divine order, God’s words… and although I have been accused of having a God complex from time to time, I don’t want to come across as having one. So perhaps to call these ‘my commandments‘ is a bit strong, maybe I should say these are ‘my suggestions‘ but where is the fun and controversy in that? So let’s stick with my original title and give my critics something to moan about…

These ‘commandments’ are based on my observations, interactions and experiences, and are heavily influenced by the few great physios I’ve worked with over the years. Those whose moral compasses have been straight and true. Those who have reason and rationale in a profession that is swamped with the just opposite. Those who taught me the real ‘art’ of great physiotherapy isn’t in the hands but rather the head and the heart.

They are also heavily influenced by the many others who I have discussed, debated and argued with, who have caused me to think and reflect long and hard on my views, opinions, beliefs and biases.

So here are my 10 commandments of physiotherapy!

Commandment 1: Active over passive treatment… always!

If you know me or have read any of my other blogs you will not be surprised that this is my first commandment. I have long been discussing, debating, some will say banging on for physios to useless if not completely move away from passive treatments for all conditions.

When I say passive treatments, I mean anything that involves a patient lying down on a treatment couch and having something pressed, pulled, poked, rubbed, cracked, needled, and when I say less, I mean less use of and less promotion of!

Now that’s not to say passive treatments don’t work. Some do, a little bit, for a short period of time, in certain circumstances, with certain patients. But all passive treatments no matter how you interpret, twist, contort or torture the research are simply low-value interventions, costing a lot, wasting resources, and more importantly, diverting attention away from the real issues and better treatments we should be offering.

Simply put if your physiotherapy is more doing, and less doing-to, positive long-lasting results will follow!

Commandment 2: You can’t go wrong getting strong!

Despite my background as a past S&C coach and my clear bias towards strengthening exercises, there are many other factors to consider when using exercises. Strength, power, endurance, motor control, all have their place and different methods to achieve their goals.

A thorough understanding of how human physiology responds and adapts to different modes and methods of exercise is essential and recognising when a patient needs one or the other is vital.

However, strengthening exercises are not only about strengthening muscles, tendons and bones. Strengthening exercises affect the human being doing them. Strengthening exercises strengthen a person

Exercise is not just about physiological responses, exercise is also about psychological responses. It should never be forgotten that exercise can reduce pain, fear, anxiety, depression and a host of other psychosocial issues, and so should be a consideration for all therapists to use it.

Commandment 3: The nervous system is king!

Many therapists place importance on one tissue over another, often this is fascia, or tendon, or muscle, but for me, the nervous system is king!
When the nervous system is unhappy, everything is unhappy!

It is beginning to be more widely recognised that we don’t treat fascia, we don’t treat muscles, we don’t treat tendons. We actually ‘treat’ people.

It really doesn’t matter how good you think you are at myofascial release or spinal manipulation. It doesn’t even matter how good at rehab or strengthening exercises you think you are. If you have pissed off your patient and their nervous system with some fear-inducing comments, poor explanations, or just not connecting and building a rapport and a therapeutic alliance with your patient, you won’t be getting any positive results any time soon!

Commandment 4: Interaction over intervention!

The connection and alliance you have with your patient is everything! From the 70-year-old pensioner recovering from a total knee replacement to the stressed-out middle-aged manager enduring chronic low back pain for 5 years, to the snot-nosed 18-year-old football player hobbling in with a pulled hamstring muscle from yesterday’s game, you need to connect with them all, in an individual tailored empathetic approach.

Giving your patients reassurance and confidence in your professionalism and technical ability. Demonstrating that you understand, empathise and care about their problem. Showing them you are a trusted honest professional and caring human being, with a personable, natural and friendly manner is the biggest skill of all

You don’t need to be best friends with your patients, but a good connection is absolutely vital for a successful outcome.

Commandment 5: Listen more, talk less!

The average time a patient gets to talk un-interrupted in a medical consultation is short, really short, between 12 and 23 seconds in some research. Make a conscious effort to let patients speak freely and actively listen to what they are saying and how they are saying it, don’t just wait to speak next, or be thinking about the next question you want to ask.

You will learn so much more and be able to get a much clearer picture of a patient is allowed to speak freely. Don’t follow a tick box standardised assessment that can come across robotic, sterile, and uncaring. I realise this can be tricky and challenging to do, it takes practice and experience, and you do need to ensure you ask all the relevant questions, but start practising active listening and flexible assessments and see the benefits it creates!

Commandment 6: Don’t be afraid to ask questions!

That’s both patients and other healthcare professionals! Talking to patients more, a lot more, to gain as much information as possible is something I truly believe in. Getting as much information about a patients past, family, hobbies, lifestyle and interests not only helps builds rapport but also gives you valuable insights how to manage them and what may have caused the issue in the first place.

It obviously needs to be done tactfully and considerately, you don’t want to appear nosey, disrespectful or prying, and it doesn’t have to be done all in the first assessment!

Questioning other healthcare professionals is even more vital. This means your peers, specialists, doctors, nurses, consultants etc. Don’t ever assume that someone with more experience than you is right, they often are, but people in authority often make mistakes or can become outdated.

If you have doubts or questions ask, and if needs be, challenge them. But just as you question and challenge others, expect and welcome it when others do the same to you.

Commandment 7: Admit mistakes and make adjustments as you go!

To err is human. Cock ups and misdiagnoses happen. However, there is nothing worse than a professional trying to cover up an honest mistake or trying to bluff and blag their way out of a balls up! If you made a mistake, admit it, everyone does.

However, making mistakes is fine, not learning from them is a crime!
Hypotheses and diagnoses can, and often do change as a course of treatment and time progresses. That’s why it’s called a hypothesis. Be prepared to alter, adjust or even stop a course of treatment completely. Don’t blindly, stubbornly continue on if more information presents itself!

Commandment 8: Don’t be afraid to ask for help!

From newly qualified therapists to experts, specialists and even the guru’s they all need help from time to time, although in my experience the gurus don’t tend to admit it. Some ask for it more often than others, but guaranteed everybody will need help, support and guidance at some time or other.

You will never know everything, as soon as you think you do, you’re wrong! In this profession, there are no absolute answers, definitely no definite’s, and always an exception to every rule!

Asking for help when needed shows honesty, humility and experience!

Commandment 9: Confront your knowledge and biases regularly!

You will often and quickly fall into comfort zones in this job, finding ways of doing things that seem to work well and then you will stick with it!

DON’T

Whenever you feel you are going through the motions, being prescriptive with your approach, method or treatments, that’s when you need to look long and hard at what you are doing and what you know!

Never think you have it all figured out, never feel comfortable that what you are doing or what you have done! Look at what you know often and ask yourself what if…?

Commandment 10: Read more, a lot more!

Knowledge is power, and the quest for knowledge is ongoing! If you’re asking yourself questions constantly, this will drive your search for answers. Read research papers, read books, read blogs, read Twitter, read anything that’s relevant.

However remember there is more to learning than reading alone, observe, listen, talk, get involved, discuss and debate with others. Interaction is a great way to learn, and remember you don’t have to agree, in fact, I would recommend that you go and actively seek out those that hold opposing views and ideas from your own.

You can learn a lot more from those you don’t agree with, I have, believe it or not…

So there you go, my ‘commandments’ for physiotherapists, I’m sure some will disagree, and others will think I’m trying to preach! So be it. Take away what you want, ignore what you don’t. It’s not an exhaustive list and one that could be added too. In fact, I’d love to hear what your own ’10 commandments’ would be, so please leave me a comment below!

As always thanks for reading

Adam