Seven Important Lessons: An Open Letter to 2016 Matt

Hey Matt- congrats on finally finishing your formal schooling and becoming a physiotherapist. You’re going to learn a lot in 2.5 years, and I’m here to fill you in on a few lessons so you avoid some big mistakes. I hope there are some new grads out there that can also read this and maybe relate a little.

  1. Don’t get too high and don’t get too low.– I get it buddy. You just won a bunch of awards upon graduating, you’re the best. But guess what? That national exam- you know the one that you’ve been preparing for night and day? The one that FINALLY seals the deal and makes you a real physio? The one that a lot of physiotherapists have told you is a complete joke? You fail. Your awards do not mean a thing. Get real comfortable with the word “intern” when you’re signing your name. But hey, dust yourself off, don’t get too low. This failure will be your first real battle with mental health but it does not have to be. You know what you know. OH and while we are at it- lots of your patients will tell you how awful their previous physiotherapist was. And sure, some of them sound pretty awful, but how many of your patients failed with you and have moved on to a new physio? What do you think the patient will say to their new physio?
  2. Look your patients in the eye and shut your mouth.– You were a teacher before you were a physiotherapist so I get it- you want to spread your message like a dandelion spreads its seed- but shut the hell up. Patients need to be listened to and FEEL listened to, especially the complex ones you’ve signed up to treat. It is more important for you to pause, tell them you understand, and let them vent. Sometimes your most successful appointments will be an hour of talking, and you won’t even lay a hand on the patient. I know what you’re going to say- I signed up to fix muscles and bones not to be a therapist. No Matt, you donkey, you signed up to help people, and you’re not going to help anyone if you don’t build a trusting relationship with your patients.
  3. Dinosaurs are out there- don’t let them make you angry.– Fresh out of school you will LOVE sending emails to other practitioners. You will love opening a dialogue with chiros, massage therapists, athletic therapists, doctors, and other physios. About four snippy replies later, you will think twice before corresponding. Older, more experienced practitioners will chop you down, and all but tell you you’re useless. DON’T LISTEN. Keep sending your emails and keep advocating for your patients and multi-disciplinary care- good practitioners are out there and they will value the correspondance. DON’T GET JADED. You will never change how people practice, you can only control your own practice- and mute their commercials when they come on.
  4. Don’t drink the punch, and certainly don’t chug it. You know the practitioner you want to be and you think you know how to get there. Trust in the scientific evidence, and trust in your mentors but don’t buy one individual theory. There is no recipe for rehabilitation and there are many ways to make people better. If someone had the magic bullet, all physios would be using it already. Take courses you find interesting, not courses other people push you to. Always fall back on the evidence- take a few small pearls from every mentor you meet, but don’t emulate anyone. You’ll notice this letter doesn’t include anything on SFMA, FMS, Mulligan, Dry Needling, or Vestibular Therapy. Don’t get me wrong, these courses are important, but paying and attending those are the easy lessons- I don’t need to talk about them in a letter.
  5. Walk the walk.How many times will you tell an athlete that their squat is poor? Tons. You’ve already told a bunch of patients that and you haven’t even passed your national exam. How long will it take a patient to call you out on your own squat pattern? 3 months. And you will know, as you perform your piss-poor squat, that you have forever lost that patient’s buy in. So if you’re going to tell people to be active and strong, you damn well better do it yourself. You don’t have to be the best, but you certainly need to be better than where you are.
  6. You won’t bat 1000.This one is self explanatory but for some reason you really struggle with this, so let me make this really clear. SOME PEOPLE CAN NOT BE HELPED. Some people don’t even want to be helped. Some people won’t do the things that will so clearly help them. When you identify these people, have that extremely awkward conversation that they need to find assistance elsewhere. This conversation will lead to patients storming out, rude comments, and patient complaints, but it is the right thing to do. Stop taking these people’s money, explain to them why things aren’t working out, and rip off the band-aid.
  7. You are not your jobI get it, you worked hard for this and it’s shiny and new and, sure, about 0.3% prestigious. But school is out- improve your work/life balance. You do not need to reach your career goals in a year, or even five, but your loved ones will not always be around. Keep things in perspective and remember what’s important. Hug everyone.

Thanks for reading gang, hope everyone can take something away from this!

MG

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Three times a week, for six weeks.

My one faithful reader just got on my case about not publishing a blog post in a century and a half so I figured I would throw a quick post up so I can stop dealing with his chirps.

I was recently doing some education sessions in conjunction with Okanagan Hockey Academy and the Edmonton Oilers for young hockey players aged 9-16. I opened my presentation with the same question everytime:

What does a physiotherapist do?

As you can imagine I got all sorts of answers from that group of developing brains. Many described my profession as massage therapy. Many said physios fix people. Some kids even brought up modalities such as ultrasound, TENS, and IFC (which was the equivalent of them standing up and kicking me square in the crotch). Not one single child gave me the answer I was looking for. So I figured I would ask the same question of the parent group that I was lecturing. Their brains had fully developed, they had a lifetime of experience, they would be able to answer my question.

Nope. Same answers.

Which now got me thinking, what is the state of physiotherapy in the community? When someone walks into a clinic, what are they being told? What’s happening?

 Lets do a case study, because I love those.

Braun Swisscheese is unfortunate enough to hurt his medial collateral ligament in his knee. It is not a full tear, but it’s enough that it’s going to take 4-6 weeks of healing for Braun to start to feel normal. Braun gets great advice from his family doctor to pursue physiotherapy. At this point it’s choose your own adventure, and Braun can go to clinic A or clinic B. Lets see what happens next:

Clinic A: 

  • Assessment of Braun’s knee and entire lower chain
  • Education about diagnosis, healing times, gentle exercise program
  • Home exercise program taught
  • Follow up in 1 week

Clinic B:

  • Assessment of Braun’s knee and entire lower chain
  • Diagnosis given
  • TENS, IFC, ice
  • Follow up in 2 days.

Lets fast forward to three weeks into his treatment

Clinic A:

  • 3rd follow up
  • Continued education regarding healing times
  • Exercise program progressed as appropriate

Clinic B:

  • 8th or 9th follow up
  • TENS, IFC, hands on therapy
  • Home exercise program

And now lets fast forward six weeks into his treatment:

Clinic A:

  • 4-5 visits total
  • Functional testing and return to play
  • Education on next steps
  • Discharge to home exercise program

Clinic B:

  • 10-12 follow ups total
  • Functional testing and return to play
  • Discharge to home exercise program

So which Braun had the better outcome?

It might surprise some of you to know, that Braun had a fairly identical outcome at both clinics. Physiotherapists do not change the natural history of an injury- A partial MCL sprain is going to heal in 6 wks as long as you do not abuse it. The key difference here is that Braun B paid significantly more for treatment and invested a significant amount more time.

This is not to say that physiotherapists do not help. It is our job to return people to full function while their body does the healing. We help people move better and keep moving. It is our job to educate the masses on their injuries, and tell them what their prognosis is.

Physiotherapists are under constant pressure to see patients at a higher frequency, whether they need to be seen or not. This feature of private practice is running rampant and it drags us away from patient centered care. At a clinic I used to work at, a large chain, my performance was measured by how many follow ups I could squeeze out of a patient. Think about that- I was judged not by patient outcome or satisfaction, but by how much money they spent before being discharged. Disgusting.

Now, some therapists will argue with me and say “my patient is in so much pain, they need me to see them so they can make it through the day,” and I agree, those patients are out there- but they are few and far between. Do we really still believe that the only way people will get better is with treatment 3x a week for six weeks? Who believes that anymore?

In my mind we need to entirely shift how physiotherapists and other rehabilitation professionals are viewed in society, and that happens in two ways:

1) Patient’s need to be better. Inform yourself going in. Demand education. Demand Evidence.

2). Physiotherapists need to be better. It’s not about your bottom line, it’s about helping people.

Thanks for reading! Please leave a comment or provide feedback to mgoertzenpt@gmail.com.

 

 

Fakers and Attention Seekers

You’re stopped at a red light in your beautiful black Pontiac G5, on a gorgeous sunny day in June. Sun roof is open, Ed Sheeran’s on the radio, ice cold cola in the cup holder. Then suddenly, without warning, someone bumps their car into your rear end. A 5 km/h nudge, but it gave you a good shake nonetheless, cars are big and heavy after all.   You look up at the light, still red. Son of a bee sting, this donkey rear ended you while you were stopped at a red light. You get out of the car, mutter every curse word you know under your breath, and exchange information. Not enough damage for a police report, no apparent need for an ambulance ride, but annoying as can be. 

That evening you start to get some neck pain and you spend most of the evening stewing about the accident. Great. Now you’re gonna have to go the autobody shop AND the doctor cuz your neck hurts and you sure as hell aren’t gonna pay for physio yourself. Better mention that to the insurance adjustor. You’re a victim, you shouldn’t have to deal with this garbage. You crush a bag of chips and go to bed, or try to, but you have a horrible sleep because of that neck pain.

The next morning your pain has worsened. It is so horrible, that you decide you need to spend some time in the emergency room. Your back hurts now too- this is not good, you gotta go to work. Those pizza pops in the fridge are NOT free and neither is your HBO subscription, and if you don’t work you don’t get paid. So into emerg you go, where they do x-rays after they hear you’ve been in a car accident. No fractures. Phew. They recommend follow up with family doc and physiotherapy for your “myofascial pain.”

This is the turning point for most people. At this point, 90-95% of people get better. Their pain gradually reduces, they continue with their lives, they get good advice from their physicians and physiotherapists, and they return to their full function, with a fully functional Pontiac G5.

What about the other 5-10%? Don’t they get back to loving Ed Sheeran on a sunny day in June?

The unfortunate truth is that the other 5-10% trend in the wrong direction and their pain persists. The reasons and prognostic indicators for this are varied and extensive, but the fact of the matter is that a number of these individuals who have been in motor vehicle accidents will go on to experience chronic pain. These people have high levels of pain, decreased levels of function, and many times deteriorating mental health following an accident- even one with very low force like the one described above. These people have pain for months and years following the accident- and often it will never go away. Here are some quotes from some of my patients with chronic pain:

“I used to run marathons, and now I struggle to walk up stairs.”

“I lost my job as a laborer because I could no longer keep up, then my wife left me.”

“It’s like someone constantly has a fiery dagger stabbed into my back, and occasionally that someone will decide to twist it.”

“I just want my life back.”

These quotes are not included to create pity, but rather to create awareness. Cancer patients I have worked with have had similar quotes, yet these unfortunate chronic painers often deal with people telling them they are faking. They are often thought of as “seeking a settlement,” or “craving attention,” which as you can imagine is great for their mental health. Even misinformed medical professionals will often not find a mechanical cause for a patient’s pain and label them as fakers. The fact of the matter is chronic pain syndrome is a legitimate condition that can greatly change an individual’s life.

I work in a unique context where I will often see these patients 2+ yrs after their 5km/h accident and many have similar stories. They bounce between health care professionals, searching for a reason and a cure for their pain- and often they will get conflicting answers. They get a ton of diagnostic imaging that comes back relatively normal. They are on high dose pain killers and have been for an extended period of time. Often they have experienced a rapid decline in their mental health, and are now on medication for that as well. The vast majority have stopped moving- that is to say, no sports, no hobbies, no stairs. 

As a physiotherapist, when these patients come see me in clinic they are not experiencing pain because of a sprain or strain- the damaged tissues are long past their healing times. No soft tissue work or mobilization is going to change anything. What I do change, however, is their understanding of their pain and their function. I combat the deconditioning, and teach them that it is safe to move. From there, they improve.

Does chronic pain syndrome ever go away? Most practitioners consider it a permanent condition- the pain will always persist but function can be improved. I have experienced a few chronic pain syndrome patients that have improved so dramatically that they are functioning as they were before the accident- but they still have their pain.

So take home message: chronic pain syndrome is a real thing and we need to be aware of it. There are fakers out there, there always will be, but those are a very small portion of the population.

Thanks for reading! As always I welcome feedback and comments.

Concussion Consensus: Changing Our Approach

First, let me just start by saying: I am not brave enough to ever defy my dentist, especially as someone with an aggressively dominant gag reflex (no joke, they called me “Hork-up” in hockey because I gagged when I put my mouthguard in).  That being said, my good friend Dr. Bob Ridley Jr., dentist extraordinaire, recently called  me out on Twitter and said that I should update the world on the latest Concussion Consensus Statement, which was released mere days ago. Thus, my night has turned from cuddling with a new puppy and watching playoff hockey, to doing research and gritting my teeth excessively. Thanks Bob. 

Working in a multi-disciplinary clinic with several concussion experts I have learned a lot about concussion management and seen some VERY poorly managed concussions. On that note, lets start with some important concussion soap box tid-bits that I believe should be mentioned before we dive into the new concussion guidelines:

  1. Hockey parent: you are not a medical professional. You can not determine when your son or daughter has a concussion, or when/how they should return to play.  I understand you can’t see the injury, and your little superstar is not in a cast, but for arguments sake lets just play it safe with your kid’s brain.
  2.  Hockey trainer: you are not a medical professional, you are a first responder. It is your job to make sure that when an injury occurs, you get your player to an appropriate medical professional. You should CERTAINLY be involved in the rehabilitation process, but you should not lead it.
  3. Medical Professionals: whether you are a family doc, athletic therapist, physical therapist, dentist, chiropractor, physiatrist, neuropsychologist, or a brain surgeon; you CAN NOT manage concussion alone. Use your colleagues. Set your ego aside. Educate yourself.

Now, on to the meat and potatoes. Recently, the great minds of concussion management converged on Berlin to establish the 5th concussion consensus statement, an update on a previous concussion statement out of Zurich in 2012. Here are some interesting statements:

  • There is insufficient evidence to advocate for a “complete rest phase” in concussion management.
    • Up until now, many healthcare professionals have been advocating for complete mental and physical rest immediately post injury until symptoms resolve to baseline levels. The recommendation is now to rest for an initial 24-48 hours, then implement activity as tolerated, i.e. nothing that flares up the symptoms the athlete is experiencing.
  • In adults, symptoms tend to resolve in 10-14 days, but in children (<18 years) symptoms can take 4 weeks to resolve.
    • The vast majority of symptoms tend to resolve in 10-14 days in adults, but the previous guidelines did not account for children taking longer to have symptom resolution. This factor drastically changes patient education and treatment planning, and will help ensure youth are not rushed back into sport.
  • Baseline testing should NOT be mandatory, but can be helpful in managing and interpreting concussions.
    • Baseline testing in Canada has recently become a hot-button topic, after a popular media outlet published an article about clinics hosing people for unneccesary services, including baseline testing. While there are clinics that use baseline testing inappropriately, it can be very useful to determine what a patient’s “normal” is, and help guide appropriate rehabilitation if a concussion occurs.
  • Concussion interventions for ongoing symptoms should include psychological, cervical, and vestibular interventions. 
    • If an individual is going past regular concussion timelines, it is worth while for them to be assessed in the above areas. Concussions can have psychological impacts, and can also cause neck and vestibular related symptoms. These symptoms should be treated by appropriate professionals who are specifically trained in the management of concussion. I will note: I do not know any individuals who are trained in psychology, spinal, and vestibular rehabilitation. Guess we need to go multi-disciplinary.
  • Active, sub-symptom rehabilitation programs have been shown to be safe and may benefit recovery.
    • Monitored physical activity is safe while an athlete is concussed. Provided they are not increasing their symptoms, it makes sense to have an athlete engage in physical activity while they wait for their brain to catch up.
  • Multi-disciplinary care is the way to go
    • No shock there, when a bunch of smart people get together and talk about anything healthcare related, this is what comes out.

As with everything, I suspect it will take years before these new guidelines take a strong hold in sport, specifically youth sport. Truthfully, the information outlined in the previous Zurich consensus had only recently been understood by sport stakeholders- and some haven’t even gotten that far.

I challenge everyone who reads this post: educate yourself on the consensus statement and correct one person’s concussion misconceptions. It is a hot topic right now, and it is not hard to find yourself in a discussion about concussion. Even if you are just yelling at the god-awful SportNet panel as they spew medical advice: correct someone.

That’s all for now folks! Hope you enjoyed it, as always I welcome comments and questions, feel free to email me at mgoertzenpt@gmail.com if you prefer a private discussion!

“You have no impact on the game.”

The words resonate with me every time I hear them. I will be in a conversation with some friends, or colleagues, and discuss how I am anxious about a game I’m going to work later that day. I express that a mild level of nervousness never really wears off no matter how many games I work. Then like clockwork the words come out.

“Why are you nervous? You have no impact on the game. You are support staff, not a part of the team.”

And I promptly die a little inside.

Working with teams is my passion, and I’ve had the opportunity to work in some pretty cool contexts. Anyone who knows me, knows working sports is a huge part of my life, much to the chagrin of my loved ones. I spend my Friday and Saturday nights in cold arenas. I spend hours on uncomfortable buses. I often make minimum wage for my work, but I very much believe in my value and the value of medical and equipment staff that work in sport. I believe in what I do, and I pour a great deal of energy into it, so I’m gonna use this blog post to justify my work, and the work of my amazing colleagues who I am confident have felt the same at some point in their careers.

What people certainly need to understand is 85% of what a team therapist does is for performance, NOT rehabilitation. If I only worked on athletes who were injured, I would spend a lot of my time doing absolutely nothing. I am involved to make the athletes better at what they do, and if shit hits the fan, I can hop in and make sure an injury is dealt with properly. My work starts well before the game- often hours before the puck drop- and often ends hours after the game ends. I apply manual therapy, I help my athletes warm up properly, I act as a confidant, I tape, and I remedy whatever physical complaint my athletes have so they can be confident in their bodies and recover appropriately post game. My athletes know I am there for them for whatever issue they have, whether that’s physical or otherwise. I would even argue I help ease a certain amount of fear for the athlete- they know I have their back and if they get hurt they will be treated properly. I have a phenomenal bond with these athletes and often they do a great job of showing their appreciation of my work.

Maybe it’s the reflected glory, because I never was an elite athlete myself. Maybe it’s when a fully rehabbed athlete scores a goal, looks you straight in the eye and says, “you got the assist on that one.” Or maybe it’s the intensity of the game and knowing that in the event of an emergency, an athlete’s future is in my hands. Whatever it is, I love working in sport. And I have an impact on the game.

 

 

The Truth About Heat and Ultrasound

For those of you who voted: Thanks! But holy, talk about voter apathy. 23 votes?!

Anyways as promised here is another post about physio, this one focusing on a hot topic: modalities. 

I would like to start by saying that researching something as complex as rehabilitation is very very difficult. High quality articles are hard to produce, simply because SO MUCH goes into rehabilitation. There are large variabilities from patient to patient, even with the same injury, and manual therapy (soft tissue work, joint mobilization, etc.) is conducted differently from therapist to therapist. In order to have high quality evidence for ONE treatment you would have to withhold all other treatments, and standardize what people do when they leave the clinic, which just is not fair for the patient. Because of the multi-factorial nature of rehabilitative work, there is little conclusive academic evidence on a great deal of what physios do. We know rehab helps patient outcome and the research is growing everyday, but often therapists end up relying on what has worked for them and what they have learnt from mentors, rather than on what double blinded RCTs state as evidence.

HOWEVER! Modalities are an interesting case. Things like ultrasound, IFC, heat, ice, and TENS, can be added into a treatment plan, with identical parameters or even conducted in isolation. Identical parameters do not help with variability of patients and injury, but the idea that you can use ultrasound at 1.0Mhz,  at 1.2w/cm2 for 7 minutes,on 500 tennis elbows and measure the effect, lends to decent quality research. To keep this post at a reasonable length, I am going to focus on HEAT and ULTRASOUND in this post, and if people love it I’ll tackle electrical modalities at a later date.

So lets dive into it.

Heat:

Good ol’ heat. Been used by your grandparents for years, and still going strong. Pretty much every clinic uses heat, and you would be hard pressed to find a clinic that is not equipped with a hydrocollator to keep hot packs hot. But why heat? Why do people feel better after heating sore areas?

Heat is theorized to work in several ways. Firstly, applying heat to tissue increases the blood flow to the area. This increased blood flow can help remove waste products from our cells and improve the amount of fuel/oxygen coming to the area, which can be beneficial for tissues. Heat also improves the extensibility of tissues. By heating an area appropriately, it becomes more pliable and bendy, which can help us feel generally “looser.” Lastly, heat bombards the nervous system with “heat” signals, which can help your body ignore “pain” signals. Without getting to physiological, it is the same idea as smashing your thigh into a corner, and rubbing it profusely to reduce the pain (I’ll pause here to give you enough time to go try that….go on…I’ve got all day). See! It works! Your body is overloaded with the “rubbing” sensation, and starts to forget about the “pain” sensation. On this same theory, heat can break the “pain-spasm” cycle, and by reducing the amount of pain in an area, reducing the level of spasm that a muscle is in.

The Evidence: the evidence supporting heat as a therapeutic modality is relatively good. We know that heat increases blood flow which can promote cell metabolism and healing, and that heat can reduce pain and spasm when applied correctly. The biggest problem with heat is our body is VERY VERY good at regulating temperature, which makes it quite difficult to heat deep structures. In order for heat to be effective, it needs to raise tissue temperature an appropriate amount, without burning all the layers of tissue on top of it. Moral of the story is, it is very difficult for heat to be effective on deep tissue, but regardless it is an effective modality.

Ultrasound:

Ultrasound is heat’s glorified step sister. You know the one. She shows up to family functions in a massive fur coat, she is super attractive, and always talks about how successful she is, but everyone deep down knows she is in horrible credit card debt and can’t hold a job. Lots of people love her, but very few people understand her.

Ultrasound machines rely on a tiny crystal in an ultrasound head that vibrates back and forth, creating energy. This energy, when applied appropriately, penetrates human tissue up to approximately 5mm to create a therapeutic effect, and in reality the patient should at most feel a mild heating sensation. Ultrasound is applied via two main types: continuous or pulsed. Continuous ultrasound, as one might assume, applies continuous energy to the tissue. With this continuous bombardment of energy, ultrasound has a heating effect on the tissue. Think of it like this: rub your hands together as fast as you can, you get heat. Continuous ultrasound hitting your tissue with energy does the same thing. Pulsed ultrasound, on the other hand, fires intermittent energy into the body’s tissues and does NOT have a heating effect. The goals of pulsed ultrasound include “microstreaming” and “cavitation,” which (in theory) creates tiny streams and bubbles at the cellular level to stimulate organelle activity and allow tissue to heal appropriately. Continuous ultrasound would also include the cavitation and microstreaming effect, with the added benefit of heat.

The Evidence: I know what you’re thinking right now: streams? bubbles? you gotta be kidding me- I pay to get pulsed ultrasound 3x a week, and that’s to make streams and bubbles?! WELL it is a novel idea and it sounds cool, but in reality there is very little evidence to prove that this actually occurs in the human body. Some cellular research HAS demonstrated that these things occur under lab conditions, but several of these studies caveat their research by saying it is very unlikely that the parameters used in clinic are strong enough to create these effects. The vast majority of energy coming off an ultrasound head gets absorbed and refracted by tissue, and with a maximum depth of 5mm only a fraction of total energy makes it to the target. The above factors leave many clinicians scratching their heads as to WHY they would apply pulsed ultrasound to a patient. All is not lost with ultrasound though! There is no debate about the heating effect of continuous ultrasound and it can be a very effective heating mechanism. With the appropriate parameters, and a long enough treatment time, ultrasound can apply focussed heat to a specific tissues, which means it has the same benefits as heat. So take your pick: hot pack or continuous ultrasound. Quick side note: if your therapist ever says “we are going to break up some scar tissue with this ultrasound,” ask them how they have found a way to destroy biological tissue without causing any pain whatsoever. Neat trick.

And to summarize, lets be perfectly honest here physio colleagues. There are many practitioners in our profession that use modalities as time filler. It’s a fact. Not trying to take a dump on the profession, but some physios use modalities to buy time in the clinic. Sometimes it’s to keep a patient happy while they are running behind, or to keep a patient in the clinic for an extra 15 minutes because their interaction was very brief, but that’s not cool. It’s bad for the profession, and it perpetuates misconceptions. So cut it out. Patients: ask your physio why you are getting a modality. If they don’t have a good answer, they may be wasting your time.

Again, I welcome feedback on my posts! Please comment and share, my subscriber list is expanding with your help!