Top 5 Fridays! 5 Mistakes I Have Learned From | Modern Manual Therapy Blog

Top 5 Fridays! 5 Mistakes I Have Learned From


I always tell new grads and students how lucky they are. You have access to a ton of great information from social media, instantly!
You also get to learn from our mistakes, which is a huge part of experience. Jesse Awenus suggested that I post about 5 mistakes that I was able to learn from. Some of them are flat out mistakes, some are cases I learned from. By no means are these my top 5, but these are ones that are memorable.

1) Trying too much for too long

  • We all want to make patients better, but experience and plenty of failed cases told me when enough was enough
  • like many clinicians, I would often try with certain patients 2-3 times/week for 6-8 weeks with little to no change in the way a patient feels
  • even slow responders like frozen shoulders should see a change within that time frame!
  • Frank Ward, a MDT Diplomat who I mentored over the past year told me research that was done sometime in the 80s (not able to find citation) that cases that took longer than 6 visits ended up being very difficult
  • when I thought about this compared to current MDT research - 87% are rapidly responding across an entire caseload and not just acute, it made sense
  • you should make MAJOR changes within 1-2 visits, if not, change things up, within 6 visits, if you have not made a huge breakthrough AND the patient is compliant, refer out and have a plan B for the patient
    • my plan B are other providers that I trust, usually smaller practices where I know they will get the same quality care and attention
  • I normally tell patients, if there are NO changes in 4-6 visits, I will refer out, but lately, I want to see major changes in 2 visits
    • a least 3 evals in the past week, I have referred out, or sent them back to their referring neurologist because there were zero changes in 2 visits
    • another case was worse after just this week was worse after 3 visits, so I referred her to a neurologist for her HA
  • moral of this story: Trust your gut and know when to call it quits
2) Everyone deserves a fair shot
  • I will never forget one of the meanest, crankiest, impatient TMD patients ever
  • she was short tempered, and rude, starting off with rubbing my former secretary on the phone call, proceeded to upset my intern, and also my other PT
  • after a few short visits, we all started being very short with her as well
  • she would sign in, we would call her back, I'd basically tell her that heat was waiting for her on the table, I would run and do SOAPs
  • I would DREAD going back to the table, pretty much ask a VAS, do a few measurements, treat her and send her on her way
    • this was about 13 years ago, so this probably went on for 4-5 weeks at 2-3 times/week, possibly longer
  • one day, she says something like, "Maybe I'd feel better if you people showed me a bit of compassion, I am in serious pain!"
  • that made me feel like a real a-hole... and this was before Explain Pain... so I actually made sure to go out of my way to be extra special nice to her (staff was directed to as well)
  • she eventually turned around to our sugary approach and started responding, started smiling at each visit, and although she did not get more than 50% better (phantom tooth pain after all teeth extracted except 2), she was grateful for our services and any improvement she could get
  • moral of this story: Kill em with kindness!
3) Acting Like The Case is Simple
  • again, this was very early in my career
  • I saw an older gentleman with shoulder pain, and a separate time for lumbar pain
  • both cases resolved well (back then, that probably meant 20-30 visits!)
  • he then came back with a referral from his neurologist for headaches that were constant and unremitting
  • he had objective findings consistent with cervicogenic HA - loss of upper cervical mobility, tenderness in the occiput, general loss of cervical mobility
  • anything I tried at that time, which was probably a lot of joint mobilization and suboccipital release - I was only 1 year out, did not help
  • I was dumbfounded because he responded so well to PT with his other conditions
  • He thanked me for trying, and I never forgot that because he was so genuine about his gratitude
  • several years later, I just finished up getting certified by Dr. Rocabado, and felt like I could handle any cervicogenic HA
  • the patient came back, with the same complaint of headaches, and I basically stated I just learned a whole new form of assessment and treatment, so you'll surely get some relief
  • light tissue work, postural correction, MDT, subcranial shear distractions, after 3 weeks, still no change
  • each time he reported no change, I felt terrible, because he was such a nice older guy, and each visit, he thanked me for trying
  • on his last visit, I asked him how he was feeling and he broke down crying saying, "I just miss my wife so much! She passed away shortly before I started getting these headaches. I miss her every day."
  • I knew then that I could not help him with my skill set, and referred him back to his neurologist
  • I didn't think I'd see him again, but I did see him a few years later, for his opposite shoulder, which responded well to PT, he still had his HA, and thanked me for asking
  • moral of the story: Absolute certainty of case simplicity will have you eating your words
4) Cranking on slow responders
  • a true slow responder, like a frozen shoulder will NOT improve ROM quickly
  • they act like a patient coming out of a cast for 6-8 weeks, stiff in all directions
  • assuming I could somehow break up scar tissue and deform the fascia and joint capsule with superhuman strength, I would crank on patients and nicely tell them to suck it up
  • I now liken tissue deformation to muscle hypertrophy... it will happen gradually over time given the right stimulus and conditions, just not rapidly
  • you will have more compliant patients if you do light soft tissue work, plus joint mobilizations, then have them move regularly and often in mid ranges
  • moral of the story: Slow and steady wins the race
5) Good PT/Bad PT
  • this is not a case from over 1 decade ago, but just 6 months ago!
  • as you know, I am hard on my patients, and it gets results, but this is when I got schooled by Southern Hospitality by the aforementioned Frank Ward
  • moral of this story: Everyone has something that motivates them, and it's usually not someone being a hard ass
 That's all for now! I hope everyone has a great weekend! Does anyone else have a memorable case or mistake that taught them something they would like to share?

Keeping it Eclectic...

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