Top 5 Fridays! 5 Things I Wish I Learned In School | Modern Manual Therapy Blog

Top 5 Fridays! 5 Things I Wish I Learned In School

This edition of Top 5 Fridays comes from Dennis Treubig, PT, DPT, SCS, SFMA, CSCS

Over my years of practicing, there have been many thoughts, ideas, principles, etc. that I have adopted which have made me a better clinician.  These changes have helped to make my treatments more effective and efficient and thus, improve patient outcomes.  My only wish is that I had learned these things in school (or at least earlier on in my career). 

In PT school, I was primarily taught a pathoanatomical, evidence-based approach to diagnosing and treating patients (which suited my scientific, analytical mind well).  While I feel this approach is comprehensive and probably the best route to go for educating students on the vast amount of material to cover, I also think it is incomplete.  But don’t get me wrong, I’m not knocking my schooling.  In fact, I am extremely grateful for the solid foundation of knowledge and clinical skills I received at the University of Delaware (and I always highly recommend their program).  This solid foundation has allowed me to readily further develop my knowledge and clinical “toolbox.”  I just wish they had educated/exposed us to some of the following ideas that have made me a more effective clinician (and if you read this blog regularly, I’m probably preaching to the choir). 

1. Your treatments are not that specific and not that deforming

Not being that specific refers primarily to treatments regarding the spine.  Research says that when locating a specific spinal segment, inter-rater reliability is ±1 level.  So basically, 3 clinicians can try to palpate “T5” and all end up on different segments.  And there is just no way that your joint mobilizations/manipulations are moving only 1 segment at a time (the body isn’t that “disconnected”), rather they are moving a bunch of segments together.  So put this all together and you realize we are just treating general regions of the spine – and that’s fine…and effective…and less stressful/time-consuming to you!

By not that deforming I mean we aren’t “stretching” or “lengthening” soft tissue like we think we do.  If soft tissue “stretched” that easily, we would all be super-flexible and probably collapse to the ground like a wet noodle.  Typical example: a clinician “stretches” a patient’s hamstring and after doing five 10-second holds, the patient achieves more hip flexion.  Did we just lengthen the patient’s hamstrings!?  Of course not, rather we just elicited a neurophysiological response and altered the tone (the premise of contract-relax “stretching”).  One research article found that it took hundreds and hundreds or pounds of force to change the length of fascia 1% and even that was transient.  Let’s look at another typical scenario: performing a massage or doing joint mobilizations to break up scar tissue.  Think about how a surgeon gets rid of scar tissue – they open you up and cut it with a scalpel.  I’m not saying that it is impossible for the body to break up scar tissue, rather our fingers are unlikely to do it; repetitive/frequent movement by the patient will lead to mobility improvements.  If you make any significant changes in mobility within a treatment session, it is due to neurophysiological changes. 

2.  Develop or adopt a movement assessment system (adopting one is a lot easier)

In school, we looked at how people moved and the quality of their movement at times, but more often than not we were taking goniometric measurements, manual muscle testing, and performing special tests.  When I go back and think about those days, I realize that for some patients I had lots of objective measurements, but I really didn’t have an idea of how they actually moved.  We did not follow any system or have standardized terminology, so assessment varied from clinician to clinician.  The concept of regional interdependence was taught to us in school, but I don’t think I truly understood its vast implications and significance until I started assessing movement patterns.  The system I have come to like is the SFMA (and I’m not saying you have to use this system, just letting you know what I use).  It seems complicated when you first get exposed to it, but it is actually rather simple, I really like the terminology it uses, and it is easily reproducible/reportable between clinicians.   Using the SFMA has definitely made my treatments more effective and efficient (and no, I don’t use it on every patient and I don’t necessarily go through the entire assessment on a patient, but I do use big chunks of it all the time).

3.  Understand the modern science of pain

The recent science behind how we perceive/feel pain has developed greatly and subsequently debunked older views.  Understanding how pain is a multi-factorial output from the brain (and I’m really summarizing this) will make you a better clinician by improving the way you interact with and educate your patients - both on how/why they are in pain and what your treatments are actually doing.  I don’t want to go into much detail here because it could be an entire article on its own and I also don’t think I would do it justice.  I highly recommend you either read Therapeutic Neuroscience Education by Adriaan Louw or take a course from him (there are other clinicians out there who teach courses on it, I just found Adriaan easy to listen to).

4.  How to better pick CEU courses

I wish someone had told me to prioritize courses that teach you a skill, rather than purely didactic courses.  Early on in my career I attended a bunch of lecture-based courses and, in addition to being expensive (registration fees, travel expenses, etc.), I didn’t find myself getting that much out of them.  Many of them felt like a review course for what I had learned in school.  And with the improvements in technology, why go to a didactic course when you can just view it online from the comforts of your own home and on your own time.  If there is a didactic course that you would like to take, see if it is offered online or via webcam.  I personally use Medbridge for those types of courses – they have a slew of courses on all different topics.  Courses that teach you a skill give you more tools to put in your clinical toolbox and actually use on patients – these types of courses should take priority over anything else.

5.  Diagnostic imaging is essentially clinically irrelevant

As physical therapists, we treat people and what they complain of and how they move, not MRIs.  I tell this to patients all the time and it amazes me how most of them still look at me with a puzzled look when I say this.  This is especially true for spinal imaging/tests – I have never had a patient who feels better after getting a spinal MRI or EMG.  They always show something and all it seems to do is increase patients’ anxiety and put more fear in them. They also tend to “rule in” more invasive (and possibly unnecessary) procedures – whether it be injections, surgery, etc.  Numerous studies have shown high percentages of MRI “abnormalities” in asymptomatic people (i.e. disc pathologies, rotator-cuff pathologies, arthritis).  This isn’t to say that I think diagnostic imaging is useless; just that they are grossly overused and you shouldn’t make your diagnosis and develop your treatment plan based on imaging results.

This list could obviously be longer, but those 5 things covered a few different aspects of our field and seemed like a good starting point. What are some things you wished you had learned in school or earlier in your career?

Dennis received his Doctorate of Physical Therapy from the University of Delaware and is a Board Certified Specialist in Sports Physical Therapy by the APTA.  He is also a Certified Strength & Conditioning Specialist and is SFMA Certified.  Dennis currently practices at ProHEALTH Physical Therapy in Lake Success, NY.

edit - Amen, Dennis, echoes many of the messages I impart in my blog and courses. What can drive this change? Newer grads/current students are very fortunate with all of the amazing resources out there available to you. You do not have to make the same mistakes and learn the hard way like Dennis and I did.

Keeping it Eclectic....


  1. As a current PT student this was very interesting and relevant for me. I recently went to a lecture on diagnostic ultrasound and the possibility of PTs using it. I actually brought up the same point you did about how diagnostic tests can be useless and often do more harm than good. But I was wondering about your thoughts on the possibility of PTs doing them.

    The benefits I see is PTs could control the message and perhaps allay some of the fears patients have when they receive a diagnosis. It also could add legitimacy as well. There is something about seeing seeing a clinician use a piece of equipment like that that could change the perception of patients.

  2. I think it may be useful for cases that actually need a structural diagnosis. I'd also say that is very few cases.

  3. I apologize for the delayed response. I was actually at the FMT Rocktape course yesterday and got home later than expected (and I prefer typing at an actual computer - I guess I'm a little old school that way), but there was a quote from the instructor, Dr. Perry Nickelston, that seems very apropos for your question. Sorry if it's lengthy, I tried to touch on a few of the thoughts you brought up in your comment.

    First, I have only heard a few lectures on diagnostic ultrasound, so I most definitely don't consider myself an expert on the topic, but I seemed to have gotten enough info to see its potential clinical applications.

    So the quote I was talking about is "Pain only tells you there is a problem, it does not tell you what it is." If a patient complains of pain over a certain area, it doesn't necessarily mean that that area is the source of pain (and most likely it isn't). Therefore, ultrasounding that area to see what that structure looks like wouldn't provide you with info that you could then use to develop your treatment plan. It doesn't give you the "why," it just tells you what that structure looks like. And as therapists, we want to treat the "why."

    Even if a patient gets a placebo effect from you using a cool medical machine (and I am fully aware that happens), is it worth your time to set everything up, image multiple structures (because you know patients complaints tend to be vague), and then just tell them, everything looks ok (even if it doesn't, because you don't want your potential placebo effect to become a nocebo effect)!?

    You talked about adding legitimacy to our evaluation and I get where you are coming from, but rather than just use a cool-looking machine I think you can go a different route to get it. I feel the best way to capture a patient (and I do realize it's not the only possible way, but I think it applies to the majority of patients) is through pre-test, treament, post-test (and subsequent education). If you can get the patient to feel or move better then you are on the right track. I guess if a patient feels better after your treatment you could do an ultrasound to show them how structures are moving differently (which would also require a before ultrasound of however many movement patterns you have the patient perform), but you are going to waste a lot of time doing this. Many times in the medical community we are the first ones who actually treat the patient, and while this is unfortunate for the patient (and a sad fact of the medical community), it tends to make us look like a hero at times. So in my opinion, the best way to add legitimacy is, simply, to get people better.

    With all that being said, I do think diagnostic ultrasound will continue to have a bigger and bigger role in the medical community - just not necessarily ours. I think it will take the place of MRIs in some diagnoses as it is cheaper, less time-consuming, and gives you similar info (all music to insurance companies' ears). I also think it should be used by the orthopedic community when giving injections. The research on doctors' efficiency of putting an injection in a particular area is eye-opening (they are not nearly accurate as they think) and real-time ultrasound makes that essentially fool-proof. Another use is the breaking up of calcific deposits - the clinicians who do this seem to get good results. The PTs that will probably use ultrasound the most are those in the research world as it is relatively cheap, quick, and provides images of how structures are moving As a very recent example, the Rocktape course had some really cool and powerful ultrasound videos.

    Hopefully this helped, if not, just let me know.

  4. Well said, is this the author of the above post?

  5. Dennis, this was a great peice. As one of your patients in 2008 and now 3rd year PT student -- before coming to you as a patient, my physical therapy experience was not successful. You always had a unique way of treating that was not the "norm" and as a patient and now future colleague I can appreciate your expertise even more. I believe academia is set to build the foundation and it is up to the individual and student to pursue greatness and find true mentorship.

    looking forward to reading more !!

  6. Yes. I guess I should have stated that. Oops.

  7. Dennis, the reply is so good, I'll use it for a future Q&A Time, or Thursday Thoughts on Realtime US.