Friday 5: 5 Important Things I Didn't Learn in School | Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

Friday 5: 5 Important Things I Didn't Learn in School

There are many facets of being a health care provider that they do not cover in school or even the best courses.

Here are 5 Important Things I Did Not Learn in School or Courses

1) Provocation tests actually "provoke"

We are taught to use tests like Neer's, Patellar Grind etc. It's sad that students are still required to know a battery of tests that even the texts say have  little sensitivity and/or specificity. They have to know them for the licensure exam and to communicate with CIs and other clinicians who insist on getting information from something like cervical compression.

With what we know about modern pain science, we should try our best NOT to provoke our patient's complaints as much as possible. These patients are already anxious and possibly close to being centrally sensitized. I saw a young black belt who had excellent outcomes with his shoulder. He returned a year later for acute lumbar pain with a lateral shift. Upon explaining possible causes (being as vague as possible), his eyes widened, he became anxious and asked to be referred for all kinds of specialists. He also even volunteered at our clinic for several months and knew how we emphasized conservative Tx, HEP etc... These cases are specific to individuals (and different areas on the same individual) and our choice of words may provoke, much less sensitizing movements or tests.

One of the biggest parts of MDT, the repeated motion exam can do this. If a patient tells me that bending, sitting, and squatting hurts them, it's probably not a great idea to test flexion in standing and lying repeatedly. I try and just check the motions that more than likely are going to be their directional preference.

2) Patients are consumers

You may be the expert, but you're also a salesperson, for you, your practice, your profession, and the approach you are using. The interaction between everything from the first phone call, to the website, and with everyone in the clinic make a difference on their outcomes and whether or not they are likely to refer you their family and friends.

We have an unwritten rule in our practice, say hello to everyone, especially if they are not your patients, and it's the same thing with good bye. When a patient tells me thank you at the end of the visit, I tell them "Thank You!" Not "You're welcome."

3) Patient positive expectation of a treatment is important

One of my favorite recent research articles to be published recently is the Cervical Thrust CPR by @aussielouie. It is very simple, and takes into account patient's positive expectation of a treatment. As an MDT practitioner, I do try to talk patients out of repeated passive treatments like maintenance adjustments, however, if they are hell bent on getting a manipulation, and think they're going to benefit from it, I do a thrust manip. I then teach them cause and effect, loading and unloading strategies based on their DP and make them responsible for their symptoms.


You think of the HEP in school as simple stretches or strengthening exercises. In reality, due to the transient nature of the treatment we perform in the clinic, the HEP is what helps lock in part of those changes. Making cortical changes in movement tolerance, pain thresholds, decreasing perceived threat, and redefining smudged virtual somatic representations takes both time and repetition. The time we spend in the clinic with our patients is so little compared to them being on their own. Even seeing a patient daily would not be enough. This message is one of the most important you can tell a patient from day 1 and shortly into evaluation and treatment.

5) The only rules are, there are no rules!

Bonus points for those who can identify that cheesy quote from one of my favorite 90s martial arts movies without googling it!

What works for one patient may not work for another with exactly the same subjective complaints and objective measures. My most personal example is not being able to treat myself or respond to treatment by my business partner for my own DeQuervain's like issues. What worked on most thumb and radial neurodynamic dysfunction only worsened my complaints. I ended up coming up with a very novel and easy strategy of repeated wrist flexion with radial deviation that has since also helped a patient I thought only had radiating cervical issues into her wrist.

I had several other points that almost made the list, but that will have to wait for a future time! In the meantime, please vote for this blog as best overall PT blog and share the link with your colleagues! Thank you for all your support and compliments!

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