After 40 years practicing as a physical therapist, I’ve been thinking a lot about what has kept my interest going all these years, long after graduating from PT school, and what’s helped to keep it all fresh. From the beginning, I’ve felt like a sort of Sherlock Holmes in my approach to patients. The challenge of patient evaluation and diagnosis has always been of great interest to me. Advanced, ongoing training with leaders in the field has taught me to “follow the clues” and establish a plan of care for my patients, but only after clearly identifying the issue and cause. I’ve enthusiastically studied under some of the most creative leaders of the PT world in the years between graduating and now, as well as orthopedic and osteopathic leaders. Some are still teaching, even as new leaders emerge in the field. The following are a few of the important lessons I’ve learned along the way from these excellent teachers and that I carry with me everyday in my work with patients.
Listen to the patient!
The greatest advice was to learn everything I could from the patient’s own awareness and story. Details of what came before, during and along with their specific complaint often leads me to a certain path of inquiry. By listening to the symptoms of the patient, a physical therapist can often get a precise direction for evaluation. “Listen to the patient!” is a mantra that rings loud and clear from my training.
Understand the clues of the shoulder.
Dr. James Cyriax, an orthopedic leader I was lucky to study with, helped me learn to follow the clues of the shoulder to discern between problems caused by the rotator cuff and biceps, or the tissues of the joint itself. I learned to be able to zero in on whether to assist with movement, or if other treatment was needed. Would I help with gaining range of motion, perhaps with mobilization techniques and home exercises? I remember a lady who flew hot air balloons, who worked hard to get her range of pain-free motion back. She was so happy that she offered me a ride up in her balloon! Or, would I approach the shoulder with ultrasound, ice, scapular and rotator cuff muscle strengthening, posture adjustment, as well as creating a home exercise program? Training with Dr. Cyriax gave me the confidence to know that I could figure out what to do.
Mobilize the extremities.
Freddy Kaltenborn of Norway taught me how to mobilize the extremities, from the shoulder to the fingers and the hip to the toes. Though this training was many years ago, I use his techniques to this day and see my patients get better. A recent patient who came to me after a total ankle replacement had lost her ability to bend her foot up. After lots of casts and boots, it was my job to help her do that. Those trusty mobilization skills helped us to easily achieve our goals.
Put patients’ muscles to work with the Muscle Energy Technique.
I then enjoyed learning from osteopathic leaders, Philip Greenman and Fred Mitchell, diving into the world of Muscle Energy Technique (MET). MET allowed me to treat areas of the neck, thoracic and lumbar spines gently using the patients’ own muscle contractions, rather than using a “passive” technique of moving the joints by myself. One of my patients in significant pain was able to tolerate being put into a position from which she gently pushed into my hands, and then relaxed and moved toward the desired direction. She couldn’t believe how much better she felt with such little effort! This then allowed her to relax for further treatment.
No need to mobilize if it’s moving well by itself!
The world of direct mobilization (as taught by Stanley Paris and others) was always combined with a careful evaluation of the patients’ movements as well as passive movement by the PT’s hands. I learned the valuable rule that there’s no need to mobilize if the joint is moving well by itself. I’m reminded of a young woman who had pain in her shoulder, and who had previous unsuccessful joint mobilization treatment. I found instead, by careful listening and evaluation of her shoulder, that she had loose joints and that her shoulder indeed sometimes subluxed, meaning the joint was moving too far and beginning to dislocate. Rather than working on mobilization, we worked on strengthening of her rotator cuff and the scapular muscles—a treatment approach that hadn’t been tried. I joked with her that she would be done in PT once she could throw me across her on the treatment table. Well, she went for it. As she pulled me, I threw myself up and across her, both of us laughing hard. Don’t worry. We were both young at the time!
Posture begins with core muscles.
I learned about posture and its importance through my studies with Florence Kendall and Shirley Sahrmann who taught that a patient’s posture begins with evaluation of their core muscles. This includes the upper back and shoulders and the abdominals, including the transverse muscles and the buttocks. Correct posture and awareness of it can be a strong preventer of ongoing symptoms. They talked about the need to avoid being fooled by a tight muscle in one region, causing another area to be hypermobile— relative flexibility. That knowledge has helped me to zero in on exactly what came first. For instance, with a patient who was hypermobile in most of her joints, a tight quadricep muscle on top of her thigh was adding to the hypermobility of her low back, causing ongoing back pain.
Feet are indeed connected to everything else.
I took a course called When the Feet Hit the Ground Everything Changes. I was working at a University of Michigan Hospitals runners clinic and I needed to understand how foot position can cause pain from the foot and ankle up to the knee, hip and back. Most importantly, I learned that back and hip weakness, along with knee position, can affect the foot and ankle. Strengthening of the hip and core muscles, awareness of knee and foot posture, and mobilization of tightness in the foot were key takeaways. Only then would we consider a program of foot exercises and possibly orthotics to maintain good function. I continue to love to work with foot patients, be they runners, walkers, hikers or those who stand a lot all day.
So, what keeps PT fresh after 40 years? I admit that I love it when I can figure out the answer and or direction, and know what to do—the Sherlock Holmes aspect of it all. Thanks to time, excellent teachers and great patients, I’ve been able to just “keep following the clues.” And, I love that I’ll never stop learning.
~ Martha S. Torrey PT