The 10 Commandments of Physiotherapy

A commandment is a decree given by a higher power, a divine order, God’s words… and although I have been accused of having a God complex from time to time, I don’t want to come across as having one. So perhaps to call these ‘my commandments‘ is a bit strong, maybe I should say these are ‘my suggestions‘ but where is the fun and controversy in that? So let’s stick with my original title and give my critics something to moan about…

But apart from winding my critics up, what I want to do in this blog is put down some thoughts on what I think makes a good… no actually, what I think makes a great physiotherapist.

These ‘commandments’ are based on my observations, interactions and experiences, and are heavily influenced by a few great physios I’ve worked with over the years. Those physios whose moral compasses have been straight and true. Those physios who have sensible reason and rationale in a profession that is swamped with the just opposite. Those physios who taught me the real ‘art’ of great physiotherapy isn’t in the hands but rather the head and the heart.

This blog is also heavily influenced by the many other therapists who I have discussed, debated and argued with, who have caused me to think and reflect long and hard on my views, opinions, beliefs and biases.

So without further ado here are my 10 commandments for physiotherapists!

Commandment No 1: Active over passive treatment… always!

If you know me or have read any of my other blogs you will not be surprised that this is my first commandment. I have long been discussing, debating, some will say banging on for physios to use less if not completely move away from passive treatments for all conditions.

When I say passive treatments, I mean anything that involves a patient lying down on a treatment couch and having something pressed, pulled, poked, rubbed, cracked, needled, and when I say less, I mean less use of and less promotion of!

Now that’s not to say passive treatments don’t work. Some do, a little bit, for a short period of time, in certain circumstances, with certain patients. But all passive treatments no matter how you interpret, twist, contort or torture the research are simply low-value interventions, costing a lot, wasting resources, and more importantly diverting attention away from the real issues and better treatments we should be offering.

Simply put if your physiotherapy is more doing, and less doing-to, positive long lasting results will follow!

Commandment No 2: You can’t go wrong getting strong!

Despite my background as a past S&C coach and my clear bias towards strengthening exercises, there are many other factors to consider when using exercises. Strength, power, endurance, motor control, all have their place and different methods to achieve their goals.

A thorough understanding of how human physiology responds and adapts to different modes and methods of exercise is essential and recognising when a patient needs one or the other is vital.

However, strengthening exercises are not only about strengthening muscles, tendons and bones. Strengthening exercises affect the human being doing them. Strengthening exercises strengthen a person

Exercise is not just about physiological responses, exercise is also about psychological responses. It should never be forgotten that exercise can reduce pain, fear, anxiety, depression and a host of other psychosocial issues, and so should be a consideration for all therapists to use it.

Commandment No 3: The nervous system is king!

Many therapists place importance on one tissue over another, often this is fascia, or tendon, or muscle, but for me, the nervous system is king!

When the nervous system is unhappy, everything is unhappy!

It is beginning to be more widely recognised that we don’t treat fascia, we don’t treat muscles, we don’t treat tendons. We actually ‘treat’ people.

It really doesn’t matter how good you think you are at myofascial release or spinal manipulation. It doesn’t even matter how good at rehab or strengthening exercises you think you are. If you have pissed off your patient and their nervous system with some fear-inducing comments, poor explanations, or just not connecting and building a rapport and a therapeutic alliance with your patient, you won’t be getting any positive results any time soon!

Commandment No 4: Interaction over intervention!

The connection and alliance you have with your patient is everything! From the 70 year old pensioner recovering from a total knee replacement, to the stressed-out middle-aged manager enduring chronic low back pain for 5 years, to the snot nosed 18-year-old football player hobbling in with a pulled hamstring muscle from yesterday’s game, you need to connect with them all, in an individual tailored empathetic approach.

Giving your patients reassurance and confidence in your professionalism and technical ability. Demonstrating that you understand, empathise and care about their problem. Showing them you are a trusted honest professional and caring human being, with a personable, natural and friendly manner is the biggest skill of all

You don’t need to be best friends with your patients, but a good connection is absolutely vital for a successful outcome.

Commandment No 5: Listen more, talk less!

The average time a patient gets to talk un-interrupted in a medical consultation is short, really short, between 12 and 23 seconds in some research. Make a conscious effort to let patients speak freely and actively listen to what they are saying and how they are saying it, don’t just wait to speak next, or be thinking about the next question you want to ask.

You will learn so much more and be able to get a much clearer picture if a patient is allowed to speak freely. Don’t follow a tick box standardised assessment that can come across robotic, sterile, and uncaring. I realise this can be tricky and challenging to do, it takes practice and experience, and you do need to ensure you ask all the relevant questions, but start practising active listening and flexible assessments and see the benefits it creates!

Commandment No 6: Don’t be afraid to question!

That’s both patients and other healthcare professionals!

Talking to patients more, a lot more, to gain as much information as possible is something I truly believe in. Getting as much information about a patients past, family, hobbies, lifestyle and interests not only helps builds rapport but also gives you valuable insights how to manage them and what may have caused the issue in the first place. It obviously needs to be done tactfully and considerately, you don’t want to appear nosey, disrespectful or prying, and it doesn’t have to be done all in the first assessment!

Questioning other healthcare professionals is even more vital. This means your peers, specialists, doctors, nurses, consultants etc. Don’t ever assume that someone with more experience than you is right, they often are, but people in authority often make mistakes or can become outdated. If you have doubts or questions ask, and if needs be, challenge them.

But just as you question and challenge others, expect and welcome it when others do the same to you.

Commandment No 7: Admit mistakes and make adjustments as you go!

To err is human. Cock ups and mis-diagnoses happen. However, there is nothing worse than a professional trying to cover up an honest mistake or trying to bluff and blag their way out of a balls up! If you made a mistake, admit it, everyone does.

However, making mistakes is fine, not learning from them is a crime!

Hypotheses and diagnoses can, and often do change as a course of treatment and time progresses. That’s why it’s called a hypothesis. Be prepared to alter, adjust or even stop a course of treatment completely. Don’t blindly, stubbornly continue on if more information presents itself!

Commandment No 8: Don’t be afraid to ask for help!

From newly qualified therapists to experts, specialists and even the guru’s they all need help from time to time, although in my experience the gurus don’t tend to admit it. Some ask for it more often than others, but guaranteed everybody will need help, support and guidance at some time or other.

You will never know everything, as soon as you think you do, you’re wrong! In this profession, there are no absolute answers, definitely no definite’s, and always an exception to every rule!

Asking for help when needed shows honesty, humility and experience!

Commandment No 9: Confront your knowledge and biases regularly!

You will often and quickly fall into comfort zones in this job, finding ways of doing things that seems to work well and then you will stick with it!

DON’T

Whenever you feel you are going through the motions, being prescriptive with your approach, method or treatments, that’s when you need to look long and hard at what you are doing and what you know!

Never think you have it all figured out, never feel comfortable that what you are doing or what you have done! Look at what you know often and ask yourself what if…?

Commandment No 10: Read more, a lot more!

Knowledge is power, and the quest for knowledge is ongoing! If you’re asking yourself questions constantly, this will drive your search for answers. Read research papers, read books, read blogs, read twitter, read anything that’s relevant.

However remember there is more to learning than reading alone, observe, listen, talk, get involved, discuss and debate with others. Interaction is a great way to learn, and remember you don’t have to agree, in fact, I would recommend that you go and actively seek out those that hold opposing views and ideas from your own. You can learn a lot more from those you don’t agree with, I have, believe it or not…

So there you go, my ‘commandments’ for physiotherapists, I’m sure some will disagree, and others will think I’m trying to preach! So be it. Take away what you want, ignore what you don’t. It’s not an exhaustive list and one that could be added too. In fact, I’d love to hear what your own ’10 commandments’ would be, so please leave me a comment below!

As always thanks for reading

Adam

24 thoughts on “The 10 Commandments of Physiotherapy

  1. Hi Adam- Im interested to know more about your first comment, active over passive treatment. I treat alot of sports injuries- runners mostly- so Im seeing alot of ITB, runners knee, planter fasciitis etc. I agree with you that exercise is key and I always make sure my patients have an extensive home exercise programme which I progress if necessary during each session. However, I do feel that patients can do exercise at home (and most of mine do). I therefore spend probably more than half of my session with a hands on approach. After whatever manual therapy techniques I use, patients tend to stay behind in the clinic and get on with their exercises. In my experience a combination of active and passive is key. Patients want to feel they are being treated and what better way to interact with your patient when you have one to one time where, as you say, with both talking and manual therapy you can affect their nervous system. I worked in the NHS for a while, and I hated the one sided mindset of putting all patients into pain groups or just giving exercises without anyone getting any hands on treatment. Everything in moderation- dont you think?

    • Hi Jodi

      Thanks for your comments, and yes I agree in part, as I said manaul therapy for some can and does help, however I am always looking to promote self management and develop a patients internal locus of control over any issue, pain or problem. Hands on treatment can remove this and create a reliance on treatment which I argue is a bad thing, even in sports injuries, but as you say it can and does help, I use manaul therapy just with the education and understanding given to the patient that they need to be aware of its transient effects.

      Cheers

      Adam

  2. Hi Adam; I am not a physio but I am an enthusiast that owns his body – dedicated to physical well being. I enjoy and learn a lot from your blog. Thank you

    Philip : )

  3. Excellent post! Can I ask for your permission to translate your article into Spanish and publish it on my website? I will cite you as the author.

  4. Well stated. I wish my current physiotherapist would employ some of your techniques — especially more caring and empathy. I crushed, and nearly severed three fingers in a workplace accident. Luckily I had an excellent surgeon who saved my fingers. But two weeks later my current and first meeting with this physiotherapist he very roughly aND harshly cleaned the remaining blood off my fingers. Considering I was still taking morphine I nearly threw up and passed out from the pain. The next visit wasn’t much better. I was sick most of the afternoon after seeing this guy. Now I missed an appointment with this dude as I got the dates mixed up and to please the Nazi workers compensation board I went to my employer to set up a light duty work schedule instead. What they have been pushing for in the first place. It has only been slightly over a month since the accident. The last three workplace accidents I refused any physiotherapy to avoid dealing with this bull. Why that is just my two cents worth. Can hardly wait for the next month of appointments with this dude. Oh, I so wish to deal with anyone other than him.

    • Sorry to hear this, you do know you can ask to see another therapist if you feel you are not connecting or getting on well.

      I often recommend patients see other therapists, we all get on better with certain types of people.

      However your dude just sounds like an arsehole!!!

  5. Great post Adam. 5 and 6 especially resonate with me because they helped me recognise the links between psychosocial issues (past and present) and chronic pain, and how to enable patients to adddress these not just as a management tool, but with the focus on resolution. We need more of us out there challenging widely accepted treatment approaches which often don’t have a strong evidence base.

  6. Hi Adam, can I ask for your permission to repost your article on my both fb fans page?

    Like this so much and i wish i could translate this into Chinese but it’s too long 😛

  7. Hi Adam,
    I am a physio student in my second year currently on an MSK placement. Somehow I stumbled across this (I literally don’t know how) and this has helped reassure me that I can play to my strengths. Im the first to admit my strengths lie in the personal side of physio and not so much the knowledge and skills. I have been really struggling with not feeling like I am allowed to talk to the patient, spend the time to get to know them and allow time to build a rapport with my patients. As such, I have felt disconnected from my patients and leaving the hospital disheartened everyday. As a student, you want to impress your educators and not feel like you need help or that you know what to do – I have felt rushed to get to the objective part of my assessment or dive straight in for follow ups. Your blog has given me the confidence to trust my instinct, allow time to talk and get to know the person as long term this will benefit my patients and therefore me.

  8. Hi Adam
    Great post.
    Relevant reflections!!
    Here are some complement references on how to be a “great physiotherapist” – also worth reading…
    Roger Kerry:
    https://rogerkerry.wordpress.com/2014/09/29/evidence-based-physiotherapy-a-crisis-in-movement/
    Peter O’Sullivan:
    http://www.jamesdavisphysio.co.uk/wp-content/uploads/downloads/2013/11/03-OSullivan-2011-Time-for-a-change.pdf
    David Butler (The Sensitive Nervous System. “”Big Picture” Evidence Based Approach, p. 370-71).

    Regards
    Jeppe

  9. Oh how I agree with “we ‘treat’ people with nervous systems!…If you have pissed off your patient and their nervous system…then you wont be getting any positive results any time soon!”. Older people such as myself can fit the bill for this one.

    I’m 65, female, broke my humerus 9 weeks ago (clean break hence sling). Of the 3 hospital doctors and 1 physio (all in their early 30s), once again I hear that condescending tone (meant for the elderly, also prevalent in Aged Care) and that feeling they think I’m too outspoken with my opinion/questions (it is my body after all) and they’d prefer I shut up and they can get on with it. I was corrected when I pointed out for example that the fracture clinic doc forgot to refer me to physio and this has hindered my progress considerably, the lack of information about what to do what week (taken out of the sling too late) and the pain and lockup this has caused. Plus being pulled up for having fear on my first physio appointment last week when some fear is to be expected if it’s your first go!

    Also, do you address imagined pain in any articles? Physio is sending me for psychological help re management. She doesn’t believe that at this stage after the accident (I fell on concrete, a lot of contusion, I am tall so have further to fall) I should have this much pain off and on.

    Thanks Adam. Great article.

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