Author: zduhamel

Physical Therapist and Certified Strength and Conditioning Specialist

Regular days

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Regular days are a new thing for me. As a recent graduate from physical therapy school (May 2016) I finished a 22-year “career” as a student. Students never have more than a few months, a semester maybe, where you have the same weekly schedule. Even within those short periods of time, you have breaks, holidays and other “routine killers.” I am now in a stage of life where I have what feel like regular days and it is very strange.

I feel like I have learned some things from this season of life so far, though.

1. Regular days aren’t as bad as I thought they would be.

Maybe it is the millennial in me coming out, but during school, I had a slight fear of the mundane, regular work days. I thought that I would feel so uninspired, bored and burned out by them. I have actually found the exact opposite. Regular days give me the sense of accomplishment, productivity, and recharge. I have found that the regular days that I once feared have become something that I cherish.

2. Regular days are what life is ultimately made up of

For most working adults our lives are really a whole bunch of regular days with a seasoning of extraordinary ones, both good and bad. Because of that, what we choose to do with ourselves on our regular days really makes a massive impact on the journey and outcome of our lives.

3. Regular days are where you become excellent or complacent

I have already felt the tension between excellence and complacency in my short career thus far. Most of that tension is felt on the regular days when I could either become more efficient at what I’m currently doing OR become more effective what would I’m currently doing. What I mean is that I could either become an expert at being mediocre, aka finishing notes super fast, treating loads of patients with OK care, being able to manage my time well…or I can hone the craft and become more effective. Now my perspective is physical therapy but I think it applies to every industry. You can either strive to make your current work easier to pull off…requiring less brain power and effort to get the same level of work done. Or you can strive to make your work of a higher quality. I want fewer things more than to do the latter.

Posted in Fun

Servant Leadership on the Ground

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Much ink has been spilled on servant leadership. Most of it tends to hang out in the nebulous, theoretical side of things. Since I was first introduced to the concept of servant leadership I have tried to model my life and any leadership roles I find myself in after it. One problem with reading about servant leadership in MBA books, entrepreneurship books, and blogs is that it rarely ever gets practical.

What does it actually mean on a daily basis?

I don’t claim to have the answer to that question in its entirety but I feel like I had the opportunity to model it today in the clinic. Let’s see if you agree.

Servant leadership at its core is making yourself lower than the people around you to raise them up. I interpret that to mean doing the dirty work when no one wants to or being a team player in order to let someone else get “the glory.”

In the clinic today we received 6 new office chairs for the PTs and front desk staff. They came in 6 big boxes and sat in the corner of the clinic for most of the morning. I had a patient cancel so I started tearing the boxes up and building chairs. I ended up building 4 chairs today and setting them up for the other staff. Now, this act felt very menial at the time, and in the grand scheme of life, it really is. BUT, I think that is the point of servant leadership. The little things add up. I easily could have just done paperwork and treated patients and went home for the day, but I went out of my way, sat on the floor with a tiny Allen wrench and built chairs. These are the types of little things that make you a servant leader and make you worth following. There are countless opportunities I have missed or actively dodged out of selfishness or laziness but this happens to be a small one that, after reflection, I’m a little bit proud of.

My point of saying all that is simply to put some meat on the bones of servant leadership. I don’t like when good concepts stay in the theoretical and never make it into the practical.

Next time you have the opportunity to do something small for someone else, take it, you don’t know what will come of it.

Posted in Fun

Daily Blog Challenge

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photo

I listened to an interview with Seth Godin today, who is a famous online blogger. The interview covered several topics from entrepreneurship  and education to theories on combatting fear and stirring creativity in your life. I have gone through phases in the last 3-5 years that I have been very into start-ups, marketing, entrepreneurship and other business topics, but I have not thought about it much as of late. This interview rekindled my love for this type of thinking.

One of the big takeaways I got from the interview was a segment when he advised people to keep a daily journal online. He said something along the lines of, “do it for two weeks and it will change the way you think, do it for six and it will revolutionize your thinking.” I probably butchered that, but the principle is there. Putting out content, whether it is a short story from the day, a post of the newest running shoe, or a poem requires you to reflect on your day.

I want to try to do this for a little bit and see what happens. Due to the fact that I have 2 kids under the age of 2 and a half years old, any consistency in life is difficult, but hey I’m going to try.

What that means for your as the reader is twofold:

  1. There will be more blogs in the “Fun” category, as I will most likely branch out of fitness, health and physical therapy topics.
  2. You should join me! There is nothing bad that can come from it, only a little more self-awareness.
Posted in Fun

Top 5 Things Students Need to Know about being a New Grad

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I’ve been a new grad physical therapist for almost 5 months now. It is much better than school…just know that and be excited about it. I wanted to take some time to jot down a few (5) things that I feel like have been the biggest learning points since graduating. Here we go.

1. You will practice very different than how you learned in school.

You don’t have to measure everything with a goniometer. You don’t have to manual muscle test every single muscle in the human body, actually, I really don’t manual muscle test much. I don’t go up and down the whole spine doing central and unilateral PAs every eval. I don’t check to see if the SI joint is rotated/upslided/etc. I don’t check if a rib is “rotated” or not. I do check how the patient moves (SFMA), how they respond to repeated motions (MDT) and if a host of other things to see how we (the patient and me) can modulate pain, move better and get them stronger. I try to keep assessment and treatment simple.

2. The evidence is not a hassle anymore.

In school, I felt like we were forced into ‘the evidence by professors.’ It felt like a burden to find references for this or that. I think in school I felt like what we were learning was the newest and best stuff so I thought “what’s the point of looking this stuff up when our professors are giving it to us every day.” Well, once you are out of school, the evidence becomes your best friend. There have been numerous times in the clinic that I have not really known what to do with a patient presentation, gone to the literature and came out with some direction. I have a new found respect and appreciation for research in our field as a new grad.

3. You are in charge of your awesomeness.

No one is pushing you to do anything anymore unless you are in one of the rare practices that constantly challenges each other. How good you become is now in your hands. This truth was both terrifying and relieving at the same time. It is terrifying because you aren’t spoon feed information anymore by professors, and that is hard. It is relieving because you get to grow in areas YOU care about. For me, I have found that recently that I am very interested in pursuing my certification in McKenzie. I can do that. I could go do some Maitland courses, some IAOM courses, get dry needling certified…it’s all up to me, and that is really cool.

4. Patient interaction matters more than [almost] anything else.

How your patient feels about you, the rehab process, the clinic you are in, the whole process is more important to their outcome than anything else. Take away point: care deeply for your patients, have fun in the clinic, and make strides towards having good customer service and your outcomes will improve.

5. When in doubt help them move better and make them strong.

This may seem really simple, but often the simple things are the best things. There have been a number of patients already in my short career that I have not really known the exact tissue causing their problems, BUT I do know that if I create a de-threatening environment, encourage the heck out of them, find ways to decrease their pain and make them move more they will do well. Layer onto all that a well progressed and designed strengthening program and you have a recipe for success with most things.

Top 3 Takeaways From Ascend 2016

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logo-ascend

I’m still marinating with much of what I learned over the weekend in Fort Worth, TX at WebPT’s Ascend conference. A couple of the things that I have the most clarity on at this point are that Fort Worth does steak right… WebPT also does a conference right.

Ascend is a rehab business conference, so I went in not expecting to come out the other side with a vastly different view of my patients, but when you are surrounded by some of the greatest minds in the industry talking about customer services, excellence, and quality…things change.

The top 3 things I learned at Ascend 2016:

1. Start with your story:

The keynote by Chris Smith from Campfire Effect was on point. His main point was that we as PT’s (or anyone serving another person) must know and be able to articulate your story. Nothing he said was truly earth shattering information but it was the way he put it all together that made the difference. Similar to Simon Sinek’s Start with Why, Chris advocated for getting to the bottom of who yo are, why you are, what you are, and how you do what you do. All things that we know, but don’t articulate well.

2. Measure your crap

Not literally. There were several talks that expounded on the importance of measuring things. Specific business metrics, marketing metrics (direct response, lead generation, social media…) and outcomes. Measuring, tracking and making sense of these metrics is what the best practices and the best therapists in the country are doing. A special note on tracking outcomes, I tweeted the below tweet during Heidi Jannenga’s talk.

We as a profession need to continue striving for excellence in evidence-based practice AND start striving for excellence in practice-based evidence. What I mean by that is, let’s start tracking out outcomes and actively using that data to fine tune our practice. We could all be better clinical scientists.

3. Relationships are everything

The most important part of the conference for me was not what I heard in any of the breakouts but all the talks I had outside of them. I met a plethora of incredible people that I now have as experts on certain topics that I can refer to whenever I need…wonderful. I had an absolute blast in Fort Worth and I look forward to continuing the relationships that I started in Texas.

 

Ascend was overall a very well done conference. The WebPT folks and the people at the Omni Hotel really nailed it. Look forward to next year, see you there!

Why I don’t Manual Muscle Test

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Ok, so I actually do manual muscle test but not the way you are taught in school. Let me explain.

In PT school I had to manual muscle test coracobrachialis…

In PT school we are taught how to target and manual muscle test every single muscle in the human body…it was daunting and it felt like I would never be able to remember all of it. Since I wouldn’t be able to remember all of the tests I felt like there was no way I would be a good PT, the struggle was real.

Well, now that I have graduated and I practice on my own I have come to the realization that most (almost all) manual muscle tests are a waste of time. Yes…I hardly every manual muscle test anything.

I will tell you the 3 reasons I manual muscle test.

1. Neurological weakness

More than wanting to grade the quadriceps (or even worse the VMO..) a 4-/5 so that I can strengthen it because of this or that. I look to see if there is profound weakness side to side in patients, to help rule in a true neurological compromise, from a nerve root irritation for example. It doesn’t matter to me whether the quad is a 4/5 or 3+/5 or whatever, it does matter to me if there is a profound in knee extension compared to the other side. Most of the good PTs I know use manual muscle testing in this fashion as more of a myotomal test than a true muscle test.

2. To “paint a picture of dysfunction”

Sometimes patients present with movement pattern dysfunction (see SFMA for my definition of movement dysfunction) with areas of true muscular weakness contributing to that dysfunction. I will do a quick manual muscle test on a few muscle groups that I know are weak after seeing a few movement patterns (aka hip abductors in a gross looking squat or single leg stance) to confirm that they are truly weak. I check the hip abductors and extensors often but again I don’t really care if it is a 4- or 4+….it just matters that it isn’t a 5/5. In other words, it’s a way for me to document, to myself/other PTs/ insurance companies, that there is a weakness present. It’s a pretty terrible way to measure progress due to subjectivity and average inter-rater reliability (depending on the study).

3. To make insurance companies happy

Insurance companies love numbers and progress. Manual muscle tests, while poor at showing progress objectively, are any easy way to show that a patient is improving. I usually will say a patient is 4-/5 to “paint the picture” of weakness and as the patient progresses and is able to complete movement patterns more functionally (again SFMA) I will retest the muscle and document progress.

 

What does this mean for you, the student? My point is not to be lazy in your examination to make you frustrated that you have to learn this stuff, but simply to say when you get out of school (big caveat) you will find that you can spend your time more effectively and get more diagnostically relevant information with other tests.

What does a PT do?

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“Do you like have your own patients?”

“Yeah, but my neck hurts so I should go somewhere else, right?”

“Do you guys treat backs?”

“You guys just kind of do a lot of stretching, right?”

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(The infamous PT picture…)

These are only a few of the quotes that I hear regularly, in my daily practice as a physical therapist. In school our professors would occasionally go on a short rant about how the general public doesn’t know what we do, but we students always brushed it off thinking, “there is no way people don’t know what we do and how awesome we are, they will flock to me when I graduate.” Wellll, turns out they were right (source).

So, what do I do? What do I treat? How? And why you should come see me (or another PT).

*Disclaimer- PTs work in several very different settings, this is what I do in outpatient private practice*

What I do:

Put most simply, I figure out where you hurt, and why you hurt then help you move better and hurt less. I do a thorough ‘interview’ of my patient to get an idea of what is going on, then do a thorough physical examination to try to prove myself wrong, if I can’t, then I’m on to something. Once I have ‘diagnosed’ you. We chat about all that I found and address each thing with a number of treatment options.

What I treat:

Nerd language: [neuro]Musculoskeletal pathologies and movement dysfunction.

Actual human language: If a muscle, tendon, bone, joint, ligament, nerve is hurting I treat it. If you aren’t moving the way you used to or wish you could, I can help you. If you have a headache (a specific type that originates from your neck) I can help you. If you have an ulcer, I cannot. If you have a [currently] broken bone, I cannot. If you have heart disease I cannot give you appropriate medication. I do not treat those systems, but I have brilliant colleagues who know WAY more about those systems than I do, and I will give you their number.

How I treat:

After a thorough assessment, I will have a number of ‘problems’ to treat. Physical therapists are positioned in a really cool place, because we have the ability to treat you with our hands, called manual therapy, with instruments, called instrument assisted manual therapy, with modalities, like ultrasound and other and with exercise (which is a REALLY broad category). Some dysfunctions respond best to hands on treatment, others do better with exercise. It all depends on what we find in the exam! No one gets the same treatment because no one has the exact same problems.

Why you should come see me (or another PT):

Physical therapists, especially outpatient physical therapists, are easily accessible (compared to most orthopedic surgeons), thorough (we get more time with you than most professions 30-1 hour), experts in our area of practice (look above). We are effective (source, source, source, source) and cost-effective (source, source). We are a great first contact point for you if you are in pain, because if we can help you we will and if we can’t we will know where to send you!

 

If you want to see me in particular (and you live in Northwest Arkansas), I work at Premiere Physical Therapy, call (479-273-9933) and I will do my best to help you or get you to someone who can.

The Tension

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There’s a tension that I feel needs to be discussed in the world of the new grad physical therapist. It’s the tension between clinical excellence and raw practicality.

Let me explain:

In physical therapy school a few things happen: 1. You are exposed to various ways of thought and various levels of expertise, 2. You incur a silly amount of debt. The exposure to different ideas and philosophies in PT are usually presented by people that are clinically impressive, whether they are a CI, guest lecturer, or a professor. If you are like me, when you see these people talk or treat you want to be like them, or better. One example, is a CI I had that was 15 years out of school had his ScD, and COMT, which took him a collective 9 years to acquire/accomplish. He is insanely skillful in the diagnosis and treatment and I want to be like him, or better. But I have debt that his generation didn’t. And here lays the tension. In order to get the formal training that he had I would have to pay an additional $10k and take a minimum of 9 weeks off of paid work to get there. This is not out of the ordinary for advanced clinical degrees and certification.

The tension is that for most new grads they are not making nearly enough money (compared to the debt they just incurred) to drop that much cash and take time off work to increase their clinical skills and not make any more money. I think that this is a huge problem that will really hinder our profession. It is borderline martyrdom to pursue residency/ fellowship after incurring $150,000 of debt just (I use this carefully, because technically you aren’t making more to have advanced certs…paid the same) to advance your clinical skill.

 

Do you fill this tension DPT Student or New Grad? Let’s chat. Is clinical advancement worth it? Let’s stop avoiding this conversation and let’s have it.

The Student’s Struggle

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Every student that pays attention online is constantly getting punched in the face with paradigm shifting information. Hot topics like pain neuroscience, PT role in prevention/ population health, manual therapy…the list goes on. Every time I think I learn something solid, I see a blog post that blows it up. Every time I think I have a grasp on something it seems to slip out of my hands, because “it doesn’t work or there are better ways to go about this.” It can be ultra frustrating as a student because at the end of the day you have to do something with your patients…I expect that this is how I am going to feel for a while, or maybe the entire time I am practicing PT.

My most recent paradigm shift has been a really radical one for me. It is centered on the idea of manual therapy or more specifically tissue specificity in manual therapy. Since the beginning of PT school, when I was spending HOURS learning anatomy, I always thought anatomy and tissue location, type and function were the most important things I could know as a PT. It’s like trying to write a novel without knowing english, it is the language of medicine. Scapulae, transverse processes, ligamentum flavum, multifidi…I continued to pound these things into my head because I wanted to be good. Then we moved from the basic sciences to more clinically relevant courses, like our movement science classes and our musculoskeletal series. During these classes, the clinical side of things built right on top of the anatomy. “If you have an increased dynamic Q angle, it loads the lateral compartment, the ligamentous structures of the knee and so on which causes injury and ultimately pain.” “Mobilize this, move that, stretch this, strengthen that.” It all was making sense. We went on further, more conceptual now. Find the dysfunctions, find the “pain generators”, find contributing factors, concordant signs….again it all made sense. When things hurt, we do a bunch of tests clinically and figure out what the thing is that is messed up and is causing the pain and we fix it…yeah go us!

Well, then I got into the clinic and then I started reading the literature.

What I kept seeing frustrated me…manual therapy isn’t doing what you think it is, connective tissue is too strong to change, all these effects are transient, palpation is awful and unreliable and on and on and on. Well then…looks like all the things I know are wrong…cool beans. So what the heck do I do with people? Well the only thing that is clearly good for everybody is strengthening the crap out of everything, so that’s good. But there’s no system to that, there’s no structure. The people saying that nothing I know works are the ones who have been practicing for 10 years, went through all the additional training in the stuff I know and are NOW saying that. They have a framework. I don’t. So I’m a little lost at this point. Where do I go to figure this stuff out? Now that boards are over (hopefully) how can I get effective in the clinic and not feel like I am maxing out my brain every moment of every day trying to treat “regular” patients.

Enter MDT.

I hated MDT when we learned about it in school. We had one lab on it and we talked about derangements, dysfunctions and postures…all of which were words that I had either not heard of or had very different meanings to me than what they mean to MDT people. We talked about how extension is great for disc patients, practice prone press ups, mentioned that centralization was a thing and we were done…Well that was dumb…they didn’t even tell us how centralization works, or what all this is doing to the specific tissues. I immediately casted it out of my brain and my framework, back to tissues, manual therapy and the sexy cool manipulations and things. Fast forward 2 years, to now. Centralization, directional preference and classification are all part of the clinical practice guideline for treating LBP. Which by the way doesn’t mention a whole lot about tissue specific manual therapy.

My brain is now exploding. My biases and my “system” are being challenged and I don’t like it at all, but I want to know more and be good, so I press on (pun intended). I reach out all the MDT people I know and grill them with questions, Allan Besselink, David Grigsby, Keaton Ray, and some others and they continually impress me. Everything I ask them fits into the system. Turns out MDT doesn’t suck… It is simple. And it is based on movement. And I don’t have to have “good hands” and I don’t have to know if it’s a facet capsule synovitis or a facet joint arthrosis…as much as I freakin want to.

The thing that I thought was a dumb and poorly explained exercise routine turns out to be the best system for evaluating and treatment people without fumbling around with tissue diagnosis. Now, I understand that there is no perfect system out there, I know that MDT has its flaws, like the disc material being pushed here and there, BUT it is a system and a reliably effective system nonetheless that as a new grad I need.

I welcome comments and papers and direction on this topic because ultimately I want to get better and I hope you do too. This is not a dead topic for me…it is still an active struggle and I’m sure it will be for some time but I think the struggle is good.