This post is for a change far less clinical than all the very interesting recent blogs from my IMTA colleagues, but it may also be a food for thought, at least for some of you:)
As a fresh IMTA assistant, still much closer to the students than our teachers, I have a chance to look at the teaching and learning process from “the other side”. And this is at times pretty intriguing, very fascinating and oh, so surprising for me! Some teachers would tell me: “You will get used to it soon.”…but before I do, I would like to share with you some of my observations and thoughts. This time it will be about expectations of some course participants, and how they perceive “the technique”. Lately I’ve heard some voices saying: “We need more techniques!” or “Too many revisions!”….and that makes me wonder a bit… so maybe it would be nothing but fair to write about it here and avoid some surprises, or maybe even frustrations of some of us 🙂
Needless to say, reading literature and attending courses for us, physiotherapists, is not a privilege. It is an obligation not to take the eye off the ball.
Nowadays there are thousands of different courses to choose from on the market. Not an easy task to pick the best one for you! But let’s assume you already see yourself in the field of manual therapy in the future. Alright! Good choice;) Now you just have to decide, how you will get there…
So you start digging through the bewildering mass of course names: some well known, some sounding more “sophisticated”, “scientific”, or even “exotic” (have you heard of T.R.E?;).
Most of them will tell you, that with their techniques you’re changing position, length or freedom to move of a certain structure. They will attribute and limit the tremendous effects of manual therapy only to these factors and ignore their effect on the central or peripheral nervous system, and disregard the whole lot of other, non-specific phenomena that manual therapy elicits.
What is even worse – most of the courses will tell you that their method is far superior to all the others, making you feel so damn unique, if you choose them. They will promise to give you “magic tools”, then show you something that you won’t have a chance to understand, but you will eagerly pretend you got it, not to feel stupid in front of the others (who didn’t get it as well!) and in front of yourself. It’s pretty embarrassing to admit, that you have just paid several hundred euro and they simply cheated you, isn’t it?
If you want to see a magic trick, better go to David Copperfield’s show.
And bear in mind – manual therapy is unspeakably effective, but “techniques” are overrated!
Am I being controversial now, saying this while I’ve just joined IMTA?! Not at all! 🙂
…What is manual therapy?
I don’t like definitions myself, however – this one we shouldn’t skip for further understanding.
“Orthopaedic Manual Therapy is a specialised area of physiotherapy / physical therapy for the management of neuro-musculoskeletal conditions, based on clinical reasoning, using highly specific treatment approaches including manual techniques and therapeutic exercise, (…) also encompasses, and is driven by, the available scientific and clinical evidence and the biopsychosocial framework of each individual patient.” (IFOMPT 2004)
Without a shadow of a doubt – human touch is a very powerful tool. It relieves pain – both physical and emotional. And despite it being just one of many tools in our workshop, this is a tool we often reach for. But when and how to use it?
Before I started my adventure with manual therapy, I’d already had several years of professional experience and many different courses on my account. Countless hours spent on learning (read: no holidays) and all the money earned – invested in courses (read: no fancy car). I had techniques for this or that, and somehow still I wasn’t satisfied, because I didn’t know when I should use them and how they were meant to work at all!
You can imagine how I felt. A looser in a pure form. Was I really THAT stupid?!
Hopelessly, I decided to give myself one last try. I asked a lot, I read a lot, and then I found a very wise quote:
“The idea of solely learning techniques and applying them indiscriminately is totally inadequate” (Maitland, 1970)
Back then in my country for a place on the Maitland course one needed to wait almost a year! But I felt this was my last resort. If it wouldn’t work, I promised myself to stop with further courses and go working in a beauty salon as a massagist (God, save me!).
I forced myself to trust the teachers and let them lead me by hand through the consecutive stages. Of course- they started off mostly with techniques. How lovely! But there needs to be an incentive like that – to make the students believe in their hands. And later on they would tell us – “a technique is the brainchild of ingenuity” (Maitland’s words again:), and almost each of them can be adjusted to the individual situation! They encouraged us to be creative!
Now remind yourself how you were taught a classic massage at school- basic movements, rubbing, tapping, vibrations; always in a certain order; always in the same directions etc. But then you started trying this out on patients, you gained experience, you began to “experiment” more and more, and eventually realized, that actually it didn’t matter that much how you poked, prodded or rubbed someone. So you adjusted the scheme you had been taught to your own needs. And does it mean that you were not doing a proper massage anymore?!
The framework is always essential to have a good starting point for further improvements, and also for proceeding to more “advanced” levels; in manual therapy be it spinal manipulations.
Yes, manipulations. For most people manual therapy means “cracking the bones”. You may imagine how happy I was, when I managed to manipulate my course partner for the first time in my life! I was jumping around screaming like crazy: “I got a click on Cyrus’ neck!”. Unfortunately, it was maybe one of the two, three manips that I was able to do properly throughout the whole course! Well, it’s ain’t easy; I was to learn that it takes years and hell lot of practice. And no course in the world will give you this just like that. However, the most important thing I learnt about manipulations was not the technique, but the true mechanism behind it (before I thought it was purely biomechanical! And they threw a bomb on my beliefs!) and a full awareness and identification of those at risk, so basically- when to avoid this approach.
Sure, for many of us, therapists, manips are sexy! Roarrrr…. But for our patients (and it’s all about them!) it doesn’t have to be sexy, but helpful. And manipulations will help just a small group of our patients. For the rest of them you need to pick another killing weapon from your arsenal;)
So yes, we started off with techniques, but right next to showing what we can do with our hands, they taught us how to use our heads! It other words, the teachers had successively taken us from the shallow and safe waters of easy techniques, to the deep and vast ocean of clinical reasoning or understanding pain itself. And actually, this is where all the fun begins!!!
The further you go in the IMTA program, the less technical it gets, but the more thrilling!
You begin to notice, that having the basic tools and all the knowledge around it, you are able to create your own techniques. And suddenly there are millions of them (do you need more?)! But at the same time you come to realize, that there’s a whole group of patients, who don’t need your hands at all! Patients for whom even “the best technique” won’t help. Is it a problem? Not a bit! Because now you know well how to successfully handle almost every situation. You work not only with your hands, but mostly with your brain!
Of course, there are some outstanding individuals in almost every group, but usually those, who complain the most about “wasting time” on revisions of practical skills, are often below the average during exams.
Sure, we can show each thing once and proceed to the next and the next one. I just wonder how it would look like at the end of the course. 80% lost? Or maybe more? To be certain, that the participants have at least an idea of a technique, we need to revise and check. What for?
- Only a safe and confident basic technique allows for virtuosity later on!
- Before getting round to manips it’s fair (at least for your partners on the courses;) to learn PPIVMs in a decent way (from my own example I know this is still a drama even after level 2a!)
- Many times during practical parts, the students are so focused on getting the “technique” right, that they don’t realize they have a death grip. So it’s good to work on soft hands and relaxed grip. Practice makes perfect, but you have to give it a chance;)
There are also these students, who would ask us: “What could I do more in addition to Maitland?”
Well, this is hard to answer. It mainly depends on their personal preferences or the patients they work with.
We are proud to simply give the best there’s to give – up to date and a very comprehensive program, but of course we cannot teach it all!!!
Therefore we mention research, we offer sources for those wanting more profound understanding. We encourage them to give themselves a kick and read more, a lot more; about pain, neuroscience, human behaviour…
However, for all these hot-headed participants, who want everything at once, I have good news:
We actually have a magic tool for you – Clinical Reasoning!
So first, structure your thinking and just then, if you feel you still need more, take some additional courses.
Even if they’re purely technical, even if it’s Flossing or Dry Needling (my colleagues have posted interesting thoughts about it some time ago!), even if it’s any other cosmic method, they all have a potential to work if you can implement them, staying fair and honest with your patients and with yourself.
We are not politicians and we don’t have to promise you anything, eg. that after our course you will be running on to football pitch to rub down Christiano Ronaldo’s legs. We won’t tell you that we will give you a super healing powers, which would promise some of the physiotherapy ‘guru’s’ pushing their fanciful teachings and wild claims for their own profit, rather than helping patients.
We won’t announce, that with us you will learn a new language within a week. But what we teach is indeed a new language for your interaction with patients!
Being able to connect, relax, reassure and calm people is a ‘skill’ not to be taken for granted. And this, combined with confident, comfortable handling skills, distinguishes a great manual therapist from a good one, not any Jedi abilities.
As in life in general, we are not able to please everyone, but we’re doing our best to satisfy as many of our students, as possible. And it works!!! As you might guess from my writing, currently I am not rubbing necks of posh people in a beauty salon, but I have my own small clinic with happy patients and I have an honour to be the IMTA assistant:)
And for those still looking for a magic wand –
Yours Daria 🙂