50 years a physiotherapist

Introduction
Twelve years ago, on the occasion of my 50 years of being a physiotherapist, I made a review of the ups and downs of our fine profession. It disappeared into a drawer of my desk. Some colleagues and former patients urged me to pull it out again. Nowadays, of course, things have changed but the intention has remained for me. And it might be fun to read it anyway.

1 June 2011 was the day. On that date, I had been a physiotherapist for 50 years. How did it all start? Has our profession changed? Is it still fun?

I was born a 'leap child'. 29 February 1936, a fine vintage year. For my parents and family, the event was a nice gift. Just a bright spot in a world that was especially unsettled in Germany. Even frightening for many.

I grew up in a nice environment. My own room, lots of toys and a mum and dad who spoiled me very much. Unfortunately, I would not get a sibling. No, I would stay alone. But then really all alone. In 1942, my parents were transported via Westerbork to Auschwitz, where they were gassed, murdered along with thousands of others.
I survived the war by being able to go into hiding at nine different addresses. I returned to Amsterdam after the war as an asthmatic, small, scared boy. Four years behind my peers. But it all worked out in the end*.

I attended Dongeschool in Amsterdam. A nice primary school where I not only learned to do maths and read, but also learned to play. Something I was never allowed or able to do during the war. This was followed by the Amsterdam Lyceum, to end up at the Second Public Trade School ( the OHS). That turned out to be a wrong choice. Not that the school wasn't good or fun, on the contrary. After all, I wanted to become a doctor. But there was no Greek and Latin in my package. So I went into 'commerce'. I received training at the well-known timber trade Ambagtsheer and van der Meulen as assistant manager. Between eighty purebred Amsterdammers in the timber port, I was well schooled. In all areas.

Another Education
One day, my (foster) mother saw an advertisement in the newspaper: Opleiding tot Heilgymnast-Masseur. It was a three-year evening course at the Vakschool voor Heilgymnastiek en Massage in the Kerkstraat in Amsterdam. This seemed like something for me. True, not a doctor, but something like that. Working with people, who have something wrong with them. My previous education was more than enough to allow me to enrol. There was no 'framework' I had to fit into. I was highly motivated and that was enough. So in 1957 I started a study that I have never regretted. On the contrary. Fortunately, it was an evening course, so I could just keep working in the timber trade. Lessons were given in Jan Rodenburg's practice in Amsterdam's Kerkstraat. On the first floor. Mr Rodenburg himself gave the massage lessons, both theory and practice. Sometimes his mother took over a few times. The other lessons were mainly given by doctor Eckhardt. A great man, with fantastic knowledge that he could also convey to the students. Sometimes doctor van Hasselt ( the well-known and famous family doctor) took over the lessons from him.

The evening started at six and ended at 10:30. Many of us worked during the day and then had to rush to get in on time. It was not easy. In the first year, you had to memorise a lot of learning such as: anatomy, physiology and hygiene. All the muscles, bones and joints. And how these work. The hygiene subject was absurdly extensive. For instance, you had to know that a packet of butter should not be next to a packet of margarine on the shelves. But it was part of the course Of course, there was also a lot of focus on first aid. The second year was largely taken up by lectures in pathology, diseaseology and orthopaedics, disorders of the musculoskeletal system, such as bones and muscles. Things really got fun for me when we started massage classes. Feeling where the pain was, massaging the pain away. Great. In the third year, you had to do internships. I was lucky enough to be assigned to the then Wilhelmina Hospital with the famous doctor and tennis player Hans van Swol.
Only here did I learn the real trade. Van Swol was strict and very professional. Lateness was out of the question. Saying something twice was out of the question. Listen, don't whine! The female patients sometimes found it strange and uncomfortable that a young masseur entered the cabin. If I then asked them to take off their jumper or blouse, the patient sometimes refused. I didn't know what to do then. Then van Swol came in and it was soon over. Either take off the clothes or go home. After some time, both the patient and I got used to it. For the theoretical subjects, I was supported by Henk van Leeuwen. He was a graduated physiotherapist and worked in the hospital. I owe a lot of knowledge to him. Then I had to do an internship in the rehabilitation centre 'De Hoogstaat' in Leersum. I had a fantastic time there. My teacher here was Theun Andeweg. A master in his field. I felt like a full-fledged masseur and remedial therapist there. I was called 'the Executioner', because of my boldly harsh approach and treatments. But the results were so good that I was asked if I didn't want to stay on after my apprenticeship. Here, I treated very severely disabled patients. The cause was usually a motor-car accident or a fall.

One patient has always stayed with me. The man was a surgeon. He was standing to operate, made a slip and slipped. He lands on his head and falls into a coma. He needs surgery. What eventually remains is a cash crop. Horrible. A child of about six. Under treatment, I sing nursery rhymes with him. "In den Haag daar woont een graaf" I can still sing flawlessly. In the beginning, I was upset by such patients. But you learn to deal with it. And get used to it. I would have liked to stay on 'Hoogstraat', but something came up! My massage teacher Jan Rodenburg, was the carer for AJAX*. He liked my massage so much that he asked me if I wouldn't like to come along to Ajax, so I could assist him. I was sold. First three times a week and later every day. My salary was 250 guilders a quarter. The players were satisfied with my work and when Rodenburg quit after a year, I was allowed to stay. I kept that up for fourteen years. Of course my salary went up. In the Golden Age, I earned 14 thousand guilders net per year. Not a lot of money, but I loved the work.

Meanwhile, I had passed my preliminary exam, my propaedeutic. After the third year came the final exam. That was in The Hague. A state exam. We took exams with 14 students at a time. Practice first. We were given a gymnastics lesson by a 'madman'. He certainly wanted to show how good he was. After forty minutes, we were all lying dead on the floor. I had scored a six, thinking I had earned a gold medal. Then orthopaedics, pathology, massage and theory of exercise therapy. I was satisfied though. The exam board was not. I failed! My world collapsed. I was heartbroken. Really. I fell into the familiar 'black hole'. I didn't want anything anymore. I scolded the whole world and especially those old, dusty people at the exam board. I did still work at Ajax and that is actually where my so successful life began.

The Beginning
The year after this, 1961 I passed with a ten for massage. Justice, I thought to myself. After fourteen years of working for Ajax and becoming a well-known Dutchman there through my work, I was forced to start my own practice.* A time of hard work began.
I first applied to the Amsterdam health insurance fund AZA, Algemeen Ziekenfonds Amsterdam, and the Amstelveen health insurance fund. It first started at home on Biesbosstraat in my bedroom. That was tolerated for a while. In the middle of my not-too-large room was the massage bench. That was all there really was. It did have a washbasin, which then housed my shaver and toothbrush. A folding bed on which the patient's clothes could be placed. Exercises could only be done on the massage couch.

The Health Insurance Fund
Then I got married to Conny van der Sluis, on a Sunday when Ajax did not have to play.
We went to live in van Breestraat. There I had space. I set up the large front room on the first floor as a treatment room. Everything according to the guidelines of the health insurance fund.
1. An easily accessible and well-ventilated space.
2. A non-slippery floor covering that does not attract dust. So no rugs or fitted carpets.
3. A wall rack should be provided. A mirror for exercise therapy. That the patient can see themselves.
4. A chair and a good opportunity to hang clothes.
5. A massage bench that is at the right height, with a step-up bench. There should also be a roller to place under the patient's knees.
6. Non-smelling massage oil.
7. A sink to wash hands with a bar of soap. A toilet
8. Good lighting.
9. Sufficient towels, to cover the body parts that did not need to be massaged.
10. A shoehorn.
11. To practice, clubs and at least one medicine ball should be provided.

The control doctor from the health insurance fund came in person to inspect whether everything was fine. Nervously, I waited for his verdict. But no result came. A letter would follow. Two weeks later I received it. Doctor van der Bijl wished me well. Everything had been found to be in order. That's how it was in the sixties. Good supervision of the work and its execution. Patients were regularly summoned by the health insurance fund. They were then questioned by a colleague, who was employed by the fund. Whether one was satisfied with the remedial gymnast-masseur. Whether he or she did a good job. Insane questions. How could and could a patient judge whether he was being massaged or exercised properly. But the health insurance fund placed great value on the patient's lay opinion Fortunately, they were satisfied with me! So I met the requirements of AZA, AOZ and ZZ, which later merged into ZAO. Ziekenfonds Amsterdam en Omstreken. So I then began a career that lasted 50 years. Of course, it was not as easy as it seems now.
Back then, patients were treated only on doctor's advice. Without a referral letter, you were not allowed to treat. At the end of the treatment period, you had to send the referrer a detailed report with your findings. For settlement with the health insurance fund, you had to send well and clearly filled-in lists with the names, date of birth, condition and therapy given. This too was regularly checked by the fund Many patients found this very annoying. A kind of cross-examination. The colleagues employed by the health fund were not exactly the most popular colleagues. They had too much power, control I mean. From behind the desk, they often decided whether a patient was allowed to continue treatments or not. This often caused tensions with the patient.

The Society
It was a fine time for me, when hard work was still rewarded. You also had nothing to do then with the absurd interference of the professional organisation. At that time, the Nederlands Genootschap voor Heilgymnastiek en Massage was still an organisation that fought for its members. It did not cast itself as a meddlesome organisation, but it helped members where it was needed. Consequently, I became a proud member. However, there were minimum fees. For a treatment at the practice, one received five guilders. If you had to treat a patient at home then you could claim seven guilders and fifty cents. Not a lot of money. But it was a free and new profession. I loved it and got on very well with the patients. However, most of my time was spent at the Ajax stadium.* There was immediate work for every graduate student. Hospitals, rehabilitation centres always had room for a remedial gymnast-masseur. But the profession was not really 'hot'. There were still too few doctors, who really took the profession seriously. "They are mostly people, playing doctor," was often said. Cooperation was also very difficult. The doctors were (and still are) often difficult to reach. Something that did not help a consultation. I never liked the fact that newly graduated physiotherapists could immediately start their own practice. I was more in favour of the practice as arranged with GPs. First shadowing for a year in an existing practice, where one could then master the practice much better. A kind of physiotherapist assistant.

Opportunities
Nowadays, as a graduated physiotherapist, one can work in a hospital, private practice, rehabilitation centre, nursing home, psychiatric institution, health centre, at a sports club, at a company, in education, and at a gym. For this, however, one must take an additional course. In regular physiotherapy training, one learns little or nothing about a gym. There, one has curricula mostly in English. Why that is I don't know. But terms like Pilates (intermediate) Body Shape and Step and Shape are very common. The exercise material almost all comes from America. Also, the training is different from my time.

Training
If you click on one of the many courses on the internet, you will see that the course falls under the heading of HBO training in Physiotherapy. One must then have at least an MBO diploma at level 4. A HAVO, VWO diploma gives access to any profile. Whatever that may be.
How else do you find out if it is a suitable course for you? One of the courses has a stat on the internet.
a. are you nimble and agile?
b. Would you like to help people?
c. Are you curious about how your body moves?
d. Do you enjoy interacting with different people?
e. Are you willing to serve as a test subject for a fellow student?
f. Does treating and counselling people appeal to you?
g. Don't shy away from physical contact?

Then this course is for you. I think what is requested under f and g should be self-evident. This is precisely why people want to become physiotherapists.

But back to my time. At that time, apart from sports injuries, my practice consisted mainly of patients with pulmonary problems, such as asthma and pulmonary emphysema, rheumatic complaints and orthopaedic conditions. Patients with neurological disorders also came into the practice. In those days, GPs knew little or nothing about our treatments. Today, that may have improved a little. A few years later, in addition to remedial gymnastics training, came physiotechnology training. The doctrine of treating with heat, water and electricity. It was a tough course for me. I had little time because of my work at Ajax. You had to do internships again, which was almost impossible for me. Nevertheless, I found a nice place. The Hoogovens in IJmuiden with Mr Peper. I was lucky. He understood my situation and agreed that I would only be there on Wednesday mornings. He neatly signed off my work placement booklet, as if I had been on work placement all day for three months.
"You have so much talent, you can manage without your internship," he said, when I really couldn't come any more. Ajax swallowed me whole. I could have kissed him. Then, when you got your physiotechnical diploma, you had to submit it to the Ministry of Health, along with your diploma of remedial gymnast-masseur. Then you received the diploma of Physiotherapist. I passed. With macaroons in the ajax dressing room, my passing was celebrated. Now I was a physiotherapist. Under the interest of all the players and trainer Buckingham, my board was smashed to the wall. Later, the board was stolen. I then had many more opportunities to treat. Besides massage, I used infrared radiators, ultra-short wave, current therapy (faradic and galvanic current. Interference later replaced this), sauna and water therapy, such as underwater massage.

Canada
But I missed out on sports physiotherapy training. Ajax allowed me to go to Canada for three weeks in the month of July. At the Toronto Maple Leaf's ice hockey and football club, I was taught by their physiotherapist Karl Ellieff. I was then able to see how they run a sports club there in a professional manner. I learned a lot in those few weeks. A year later I went there again.

Sports physiotherapist
This also allowed me to call myself a sports physiotherapist in the Netherlands. I was proud of that. Sports physiotherapist did not yet exist in the Netherlands. Nor did sports doctor. Those were general practitioners who also liked to treat sports injuries. People therefore often called me the 'Godfather of Sports Physiotherapy'. A title I am quite proud of.
I now had a much better understanding of the origins and treatment of sports injuries. I could also now get patients to take preventive measures. Taping vulnerable joints, such as ankles and, in some sports, the fingers (basketball, volleyball and handball). I could also bandage the ankles and knees. I always did that at Ajax. I also taught the players themselves how to bandage or tape a joint. As a result, injuries decreased and I often prevented an injury. But I also applied these measures to my 'regular' patients.

Two types of patients?
Is there a difference between an 'ordinary' patient and an athlete? And especially an elite athlete? Athletes are generally treated much more aggressively than 'ordinary' patients. For a start, often several times a day. Also, the treatment time is longer. Often a treatment takes several hours. Nowadays, the emphasis is on 'rehabilitation'. In my time, there was a lot of massage. A lot of equipment was used. I worked very much with paraffin wraps and then deep frictions. Only when the pain was over and the athlete himself thought he could start training again then I started the 'rehabilitation'. Together with Bob Haarms (Ajax's recovery coach), a player was then properly taken care of. Usually a de had to be slowed down. He wanted to get back to work as soon as possible. My motto was always "Better a week late than a day early". And that certainly applies to muscle injuries. Nowadays, many athletes with muscle injuries are injured for an unnecessarily long time. This is often because people keep starting too early. A muscle injury has to be completely healed before the athlete can start again. That can sometimes be as long as four to six weeks before the injury is over. Not feeling anything anymore does not mean that the muscle condition has actually healed. Many muscle injuries are caused by excessive stretching. Stretching too intensively often causes very small muscle tears. They are so small that the athlete hardly feels them. But the muscles are made more vulnerable. If a long sprint has to be made then there is a much higher chance of getting injured ( again). The most well-known is the hamstring injury. The muscles at the back of the thigh. I was therefore never an advocate of stretching. Especially not in athletes who were very injury-prone. American studies prove me right in this. A good warm-up is many times better than stretching. Players/athletes who get a lot of muscle injuries always had to do extra training in the 'strength room'. With heavy medicin balls they then went to work. If an injury, with no apparent cause, lasted too long, the doctor would be consulted and often things would be backed up with an injection. I was never happy with that, but if the player insisted on it himself, I couldn't do anything against it either. In the end, the athlete himself is responsible for his actions and the doctor and physiotherapist can only advise. In the 1960s, of course, there were very few physiotherapy practices. Unlike today. While there used to be a bank on every street corner, today you can find a physiotherapy practice. There is now too large a range of care providers. I don't think this is a good thing. Too often, the patient is now the boss. He or she says what needs to be done. "I need to be massaged, I want to exercise. The doctor says...". It's a good thing, though, that patients don't always need to be referred these days. And are more empowered. But the physiotherapist is still the boss! There used to be little or no specialisations. The therapist treated every patient. Regardless of the condition. Sometimes you did have a therapist who treated only children. But that was about it.

Specialisms
Much later came the specialisations. Manual therapists, acupuncturists, haptonomists, sports physiotherapists. Some therapists specialised in, say, only the shoulder, pelvis, lungs or knee. Still others dealt only with musicians or ballet dancers. Again later came the physiotherapists who specialised in oedema therapy, psychosomatic therapy, and therapy with geriatric patients. We also treated very many war victims. These patients required a special approach It was often not just about the physical complaint but often more about the psychological problems. Moreover, the treatment time of these patients was much longer than normal. Yet these patients were not allowed to be charged a different rate. So in my time, you were 'just' a physiotherapist. We treated all conditions. Although my interest at the time was more in (sports) injuries. Of course, these were not just footballers. Ballet dancers, artists, athletes, basketball players, cyclists, rowers and others also frequently came to the practice if they had been injured by a fall or bump or overexertion. All these people required a special approach. It really wasn't just 'just' treating the injury. We looked at the footwear, the clothing, the training programme, the posture during sport or play. We put the therapy together based on this. At that time, we were frontrunners with our approach and because of this, the practice was overcrowded. Not everyone could be treated just like that. People had to be referred to us by a doctor.

Referral pattern
But the referral pattern was closely linked to the doctor's knowledge. His understanding at the time was inadequate. Often even absent. I was regularly called by doctors asking if his patient could be treated. And what I did then. Once a month on Monday evenings, a number of specialists and GPs used to come and see how I worked. Then I gave a kind of 'refresher course'. Nowadays we speak of a 'workshop' .This gave me a very good contact with these doctors. I mention the specialists Stork, Hootsmans, de Voogd, Wawaruntu, Marti, v.d. Bijl, Noach, and van Swol, the GPs Levie, Weijel, de Goey, May, Dokter, and later Verhorst and van der Hart, Hoonhout and Sarlui. And many many others. They were great evenings and very educational for everyone. Nowadays, doctors are unfortunately so busy that they no longer have time for such things. I reported the ups and downs of their patients every month . I often visited these doctors to discuss certain problems. But of course, it was also easy to get the doctors on the phone. Despite their busy practice, they were always willing to speak to me.

Accessibility
These days, with few exceptions, this is very different. To get a doctor on the phone, you have to call several times. Either they are busy or the answering machine is on. There is usually no question of the doctor calling back. The assistant does the talking and then goes to ask the doctor if he or she has a moment or she asks my question. This is often annoying. It frequently happens that a therapist needs the doctor immediately and that does not work out. Contact with the specialist or GP is very important. Not only for the physiotherapist, but more so for the patient. Is patient allowed to be massaged, is he/she taking blood thinners, Beta blocker? Does he/she have foreign materials in the body? For example, an artificial hip or knee. I remember a patient who had to be treated by us with Ultra Short Wave. The doctor had failed to mention on the letter to us that patient had a pacemaker. Even the patient had not told us because it was so normal for her. At a time like this, you should be able to call the doctor. And what about the patient who suffered a brain haemorrhage in the waiting room? The doctor could not be reached, but fortunately we were able to get patient placed in the then Wilhelmina Guest House. Later, the doctor came to thank us with flowers! Referral became such an important issue that in 1989 the then Secretary of State for Health, Dick Dees agreed to "introduce on a limited scale a system of referral by the GP to the physiotherapist. "This would allow more efficient and cheaper work. GPs can make targeted referrals for advice, which in turn reduces unnecessary treatments by the specialist. Furthermore, the physiotherapist can better provide his expertise to home care and GPs. Realisation of this plan cost 600,000 guilders from 1990 to 1992. The scheme was given an experimental character". Nowadays, fortunately, one no longer needs a referral. This has the advantage that a patient can be treated much faster and it saves a doctor's visit. Only for chronic conditions (those appearing on the list Borst, the then Minister of Health), a referral and often an authorisation are still needed since 2008.

Refer
Of course, it was not as simple as Dees writes. Because of his little knowledge of physiotherapy, the doctor did not know that a physiotherapist can do much more than just 'rub'. The physiotherapist was mostly seen as a coat rack on which to hang just about anything. If a patient has a pain and the doctor does not know what it is then his therapy was: the physiotherapist. That's how it was with many conditions. But also because of this limited understanding, too little was referred. The GP then preferred to send his patient to a medicine specialist. As a result, the patient has to undergo unnecessary and sometimes not even harmless examinations far too often. Moreover, there is a waiting period before the patient could be seen. He or she then ends up in an often unnecessary course:

1. Often unnecessary x-rays
2. Harmful drugs, with side effects
3. Unnecessary inclusion
4. Superfluous rest cure
5. Work stoppage.

As a result, costs skyrocket. Physiotherapy is many times cheaper and so the patient is often denied it If one does get referred, the doctor's treatment advice is often incorrect or insufficient. All this causes unnecessary problems, sometimes even conflicts, of which the patient could then suffer.

Free Choice?
So these days, thankfully, things are different. Patients are free to go to a physiotherapist. One of his or her own choosing. Although some doctors often have their 'own' physiotherapist. Unfortunately, it is currently overshooting the mark. There are health insurers who want the therapist to do exactly what they want. If he then signs a contract with the health insurer then that therapist gets paid slightly more. Outrageous practices, against which there is much resistance. Fortunately. People nowadays don't look so much at the treatments, but rather at the cost of them. Everything has to be as cheap as possible. This in turn requires managers to calculate and control it all. So it's a mess, like so much has been and is wrong in the medical world. The well-known specialist Professor Smalhout wrote whole columns about it.

Referral pattern
What is the state of the doctor's referral pattern?
Doctors who refer naturally also have an expectation pattern regarding physiotherapy. The referral pattern is usually linked to this.

1. Patient has an identifiable condition. The doctor knows exactly what is wrong with the patient and refers him/her. This is then a conscious referral.
2. The doctor does not know exactly and cannot do anything (anymore) about it himself. He sends him/her on. Patient is now under roof for a while. Have a break. Does the patient not come into the practice for a while.
3. Or the doctor thinks 'something is being done again. The patient is satisfied ( for now)'.
4. Doctor doesn't know. Patient has vague complaints. Pains here and there.
Perhaps the Physiotherapist can help. Just wait and see what the result of treatment is. Perhaps pain reduction. At least something is being done about it.
5. Patient is put to work. Practice is the prescription. Also at home.
6. Patient is taken out of his/her isolation (briefly).
7. Patient's own request.
8. Refer for a second-opinion. If a patient has been treated by a physiotherapist for a very long time, without visible results, it is sometimes good if someone else looks at the patient. Sometimes it is also at the patient's own request.

These are all reasons for the doctor to refer and also to get rid of it himself for a while.

Resources

What are the physiotherapist's tools?

The physiotherapist's best tool is and remains the hands. They are used when massaging, palpating during an examination and to tapotage, tap massage in case of stuck mucus (no longer used these days) and in passive exercise. This is when the physiotherapist's hands help to perform a particular exercise.
Thus, the therapist also has various other aids to massage.

1. Oil
2. Soap
3. Powder
4. Cream. These can include creams that work for pain, reduce bruising, or warm the muscles and joints a little.
5. Gel, Mostly used for cooling. And as an intermediate agent in ultrasound treatment.

Besides massage and exercise, there are several other tools. Applications called.
This is how we know:

1. Ultrasound (Ultra-Schall)
2. Diadynamic current, Interference current
3. Ultra Short wave and the Curapulse
4. Laser
5. Paraffin
6. Ice cream
7. Water
8. Infrared radiator, very old Red lamp

All these applications can be used to treat many conditions. Especially muscle and joint complaints. In the past, these tools were used much more often than now. I think that is a pity, because these applications always helped us tremendously in treatment. Injuries were fixed faster than without these tools. But today, these applications are ( almost) not used anymore. The emphasis is on rehabilitation. Partly because of this, injuries often take much longer to heal.

Practice materials such as:
1. Bike
2. Exercise bike or rowing machine
3. Ball
4. Stick or club
5. Weights
6. Wall rack and bench.
7. Rope

In sport, the bench at Ajax had become a symbol in my time. The famous recovery coach Bobby Haarms always used a bench. That way he weaned his players off it. And he could see exactly whether someone was fit to play again or not. He then made them jump on and over the bench in different ways. With one foot or two feet. These were just about the options in the 1960s and 1970s. Nowadays, people also exercise a lot according to a certain method and the gym is very popular, which often has a physiotherapist attached to it. The name gym is already old-fashioned. People use all kinds of names for it, but mainly fitness. So we know cardio fitness, special guidance for lung diseases, back training and many other conditions and possibilities. Some physiotherapists also deal with weight loss. They often even have a 'personal trainer', who then guides a client. But to start a gym, or what name one gives it, one does need training. Many unfortunately do not have that, which can often lead to unnecessary injuries.

Practices
You also used to have a very different practice composition.

1. The solo practice. Here only one therapist worked
2. Meerman practice. Multiple physiotherapists, who all had their own patients
3. A practice owner, employing several colleagues
4. Physiotherapists forming a partnership
5. Practice where each therapist works on their own account.

Usually, the practice had the name of the owner. Later practices were often given the name of the neighbourhood or street in which they were located.

Requirements
After a few years, the requirements for a practice were expanded.

1. He had to be easily accessible.
2. Be easy to walk on. No high pavement. So also wheelchair accessible.
3. It had to be clean and fresh and have sufficient light and a safe floor A floor where patients could not slip, or that attracted dust. This was especially important with asthmatics and patients who were allergic.
4. Naturally a waiting area
5. A good no-smell heater
6. Separate treatment rooms
7. Possibility of privacy for the patient, so that other patients could not hear or see him/her
8. Good, clean couches, with clean towels or paper towel to be changed. Often patients had to bring their own towel,.
9. A toilet and the opportunity to wash hands for both therapist and patient, with a clean towel.
10. Good ventilation
11. Sufficient equipment
12. Sufficient space to practice
13. There had to be a changing area, a coat rack or clothes hook and a mirror and a shoehorn.

Records also had to be in order. All these things were checked with regularity back then. That was a good thing. Nowadays, in practice, checks are minimal. Moreover, almost everything goes by computer. Control from a health insurer who just walks into the practice no longer happens. However, nowadays everything is done according to strict protocols. There is a protocol for every condition.

Patient expectations
Not only did the doctor have an expectation, the patient naturally also had a certain expectation:

He or she wanted:

1. A listening ear for complaints
2. Sufficient time to listen and treat
3. Adequate care and assistance
4. An opinion that matched that of the GP/specialist
5. Good guidance
6. Good treatment
7. Is the GP well informed?
8. Giving advice.

Point 4 in particular still posed some problems. The patient comes into the practice with a letter from the doctor stating that he/she needs to be massaged. That term was widely used by doctors at the time. "Let yourself be massaged". Or " I will send you to the masseur". The doctor often did not really mean that massage was needed. But the patient sometimes didn't understand that. Then the therapist had to calmly go and explain that a 'whiplash' should not be massaged. It could, however, be exercised, within the pain limit, or water therapy, a device or perhaps taping. (This method of course came into vogue in physiotherapy practice a little later). It also happened that no treatment was allowed at all and rest was the right therapy. Point 8 also caused some confusion. In the case of an Achilles tendon injury, the therapist advises applying a sole/enhancement under the heel. The doctor finds this unnecessary or even pointless. The patient should not be pampered too much the doctor thinks. This was yet another proof that the doctor knows too little about therapy. Fortunately, there were also many doctors who did understand and left much to the therapist. But they did want to be properly informed. Which, of course, was their right.

Authorisation request
So therapists worked with health insurance companies. You then had to sign a contract with them. If you had a contract with a health insurance fund, you could usually treat patients from other health insurance funds. To treat people with health insurance, you needed authorisation from the health insurance fund. The treating doctor had to request such an authorisation from the health insurance fund to which the patient was affiliated. "Without authorisation, no treatment". The health insurance fund ensures that their insured receives the optimal help. Doctors and consultant physiotherapists, who are employed by the health insurance fund monitor this. The medical advisor should be informed about each patient after a treatment period of (usually) 6 weeks, two treatments per week, by the treating physiotherapist. At the end of the treatments, the physiotherapist sends a monthly statement to the health insurance fund. This declaration must be accompanied by a pre-printed list which then shows the patient's name, address and date of birth, condition, treatment, and treatment duration.

Declarations
The health insurance fund pays the claim directly to the physiotherapist.

For private patients, it was a bit different. Firstly, the fee was higher and secondly, you sent the bill to the patient. The insurance company then paid that bill directly to the patient. After all, he/she was their contractor. As a result, sometimes the patient forgot to pay the physiotherapist or said he/she never received the money. Nowadays, the payment system is much easier. There is no longer a distinction between health insurance and private patients. Also, no authorisation is needed anymore ( except for Borst list disorders) and the therapist sends the claim directly to the insurance company, which then pays the amount after a month. Nowadays, there is also a kind of unit rate which is between 27 and 28 euros. For patients requiring home treatment, one receives 10 to 11 euros more. The length of time does not matter. Two treatments a day is no longer allowed either. If a patient comes to the therapist with complaints of the back and the knee, that may not be treated in one session. Either the back or the knee. This is of course strange to say the least. The patient then comes on Monday for the knee and has to come back on Tuesday for the back. If a patient comes for oedema therapy (for example, after a mastectomy, where lymph nodes have been removed), the therapist may treat for three quarters of an hour for one and a half times the standard rate. The same applies to manual therapy. The therapist was the insurance company's bookkeeper in addition to his regular work. Now that is different. Payment traffic runs through Vecozo. It is the initial letters for Safe Communication in Healthcare. It is the intermediate station between medical and paramedical care providers and health insurers. Also with regard to claiming. The contracts to be concluded with health insurance companies are done digitally. Every year there is a new contract, which then has to be signed via computer. How should this be done if one does not have a computer? Over 132,400 healthcare providers are connected to Vecozo. Through their website, a patient's insurance details, among other things, can be accessed. This is only possible if one has a declaration software package that meets the Vektis standard. Vekis is the information centre in healthcare. It collects and analyses data on the costs and quality of healthcare in the Netherlands. Its services are free of charge! Every therapist can apply for his or her own certificate. Previously, people had to keep their own daily records and then send them to the health insurance fund every month. Often, treatments by the consulting doctor or physiotherapist were not considered necessary (anymore). This regularly caused friction. The advice was then given from behind his desk, without the patient being examined or questioned about his/her complaints. This doctor or therapist was then employed by the health insurance fund. The private insurance companies also employed a counselling doctor and physiotherapist. Their advice was often somewhat more professional and, moreover, they were quicker to convince of the usefulness of treatments. There was rarely any pattern to be found in the advice of the advisers. Their advice was unpredictable. Especially among doctors. Advice was binding. No consultation was possible. Of course, one of their duties was to monitor the cost to society and therefore keep it as low as possible.

The consulting colleague
The consulting physiotherapist acted a little more like a colleague. When problems arose, consultations were often held by phone. Then a decision taken earlier was often reversed. If they failed to convince the doctor or physiotherapist that treatment was really necessary, the patient was often angry. Not only at the insurance company, but also at the physiotherapist being treated. It even happened that a patient wanted to go to another physiotherapist. "That one will get it done". Sometimes a patient was 'invited' for examination behind the back of the treating physiotherapist. Then they were asked how long the therapist was working, whether the patient was satisfied, whether the treatment was helping and what the expectations were. And whether it was the therapy, which the therapist was declaring. Nonsensical questions. It is difficult for a patient to judge whether the therapist is doing a good job. Whether he is declaring correctly. A patient may or may not be satisfied and may or may not click with the therapist. If the patient then came to the therapist with the story that she/he had been to the supervising doctor or physiotherapist then it was not very nice. The doctor was also often pressurised by the patient. "The insurance company no longer covers this condition." Then it ended up being another indication and the patient still got an authorisation. And everyone was happy! Now, there is no nationwide fixed rate. The insurance company sets the rate. It varies from one insurance company to another. Physiotherapists who work with, for instance, Physioroadmap (very detailed measurements and other things on a patient according to a certain computer programme, for which you then have to take a special course) get a higher rate. This is, of course, a crazy thing. It is about expertise and not where one is affiliated. Therapists should be free to do that. In the old days, you were still allowed to declare any type of therapy. Whatever you did. For instance, if you first gave a patient paraffin, then massaged him and finally had him do some exercise, these were three rates you could add up. Of course, this was sometimes abused. Especially with therapists who were not that busy. But because of the good checks in those days, things were not that bad and the insurance companies were not unhappy with the claiming behaviour.

How does one obtain patients?
To get patients, you depended on the doctors. The question then was:
Do the doctors know your practice?
2. Do they like you?
3. Is the practice nearby?
4. Are you familiar with the patient's condition?

Often the doctor had their ‘own’ physiotherapist. The patient then had to explicitly ask for that particular physiotherapist. This occasionally caused friction with the doctor. The patient absolutely wanted to go to that specific therapist. Their father, mother, brother, aunt had benefited so much from them! Or the therapist would be called with the request if they could just call the doctor.
But how did you become known to the doctors?

Advertisement
You weren’t allowed to advertise. You could introduce yourself to a local doctor or hand out business cards. That was all you were allowed to do. And then you just had to wait and see if the doctor would refer patients to you. That bothered me. In the world of sport, people advertise the clothes and shoes they wear. That was the case during my time at Ajax too. I could have earned a lot of money if I’d worn the tracksuit the lads were wearing. I didn’t do it. I didn’t dare. I didn’t want to get into trouble with my professional body. On top of that, genuine collegiality was sometimes hard to find. There wasn’t really any consultation between the physiotherapists. For a while, as chairman of the Dutch Association of Independent Physiotherapists, the NVVF, in Amsterdam, I had to deal with complaints. These usually concerned a colleague who had poached a patient or put a leaflet through the letterboxes in their neighbourhood. People would then cry “advertising”. That is uncollegial. You shouldn’t poach patients, but you should consult with colleagues and, if necessary, refer a patient to a colleague who is more specialised in that particular condition. That was always a difficult issue. Referrals were rare and advertising was uncollegial. At that time, I had a lot of contact with my colleague Leffelaar. He trained many physiotherapists. Later, he moved to America, where he built up a thriving practice within a few years. Abroad, and particularly in America and Canada, advertising was and is very common. Doctors, dentists, solicitors, hospitals and physiotherapists advertise their practices. Often even using attractive illuminated signs.Despite the fact that opinions differed widely, it was not permitted here. As a result, I missed out on a lot of money. Various companies wanted me to walk around wearing their logo, shoes, clothing or a bag. I always refused. I was afraid that the Association would take issue with me over this. In October 1972, I left Ajax.* Then, with four staff members, I was able to expand my practice. We moved from Van Breestraat to 88 Lairessestraat. That was in 1971. We ran the practice there for over 40 years. Thousands of patients were treated there over the years. We helped a wide variety of people during that time. Some patients still come to see us. When I stopped working full-time, I still spent one day a week at the practice. Naturally, the way we run the practice and its layout have changed over the years. But our love for the profession has remained with all of us. In addition to massage and exercise therapy, we now also focus heavily on prevention and rehabilitation. The exercise room, which used to contain nothing more than a wall bar and an exercise bench, is now filled with state-of-the-art equipment. But we do distinguish ourselves from a gym. Moreover, I have my own treatment method for various conditions.

Government control
Government oversight is minimal. Once you are registered in the Bigregister and the KNGF quality register, you are expected to undertake regular continuing professional development. For this, you receive points. There is also a classification by specialisms, for which you need to achieve separate points. To date, there have been five different courses: Methodical Practice, Reporting, Evidence-Based Practice (meaning all treatments must be proven), DTF (Direct Access Physiotherapy); and Communication. You were required to follow these courses. It is unclear to me why we constantly use English words. In Dutch, ‘it sounds just as interesting’! I have always found that rather nonsensical. To begin with, you must, of course, be aware of every condition. So, a generalist. Being registered in a type of register does not determine a therapist's professional knowledge. Furthermore, the instructors of the courses are usually newly qualified colleagues. Often, they know less than older therapists who have been working in practice for years. You truly learn the trade in practice, not from a book. Hence my suggestion of ‘shadowing’ first.

Collegiality
In the beginning, you were very collegial with your colleagues from other practices. But the greater the competition is or becomes, the less consultation takes place. In the years I was on the board of the professional association, ‘collegiality’ was always on the agenda. Don't take patients from each other. Don't badmouth a colleague. Especially not in front of a patient. Feel free to consult. Don't be ashamed that you don't have a complete handle on a certain condition. You can't know everything, after all. Especially not if you're just starting out. In the early years, I sometimes covered for sick colleagues or colleagues who were on holiday. One morning, I heard a colleague ask a patient who she had previously been treated by. It turned out to be colleague X. He was treating her shoulder. My colleague then said: “A good therapist, only he doesn't know anything about shoulders.” That has always stayed with me. But just like with doctors, there is a form of jealousy in our profession too. A shame, but true.

Consultation
To optimally support a patient, regular consultation must be held.
1. With the GP
2. The specialist
3. The podiatrist
4. The instrument maker
5. Home care
6. Nurses
7. Transport

Besides treatment, you have to perform many more actions. In practice, you often have to take care of:

1. Patient transport
Assisting with filling in paperwork for the health insurer
3. Help with dressing and undressing
4. Making contact on behalf of the patient, such as calling the GP and other disciplines.
5. Advising on the purchase of a wheelchair, walking frame and/or parking permit

Of course, this doesn't always happen. It also depends on the patient's age. Older patients often have far more difficulty with all sorts of things than younger patients. They often don't have a computer (yet) or certain forms are too complicated. If you treat patients at home, the care is often even more extensive. Sometimes you have to help someone undress, or get in or out of the bath. Make a cup of coffee or tea. I have experienced patients who hadn't eaten for a few days because they couldn't get out of bed. I would always make them something to eat, or even go and do a few grocery shops for the patient. You hardly encounter that nowadays with younger colleagues.

Two patients
My patient was a sweet, elderly lady. After her husband died, she lived with her little dog, a stubborn yapping terrier, in a small flat on the fourth floor of a large apartment building. The woman was seriously ill, so I had to treat her at home. The therapy consisted of gentle, soothing massage and breathing exercises. All this was on the advice of the treating doctors. After the treatment, I often made her a cup of coffee or tea, and sometimes I'd quickly run an errand for her. There was no one else who did anything for her. She had no children, and home care only came twice a week. Together with the GP, I arranged for a district nurse to come daily to wash her and make her bed. Her medication also needed to be managed. After some time, she was able to do these things herself again. That, I felt, was also part of a therapist's duties!

One evening, a patient rang me. She’d suddenly fallen over. No, it wasn’t because of a rug or a telephone lead. She asked if I could pop round. It was a request from the doctor. I’d visited this patient before, so I knew her. She wasn’t exaggerating, so I went to have a look. Her knees were red and slightly swollen. I took some ice cubes out of the fridge, put them in a plastic bag and wrapped the whole thing in a tea towel. She was to place that on her knees for twenty minutes. In the meantime, I rang her GP. “Go ahead,” he said. I thought it was strange that someone would just fall like that. But the doctor had seen this sort of thing before. The lady had to apply the ice packs four times a day. She was allowed to ring me at any time. On Saturday afternoon, I popped round to check on her. She was in bed with a terrible headache. Her knees looked better. She just couldn’t walk very well, and straining when going to the toilet gave her a headache. I rang the GP straight away. I didn’t trust the situation. When I was doing my placement in Hoogstraat, I’d experienced something similar before. That had ended very badly. It turned out to be a brain tumour. The GP wasn’t on duty, but the out-of-hours service would make sure he called me back. And so he did. I told him what I’d observed. He said he’d have a look on Monday and then ring me. On Monday afternoon, the doctor called. “It’s not as bad as you think,” he said. I cautiously asked if it could be something in her head. “Are you mad?” he replied. “Just carry on with the massages, and everything will be fine.” Twice a week I dutifully went to give her a massage. She didn’t have to do anything around the house. She had a ‘maid’ who looked after her well. When I came back a week later, she was in bed. Her headaches had got worse and she’d fallen again. Her condition was slowly deteriorating. I imagined she was speaking differently. I also noticed she was having more difficulty walking. She was staggering and couldn’t keep her balance properly. I rang the doctor again. “It really isn’t anything in her head, is it?” I asked again. “I’ve looked it up in my textbooks and it could well be a tumour.” “Don’t be silly. Just give her a massage, or do whatever else you want to do, and I’ll pop round to have a look today or tomorrow.“ There wasn’t much point in massaging her anymore. I got her out of bed, helped her shower and get dressed. After that, she was able to walk around the house a little bit again. Climbing stairs was out of the question. The strength in her hands was also waning. Sometimes she would spontaneously drop things from her hands. Things couldn’t go on like this. I rang the doctor and said straight away when I got him on the phone: ”Doctor, this lady definitely has a brain tumour.“ I was startled by my own words. “You might be right; something needs to be done. I’ll sort things out straight away.” She was taken by ambulance to the Antonie van Leeuwenhoek Hospital. Four days later, the results came back: three brain tumours. Inoperable. I visited the hospital. I was allowed to massage her aching muscles a little. And she actually started to feel better. She was allowed to go home. I went to see her every day. To talk and, above all, to listen. Sometimes I did some passive exercises, moving her hips and knees. She didn’t want to get too stiff. That would make walking more difficult later on! But she became confused. She wet the bed and couldn’t even hold in her bowel movements anymore. She was also in increasing pain. I massaged her as often as possible. It was more of a gentle rubbing, but she loved it. But the pain grew more intense. It became unbearable.
Then the doctor called me. He was going to come every day to give morphine injections. Then it would be over in four days. “No more unnecessary suffering.” Although I didn't expect anything else, I was still shocked. Two days later, the lady passed away. The doctor and I were there. I ensured that a niece from London came. She made the funeral arrangements. I spoke a few words at her grave. She was a strong woman, whom I greatly valued.

Why are these two patients mentioned?
Because the profession of physiotherapist involves more than just massage and exercises. If you want to practice the profession properly, it involves a great deal more. It is ‘guidance’ of patients in all respects. Especially now that the population is ageing, the role of the physiotherapist is becoming even more intensive. In our practice, we still have a large number of patients who need to be treated at home. Of course, home care is often called in when necessary, but sometimes we step in. We feel that it is part of the profession and the patients are very grateful to us for it. “Getting old is not a problem, being old often is”.

How important our musculoskeletal system is only becomes apparent when we can no longer move properly. There are very many conditions that affect our musculoskeletal system, muscles and joints. When older people can no longer perform their daily tasks, it is a serious matter. Not only because of the pain, after all, there are painkillers for that. But no longer truly belonging, that is terrible. Most patients are first referred to a physiotherapist. Together with the patient, they draw up a treatment plan. This often involves light massage, exercise therapy, an application, and the creation of a home exercise plan. If the symptoms worsen, the GP refers the patient to a specialist. After a long wait, an extensive examination begins. The diagnosis is often shocking: rheumatism, Parkinson's, a form of dementia or Alzheimer's, or in the worst case, a malignant condition. Then everyone is shocked. In the beginning, it was still “Hey old man,” or "Hurry up, don't be such a baby." Now the misery, the suffering, often begins. For everyone. Sometimes the patient has to be admitted. Older patients often have a past, have experienced a lot. They want to become independent of healthcare providers as quickly as possible. Whoever they may be: such as
Arts,
Physiotherapist,
District nursing,
Home care,
Family partner.

As a physiotherapist, you have an important role to play. The GP/specialist has little time for guidance. They usually just write a prescription and pop in for a weekly check-up! But we are the ones who are ideally placed to guide such a dependent patient. What is expected of us? In practice, the treatment plan consists of: pain reduction, improving mobility, and improving muscle function. Everything seems to be going well. The patient has less pain, a contracture in, for example, the shoulder decreases. The movements improve. Imagine our surprise when the patient replies that things are not going well at all. “I can’t dress myself anymore, shave, tie my tie, fasten my bra anymore. I can’t go to my card night, my pub, the theatre etc. “Everyone is letting me down too”. Behind this answer are often a number of different factors: The patient is alone, thus lonely. He/she has a bossy partner. An impatient partner. The patient or the partner is ashamed of their behaviour. The patient is afraid. The symptoms started in the same way with their parents, and the outcome was terrible.

What can or should a physiotherapist do?
Naturally, the first step is to listen carefully. What are the patient's expectations now? Patients often see us as a last resort. We need to make it clear to the patient that we are not magicians. Sometimes perhaps a conjurer. Patients should be able to talk, laugh, and cry with us. Patients often think their physiotherapist can help and even has the solution to their complaints. You sometimes have to deviate from the planned treatment schedule. More discussion and advice are needed. Should the GP or specialist be involved more? We often need to call upon home care, district nursing, occupational therapy, or social services. Sometimes, a dentist needs to be consulted for a particular complaint. If a patient is alone, the physiotherapist may need to talk to family, neighbours, or acquaintances. It may sound strange, but it is part of a physiotherapist's job. Especially with seriously ill or disabled patients.

“Am I still the physiotherapist?”
It becomes even more difficult when treating patients at home. Often, the patient cannot speak openly there. The patient is frequently depressed, after all, they are very dependent. Sometimes a patient is even a bit aggressive. “This stupid physiotherapy! ”Better help me go to the toilet, make a cup of coffee, tie my tie, comb my hair, paint my nails, or other things.“” And there you are. The usual approach with the elderly was and is to keep people as physically mobile as possible. Over the years, I have found that the patient themselves, as well as their partner or family, find it much more important that their partner, father, or mother feels more human. "We consider that much more important than whether their knee can be bent a little more or their shoulder becomes a little looser." Of course, we should not neglect physiotherapy, but there is a limit to it. Even for us physiotherapists. It becomes even more difficult with an elderly person with dementia. The patient is usually referred to us for a physical complaint. In a hospital, care home, or nursing home, a patient with dementia doesn't have as many problems. They are set up for it, have the necessary support. And there is an in-house physiotherapist. For a physiotherapist in practice or one who has to treat patients at home, it's something else. In addition to the condition, there is much more to consider.
We need to make it clear to the patient what we are going to do.
We must ensure that we are accepted.
3. We must ensure the patient is not afraid or does not become afraid
4. Ensuring we understand the patient and they understand us
5. We must be able to communicate with the patient. Sometimes we have to write everything down.

With this group of patients, it is important to recognise that their coordination is impaired. They are unable to carry out ‘homework’, and their partner or family has little time to devote to our treatment plan. They already have enough trouble coping with the patient themselves – a patient who is often no longer able to do anything for themselves, who understands little or nothing, and who cannot or is not allowed to leave the house. This means treatment must always take place at home. The patient also remembers almost nothing; often, they no longer recognise their carers either. Only memories from a very long time ago occasionally resurface. These patients often ask about their parents, who died years ago. It is therefore very difficult to work with a patient with dementia. Never lose your patience and always just keep talking to the patient, even if they understand little or nothing of what is being said. In situations like this, it is of course impossible to be just a physiotherapist. Whilst doing the exercises, most patients suddenly need to go to the toilet. The time we are occupied is often used by the partner or carer to ‘quickly’ pop out for some shopping. So we are left alone with the patient. We then often have to do things with and for the patient that we obviously didn’t come here to do. Singing a song together, fetching a glass of water. The patient wants their hair combed or their glasses aren’t sitting properly. They’re also very easily distracted. They suddenly see something we don’t see – or something that isn’t there at all. Sometimes a patient becomes defiant and then shuts down completely. To counter this, we often have to play games with them, do jigsaw puzzles, read aloud or play music. In between all that, we must, of course, pay attention to, for example, the contracture in their knee, their asthma or various aches and pains. We must also realise that this patient takes up much more time than ‘ordinary’ patients. The referring doctor, who has usually known the patient for years and has also seen them’s condition deteriorate, is glad to have us. Because, unfortunately, these patients place an enormous burden on the doctor, their partner, family, friends, acquaintances and any other carers. We are primarily called upon to address the physical condition. But that is not the end of the story. Once we have started home-based treatment, the patient almost always becomes a ‘long-term’ case. We usually also have carte blanche to consult other care providers. Studies have shown that good collaboration between the various disciplines in primary care results in optimal patient care.

In particular, the occupational therapist can often bring relief by making small or, if necessary, large adjustments. District nursing and often the psychiatrist need to be involved.
We are dealing with these patients

1. Health.
2. The socio-societal aspect
3. The socio-economic aspect (financial area)

The Ageing Population
All in all, we can state that due to an ageing population, more and more problems may arise that are relevant to the physiotherapist. We must then concern ourselves with the ‘total’ person and no longer just with being a physiotherapist.
Of course, there are physiotherapists who deal exclusively with these patients. “The geriatric physiotherapist”. But working with people with dementia also occurs regularly with the ‘ordinary’ physiotherapist and requires a completely different approach.

The ‘ordinary’ patients
How are our daily patients, whom we treat in the practice, doing?
Many patients linger in the practice. Sometimes even too long. The reason is usually easy to guess.

They are satisfied with the treatments
2. It clicks with the therapist
3. The symptoms lessen
4. He or she enjoys the treatments
5. The doctor wants to
6. The therapist deems it necessary
7. People come to work late or not at all. “Can you have me come at ten o'clock, then I can sleep in a bit.” “I'll come at four o'clock, then I don't have to go back to work.”.

But sometimes patients don't come back. There are various reasons for this.

1. It's no use
2. The therapist does not do what the patient wants, or expects
3. There isn't much of a connection between the patient and therapist.
4. The insurance (no longer) covers the treatments
5. A different therapist has been found, for example, one closer to home
6. Friends or acquaintances ‘call in’ on others and they benefit from it.
The doctor no longer deems it necessary
8. The therapist no longer deems it necessary. The patient has recovered from their condition, or unfortunately, nothing more can be done.

The Practice
The current practice is not comparable with the practice that used to exist. We wore and still wear a white coat. As a physiotherapist you have a certain status and patients want to see that. They like to look up to the therapist, their caregiver. That instils more confidence. Nowadays, some wear jeans and a t-shirt. Moreover, everyone is simply called by their first name. Many patients don't want this, but it's expected. It's supposed to create a better bond with the patient. Nothing could be further from the truth. Research has once again shown that the average patient goes to their physiotherapist, not to Henk or Marion. Moreover, a white coat is also more hygienic.

The Training Courses
The training is also completely different from how it used to be. Fewer theoretical subjects. The main subjects are anatomy, physiology, and pathology. And then into practice more quickly. Where there used to be two or three training programmes, nowadays you can find a physiotherapy training programme in almost every major city. ‘The Amsterdam University of Applied Sciences; the European School of Physiotherapy; Hanze University of Applied Sciences in Groningen, Leiden University of Applied Sciences, Rotterdam, Utrecht and Amsterdam, Saxion Physiotherapy, Thim School for Physiotherapy and finally Avaris School in Breda. So there's plenty of choice. There are also many continuing education courses. You can take a course in almost any area, such as: hydrotherapy in neurology, the shoulder syndrome, body awareness, stress management, a course for headaches, neurorehabilitation, back problems and pelvic issues, COPD and asthma. Many more courses are available at the Dutch Paramedic Institute. The programmes in sports centres have also changed significantly. In the past, you could do judo, boxing, and improve your fitness through exercises at a sports centre. I disapprove when physiotherapists engage in selling vitamins and similar items. We are not trained for that, and furthermore, you are no longer working as a physiotherapist. We need to shake off the image that doctors think we want to play ‘doctor’.

An average day
What did a day of ours look like? My days were packed. I got up at quarter to seven. At breakfast at quarter past seven, I went through the diary and possibly some updates on special patients. If there was any time left, I'd read through the morning paper. That way, I could discuss certain matters with the patients!
I will be at the practice just before eight. I'll answer some early callers and check the answerphone. Then, I'll discuss some difficult patients with my colleagues and we'll allocate house calls. Clear arrangements will be made with the secretary regarding colleagues, doctors, and patients who need to be called. Letters that need to be written. Preparing the reports for the various doctors and visitors who are expected. The first patients arrive at half past eight. Rotations occur every half hour. Some patients stay for an hour. A forty-five-minute lunch break is taken midday. Then, various patients will be reviewed again. Special adjustments for patients will be discussed.
Discuss with the secretary which statuses she must request from the GP, hospital or colleague. Arranging transport for patients, calling the health insurance fund and insurance companies. Obtaining aids and adaptations in the patient's home. The first patients return at half past one. Coffee or tea is drunk between patients. Patients can also have something to drink. Patients often bring something tasty. The last patients leave at half past five. Then the practice must be tidied up. Clean sheets and towels are then placed on the couches. Most patients bring their own towel. Or they keep one with us in a clean bag with their name on it.
On two evenings a week, I still have surgery hours for patients who absolutely cannot come during the day. On the other evenings, I still have a few patients who need to be treated at home. I usually get home at half past nine. Then I go through the post and at ten o'clock I finish the day. We worked hard and the atmosphere at the practice was great. We didn't have our own patients. We rotated. That might seem strange, but it worked great. That way, the patients got to know all of us. If one of us then went on holiday, or was away for a day, the patients wouldn't get a ‘strange’ therapist to whom they would have to tell their entire history all over again.
We found it worked well and, more importantly, we found that the patients were extremely satisfied with this system.

The “Tetzner” Method
One of the doctors who sent us many patients was the famous surgeon Hans Tetzner. Together with him, we treated more than six thousand knees. He himself performed surgery on more than thirteen thousand knees. Tetzner had completed his training in America. For many years, he worked as a surgeon at the renowned Mayo Clinic in California.
His approach was different from that of other doctors. He first practised at the Spinoza Clinic and later at the Boerhaave Clinic in Amsterdam. Neither clinic exists as such any more. Once the patients had been admitted, the anaesthetist would come in first for a chat. Then I would arrive. I would teach the patient a few exercises that they had to do every hour before their operation. These consisted of muscle-strengthening exercises for the quadriceps – the thigh muscles – mobilisation exercises for the knee and ankle, and finally some breathing exercises. Immediately after the operation, the knee was bandaged and placed in a steel splint. The patient was strictly forbidden to bend the knee. On the same day, I would go to the hospital for a treatment session. I would remove the splint, take out the greasy cotton wool and the dressing, and massage the leg very gently. Naturally, I did not touch the knee. The patient was then given a set of exercises to perform every hour, repeating each one eight times. I began by having him tense his quadriceps, explicitly pressing the knee down into the bed. Next, I would lift the leg a little way and hold it there for three counts. Then lift it a little further and try to make three circles: first to the left, then to the right. Then it was the foot’s turn: all sorts of foot movements and little circles. The patient always had to keep breathing properly and, above all, not to strain. At the foot of the bed, I always placed a sort of support against which the patient had to press their foot, to prevent the foot from turning outwards. After the treatment, I would reapply the bandage and the splint to the knee and leg. On the third day, the splint and bandage could be removed. I would always do that. The patient was then allowed to bend the leg slightly and would start walking. First with the aid of a walking bike, and on the fourth day without any aids. At first, the patients were afraid. “Surely nothing can go wrong? The wound can’t possibly reopen, can it?” On the fifth day, we were already carefully practising walking up stairs. As soon as the patient was able to do that – and that was almost always the case – they were allowed to go home. I would visit them at home during the first week, and after that the patient would come to the practice for a further two weeks. After six weeks, the patient was allowed to do whatever they wanted again. Even get back into sport full-time. That was a lovely time, and I learnt a great deal from Dr Tetzner. These days, patients no longer receive any aftercare following knee surgery. Only if the symptoms persist will the doctor sometimes refer them on. But it is certainly not the norm. Nor is it considered part of the operation any more. The result, however, is that the knee often remains swollen for a very long time. This restricts the patient’s movement and, moreover, often causes pain. In my opinion, it would be better if the patient did receive follow-up treatment for a short period.

Guidelines
The KNGF has a practice guideline for, among others, meniscectomy. I will spare you the entire guideline. It is a kind of brochure consisting of 31 pages and is dated number 6, 2006. In addition to this brochure, there is also a laminated folder of this guideline. I went through the folder with a patient. After half an hour, he wanted to know when I would start the treatment. After all, the doctor had given him a letter. It contained everything he needed to know. Why play doctor yourself? He was right. I started treating in the way I had learned at my internship addresses and from my own experience.

As an example, I will nonetheless list a shortened guideline for the physical examination following a meniscectomy here:
Inspection and palpation:
• hydrops, synovitis (hard swelling, not movable), colour, temperature, shape.
• Pain on weight-bearing
Statistics, standard deviations
• Current event/stage in the inflammatory process

Then the motion study:
• gangpatroon (dynamisch symmetrisch, met of zonder krukken
• actieve en passieve stabiliteit
• proprioceptie
• spierkracht (functioneel) flexie, extensie, rotatie, lateroflexie
• gevoel van ‘giving way’
• mechanische stabiliteit
• dynamische balans
• lokale/algemene belastbaarheid

Zo staat de folder vol met aandachtspunten of zoals u wilt richtlijnen. Tegenwoordig spreekt men liever over ‘protocollen’.
Ik moet bij deze richtlijnen altijd denken aan mijn eerste acupunctuurlessen. Daar kreeg ik dan een poppetje met allemaal puntjes er op getekend. Dat waren de acupunctuurpunten waar je de naald moest inprikken. Toen mijn Chinese leermeester, dokter Siow, het poppetje later tegen kwam vroeg hij of ik nooit iets had geleerd en zelf niet kon nadenken. “Weg ermee”. Die neiging heb ik ook met de richtlijnen, hoe nuttig ze ook voor sommige fysiotherapeuten kunnen zijn.

De dagelijkse praktijk
De praktijk breidde zich meer en meer uit. Vaak hadden we meer dan honderd patiënten per dag. Maar we waren een geweldig team. We keken nooit naar de klok. We gingen pas naar huis als de laatste patiënten behandeld waren. En dat was vaak laat!
Voor een groot deel waren we gespecialiseerd in blessures. Daardoor kwamen er zeer veel sportmensen naar de praktijk. We behandelden veel voetballers. Niet alleen van Ajax, maar bijna alle amateurclubs in Amsterdam stuurden hun geblesseerde spelers. Tafeltennissers, basketballers, rugbyspelers, zwemmers, allemaal kwamen ze naar de praktijk.
Het was iedere dag weer een feest. Als ik in mijn receptieboek blader dan kom ik vele bekende namen tegen, naast alle onbekenden die ons even dierbaar waren. Ik lees onder andere: Jaap van Zweden, Edo de Waart, Corry van Gorp, Simone Klijnsma, Johnny Kraaijkamp, Rijk de Gooyer, Ton van Duinhoven, Wim Sonneveld, Robert Long, Prins Bernhard, Pia Beck, Marco Bakker, Karel Appel, Rex Harrison, Rudolf Nureyev, Oleg Popov, balletdansers, waaronder Alexander Radius en Han Ebbelaar, Peter Post, Ton Boot, Edgar Vos, Ed van Thijn en nog veel meer beroemdheden. Het was iedere dag een genot om naar de praktijk te gaan.
Er werd veel gelachen en uiteraard soms ook gehuild.

Tuchtcollege
Zo herinner ik mij een patiënte als de dag van gisteren:

De beroemde chirurg Hans Tetzner stuurde mij een patiënte met knieklachten. Deze vrouw, 76 jaar oud, was erg nerveus en leed bovendien aan de ziekte van Parkinson. Ze werd vergezeld door haar dochter, die erg lief en geduldig met haar moeder omging. De patiënte was veel te zwaar en daar ze altijd een staand beroep had gehad, was het geen wonder dat haar knieën het op een gegeven moment hadden begeven. Een ernstige vorm van artrose. In het verleden was de patiënte meerdere malen bij een fysiotherapeut geweest en dat was haar slecht bevallen. Ik overlegde met Tetzner wat precies de bedoeling was. “Ze moet wat mobieler worden, minder pijn krijgen. Deze mevrouw moet eigenlijk vertroeteld worden.” “Geen zware oefeningen,” zei haar dochter nog. Dus besloot ik rustig te masseren, nadat ik de knieën eerst een kwartier had ingepakt met paraffine omslagen. Lekker warm, ontspannend en goed voor de circulatie. Opeens begon de vrouw te huilen. Lange uithalen. “Ik voel me zo rot,”zei ze. “Ik kan niets meer en iedereen laat me in de steek.”
Haar dochter vertelde me dat ze jaren met stoffen op de markt had gestaan. Nu kon ze niet eens meer rustig een kopje koffie drinken, zonder te morsen. Na de eerste behandeling beloofde ik haar een vermindering van pijn in de knieën. ( Ik stelde de meeste patiënten altijd gerust en beloofde ze altijd dat ik iets aan hun aandoening kon doen)
Ik maakte een uitgebreid rapport en stuurde een kopie naar de specialist en de huisarts. Na de vierde behandeling voelde de patiënte zich een stuk beter. Ze had minder pijn en het scheen haar toe dat ze ook beter kon lopen. In ieder geval wat makkelijker. Ik meldde dit aan de specialist. Toen kwam de terugslag op het geestelijke vlak.
Tijdens de zevende behandeling moest ze ineens weer vreselijk huilen. “Mijn kinderen laten mij verrekken. Zelfs mijn dochter. Ik ben alleen hierheen gekomen, met een taxi. Schande!” Ik kalmeerde haar, gaf haar een glaasje water en een half tabletje Seresta. Dit in overleg met haar huisarts. Door haar toestand duurden de behandelingen steeds langer. Maar ik kreeg haar weer kalm. Het beven werd minder hevig en ‘ze had er weer zin in’. Op verzoek van de specialist en van mijn patiënte verlengde ik de behandeling. Het ziekenfonds waarbij mevrouw verzekerd was, wilde eerst een keuring. Dit werd geregeld zonder dat haar huisarts of haar specialist hiervan in kennis werden gesteld!
Het resultaat was verbazingwekkend. Ze mocht niet meer behandeld worden. De arts die haar had gekeurd was een orthopeed die ik niet kende. Ik had ook nog nooit van de man gehoord. Ik belde de dokter op. Na veel vijven en zessen wilde hij wel even aan de telefoon komen. “Ik wil graag even overleggen waarom mevrouw niet meer behandeld mag worden,”zei ik. De dokter wenste hier niet op in te gaan. Hij sprak niet zo graag met mijn soort, zei hij letterlijk. Ik was perplex wat verbeelde deze beginnende orthopeed zich wel! Ik belde hem nogmaals, maar meneer kwam niet meer aan de telefoon. Hij had betere dingen te doen. Ik schreef op advies van andere artsen een brief naar het Medisch Tucht College. Het college nam de zaak hoog op en er volgde een zitting. Tot mijn stomme verbazing werd er een brief ingebracht van mijn patiënte. Keurig met de hand geschreven, waarin mevrouw in juridische termen te kennen gaf niet meer door mij behandeld te willen worden. Dat “beetje wrijven en die warme pap”hielpen immers niet. Bovendien was het ook niet de moeite waard om voor tien minuten helemaal naar mij te moeten komen. Daarvoor was de reistijd te lang. De orthopeed, keurig in grijze broek en blauwe blazer, kwam heel arrogant over. Het irriteerde zelfs de rechter. Hij liet zich juridisch bijstaan door de toenmalige advocaat Anneke Goudsmit. Ik voerde mijn eigen verweer. Ik vertelde de rechters dat de ingebrachte brief onzin was. Ten eerste kon mevrouw vanwege haar Parkinson nauwelijks schrijven en ten tweede was haar kennis van de Nederlandse taal, met alle respect, niet van dien aard dat zij een dergelijke brief had kunnen schrijven. Die moest haar op zijn minst zijn ingefluisterd. De uitspraak volgde na zes weken.
De opmerking over mij werd hem zeer kwalijk genomen. Er was geen duidelijke reden naar voren gekomen waarom de patiënte de behandeling zou moeten staken. In tegendeel zelfs. Bovendien moest de orthopeed zijn excuus aan mij aanbieden,. De orthopeed ging in hoger beroep. Dus met z’n allen naar Den Haag. Daar werden nog meer leugens ingebracht. De rechter vroeg wat de dokter bedoelde met “uw soort”? De orthopeed ging nu stotteren, kreeg een rood hoofd en zei dat hij bedoelde dat de fysiotherapeuten altijd dachten dat zij arts waren. De rechter moest lachen. De dokter moest zich wel realiseren dat hij onder ede stond.  Toen toverde zijn advocaat weer een brief te voorschijn met de mededeling dat patiënte slechts vier keer was behandeld en dat ik veertien keer bij het ziekenfonds had gedeclareerd. Gelukkig had ik de afsprakenkaartjes van de patiënte in mijn bezit. Die had ze tijdens haar laatste behandeling vergeten. Ze zaten netjes in een plastic hoesje samen met haar lidmaatschapskaart van het ziekenfonds. Er stonden vijftien afspraken op. Ik overhandigde de rechters mijn status van de patiënte. Hier stond alles keurig op vermeld. Haar huilbuien, de Seresta, de koffie, de glazen water, de vele gesprekken en natuurlijk de therapie. Bovendien had ik ook de duur van de behandelingen vermeld. Dat patiënte mij na iedere behandeling ongevraagd een kus gaf en het jammer vond dat ik haar zoon niet was, vermeldde ik ook nog even. De voorzitter van het Hof gaf de arts tijdens de zittint nog een berisping voor zijn arrogante houding. Weer zes weken later kwam de uitslag. De arts kreeg nu een officiële waarschuwing. Hij had zich niet zoals een arts betaamt tegenover mij gedragen. Bovendien was patiënte juist zeer tevreden over mij en de behandeling.
Tenslotte werd de klacht van de orthopeed dat “Muller alleen maar sportmensen behandelt”weggehoond. Hun beschuldiging over de vermeende malversaties van het ziekenfonds werd afgedaan als lasterpraat. En dat ik hierover geen klacht wilde indienen werd bestempeld als nobel. Een week later kreeg ik een excuusbrief van de dochter. Haar moeder had helemaal niet begrepen waarover het ging. Ze had alleen maar een keer haar handtekening ergens onder moeten zetten. Ik heb haar nog jaren behandeld, met respect van beide kanten. De orthopeed praktiseert nog steeds. Alleen niet meer in Amsterdam.

Notities maken
Waarom nu ook weer deze patiënte genoemd. Ten eerste moeten we te allen tijde onze handelwijze, onze bevindingen, de gesprekken met de patiënt, arts en specialist goed notuleren. Ook de brieven en de verslagen naar de arts en specialist zorgvuldig bewaren. De mondelinge afspraken met patient, arts en zorgverzekeraar altijd op schrift stellen en indien  nodig bevestigen. Tegenwoordig kan dat allemaal op de computer en dus is een mail snel verstuurd. Of soms zelfs nog per fax kan dat. Dan moeten we ons niet laten kleineren, door niemand. Ons beroep is zeer waardevol. Duizenden patiënten hebben baat bij onze hulp. En mochten we soms misschien een beetje ‘de dokter’ lijken, dan doen we dat in het belang van de patiënt en zeker niet om ‘dokter te spelen’. Die tijd hebben we gehad! Wel worden we geacht SMART te werken: Specifiek, Meetbaar, Acceptabel, Realistisch en Tijdgebonden. Wie zou deze termen hebben bedacht? Wat blijft er van ons ‘vrije, mooie’ beroep nog over?

De Beroepsorganisatie II
Vroeger was de beroepsvereniging het Nederlands Genootschap een echte club van collega’s. Daar kon je terecht met vragen, zoals het opstarten van een praktijk, afsprakenkaartjes, de tarieven en nog veel meer. Tegenwoordig is het Koninklijk Genootschap voor Fysiotherapie veel meer een club die het beroep alleen maar moeilijk maakt. Er worden verplichtingen opgelegd, nog los van het veel te hoge lidmaatschapgeld, die niet goed zijn voor het beroep. Een beroepsorganisatie is er voor de leden en moet altijd proberen om het beroep zo mooi en eenvoudig te houden of te maken. Ze is helaas geen echte professionele club. Al is het tegenwoordig gelukkig beter dan voeger.
Ze huren wel experts in, maar ze moeten een voorbeeld nemen aan de artsen, specialisten. Die vechten voor hun leden in alle opzichten. Die maken een vuist met zijn allen. Wij blijven een veel te bescheiden vereniging, waar men gemakkelijk over heen loopt. We moeten veel meer doen aan onderzoek. Bewijzen dat fysiotherapie echt helpt. Zelfs beter is dan medicijnen. Niet klakkeloos aannemen dat een rugblessure beter met rust dan met behandelen kan genezen. Dat is lang niet altijd het geval. In mijn tijd dat ik nog voor de NVVF naar Den Haag mocht gaan en met onder andere de heren Dees en Franssen (om er maar twee te noemen) heb gesproken waren ze het roerend met mij eens. Jammer, maar waar.
Er worden ons tegenwoordig zo veel verplichtingen opgelegd dat we naast ons werk als fysiotherapeut veel meer zaken moeten doen. Ongelukkig ben je als je geen computer hebt. Je wordt er toe gedwongen. En iedereen vindt het de gewoonste zaak van de wereld. Schaf maar weer een nieuw programma aan. Doe maar precies wat de verzekeringsmaatschappijen willen. We pikken alles maar. Waarom gaan er zoveel fysiotherapeuten over op de fitness? Anderen verkopen allerlei spullen in de praktijk. Vitaminen, hoofdkussens, voetzooltjes, ga zo maar door. Dat is jammer en mijns inziens ook niet nodig. Ons tarief is al die jaren afgeroomd. Het is dus te weinig. De beroepsorganisatie heeft nauwelijks duidelijk kunnen maken dat een fysiotherapeut een wezenlijke bijdrage levert aan de gezondheidszorg. Dat wij vakmensen zijn met een enorme vakkennis. Kappers, loodgieters, schilders, stukadoors verdienen veel meer per uur. En hoeven er ook niet zoveel bijzaken voor te doen. Er is dus tot nu toe nauwelijks gedegen onderzoek gedaan naar het nut van de fysiotherapie. Onder redactie van collega Thomas J.A. Terlouw is een mooi boek verschenen: “Geschiedenis van de Fysiotherapie gezien door andere ogen”. Ik lees hierin dat op 30 november 1889 werd opgericht het genootschap ter beoefening van de heilgymnastiek in Nederland. Nu is het dan het KNGF. In 1891 kwam het eerste tijdschrift, gewijd aan de Heilgymnastiek. (nog geen massage). We lezen ook dat de heilgymnastiek een onderdeel vormt van de geneeskunde. Toch ondanks alle voorschriften, protocollen, blijft ons vak mooi en boeiend.

Eigen inzicht?
Toen ik begon kon je met je kennis en inzicht iemand goed behandelen. Tegenwoordig volg je andermans kennis. De kennis van het Genootschap voor Fysiotherapie. Ze schrijven via protocollen de behandeling voor. Over de knie heb ik het al gehad, maar zo is er voor bijna iedere aandoening een richtlijn. Zelfs voor de Fysiotherapeutische Verslaglegging. Vroeger hadden we een kaart, waarop we uitgebreid iedere behandeling vermeldden. Hierop stond dan de naam, geboortedatum, en adres van de patiënt, de huisarts en/of specialist, de aandoening, de therapie die wij wilden toepassen en de data dat patient werd behandeld. Indien nodig werden er metingen gedaan, die dan ook werden vermeld. Bij de kaart werd de verwijsbrief met de diagnose en de bevindingen van de verwijzer gedaan. Dat was dan meer dan genoeg. We konden direct met behandelen beginnen. Nu is er in 2003 een richtlijn uitgegeven door de beroepsorganisatie. Die omvat acht uitgebreide punten.

Een stappenplan met verwijzing en aanmelding:
• persoonsgegevens van de patiënt
• verzekeringsgegevens van de patiënt behandelend fysiotherapeut
• huisarts
• verwijsgegevens: – Verwijzer
Specialisme van de verwijzer
Verwijsdatum
Verwijsdiagnose / diagnostische gegevens
Eventuele consultvraag
• Anamnese
• Contractreden / hulpvraag van de patiënt
• Ervaren problemen aangaande functioneren
• Medische (voor) geschiedenis
• Andere of eerdere verleende zorg

• Onderzoek

• Diagnostische verrichtingen
• Bevindingen van de fysiotherapeut
• Resultaten van onderzoek

Zo gaat de verslaglegging maar door. Er zijn bovendien nog een scala aan Plusgegevens. Om dol van te worden. Ik denk dan maar dat het richtlijnen zijn. Want als je echt volgens deze richtlijnen zou gaan werken dan ben je alleen al aan het ontvangen van een patiënt een paar uur bezig. Gelukkig zijn er tegenwoordig computerprogramma’s die een stuk eenvoudiger en veel sneller zijn te gebruiken.

Wij gingen vroeger (en dat doe ik nu nog steeds) als er een patient kwam al bij de eerste behandeling, of zoals u wilt afspraak, direct na een kort inleidend gesprek over tot het behandelen. Tegenwoordig bestaat de eerste ‘behandeling’ uit een vraaggesprek. Daar zijn de meeste patiënten niet erg blij mee. Ze willen zo snel mogelijk van hun klacht af. Onder het behandelen kan men ook praten met de patiënt

Als ik na het ontslag van een patiënt een brief naar de huisarts of specialist stuur dan krijg ik steevast de opmerking dat de brief veel te uitvoerig is. “Ik heb al zo weinig tijd en dan nog al die brieven. Een kort resumé is voor mij meer dan voldoende.
Dat jij voor zulke brieven de tijd hebt. Ongelooflijk”. Daar kan ik het dan mee doen. Ik heb er ook de tijd niet voor, maar ik moet wel. Gelukkig had ik de hulp van een fantastische secretaresse en mijn vrouw.

Nu begrijp ik best dat een pas afgestudeerde fysiotherapeut een dergelijke Richtlijn als voorbeeld best kan gebruiken, maar na verloop van tijd krijgt hij toch zijn eigen invulling.
Ook daarom zou hij/zij eerst een jaartje mee moeten lopen met een gevestigde collega. Dat zou voor beiden goed zijn. Ze kunnen van elkaar leren!
In plaats van een machtiging heb je tegenwoordig te maken met een contract. Hierover lopen de meningen sterkt uiteen.
De meeste fysiotherapeuten hebben een dergelijk contract, maar er is wel veel discussie over. Een aantal denkt zonder contract mogelijk een hoger tarief te kunnen berekenen, gebaseerd op de kwaliteit van het geleverde werk. Maar het feit dat een zorgverzekeraar dan voor een patient minder vergoedt dan aan de behandelaar die wel een contract heeft, weerhoudt nog veel fysiotherapeuten van het zetten van de definitieve stap om geen contract meer af te sluiten.
Het beste zou mijns inziens zijn dat een patient zelf de fysiotherapeut betaalt. Hij kan dan zelf het bedrag van de nota bij zijn/haar zorgverzekeraar terug vorderen.
Dat systeem kennen ze onder andere in België.

Het masseren
Voor mij was het masseren van zeer groot belang. ‘Het voelen’, daar gaat het om. Waarom zijn blinde masseurs zulke goede vaklieden? Zij ‘zien’ alles met hun handen. En dat ios een zeer belangrijk onderdeel van het behandelen.
Daarom ga ik hier wat dieper in op het masseren. De term, ‘Hands off’, die tegenwoordig veel wordt gebruikt, ken ik niet. Ik wil een klacht kunnen voelen. Ik wil weten waar de patiënt echt pijn heeft. Of de spieren inderdaad hard en gespannen zijn. Dan moeten eerst de spieren weer soepel en los worden gemasseerd voordat de patiënt met oefeningen kan beginnen. Vaak komen er patiënten bij mij voor een second opinion. Ze hebben dan al geruime tijd pijn in de rug, in de nek of elders. Ik constateer dan vaak harde, gespannen spieren. Op de vraag of ze gemasseerd worden is het antwoord bijna altijd “Nee”. En dat is jammer. Oefeningen doen is prima, maar het moet wel kunnen zonder pijn. Spierpijn mag in lichte mate. Maar niet zodanig dat men zich een paar dagen niet kan bewegen. Het beste recept dat wij nog steeds toepassen bij spierpijnen is: beginnen met warmte. Wij geven meestal paraffinepakkingen. Dan rustige, cederende massages. Is de pijn minder en de patiënt kan zich weer goed bewegen dan krijgt hij/zij een oefenschema. De oefeningen moeten dan ook thuis worden gedaan. Dat wordt door ons zorgvuldig gecontroleerd. Want vaak zegt een patiënt ‘Ja’, maar is het ‘nee’! Dat laat ik de patiënt een paar oefeningen even voor doen. En dan weet hij/zij ze opeens niet meer zo goed! Een massage bestaat uiteraard niet alleen uit fricties. Bij meerdere patiënten werden fricties met de elleboog uitgevoerd. Dat is natuurlijk raar. Met de handen kan men voelen. Eventueel ook met de voeten, maar zeker niet met de elleboog.

Bij massage kennen we vijf verschillende handgrepen:
• Effleurage, het wrijven of strijken. Het beïnvloedt de bloed- en lymfestroom.
• Petrissage, het kneden. Heeft een diepere werking dan de effleurage. Het kneden is speciaal voor de spieren. Het veroorzaakt een goede doorbloeding, waardoor er een ontspanning en pijnvermindering kan ontstaan. Bij snel kneden wordt het weefsel geactiveerd en bij langzaam kneden ontspannen de spieren.
• Frictie. Frictioneren doet men door met een constante druk op de huid kleine cirkeltjes te maken.
• Het wordt toegepast bij diepliggende spierverhardingen en soms bij geïrriteerd gewrichtskapsel en bij spier- en peesaanhechtingen. Het geeft een sterke doorbloeding in een klein gebied.
• Het is een pijnlijke behandeling, die vaak met ijspakkingen wordt toegepast. Ik deed het nooit zo hard dat ijs nodig was. Maar ik heb het regelmatig gezien van collega’s, tot blauwe plekken aan toe. Ik vind dat men dan te hard te werk is gegaan. Bovendien is het gevaarlijk. Er kan hierdoor zelfs een myositis ossificans ontstaan. ( na een ongeval of te harde ingreep ontstane verkalking van beschadigde spiergedeelten rondom de plaats van de blessure of ingreep)
• Hakken en kloppen, Dit werd vroeger bij een ‘echte’ sportmassage toegepast. en ziet het nog wel bij het wielrennen. Kloppen past men nog wel toe bij bepaalde longaandoeningen waarbij slijm vastzit. Men was er een tijd op tegen, maar tegenwoordig past men deze methode weer meer toe Ik zelf heb er goede resultaten mee bereikt. Het slijm komt los en de patiënt kan nu ook beter ophoesten en daardoor beter en makkelijker ademen.
• Vibreren en schudden. Vibreren paste men vroeger veelvuldig toe. Het is het zeer snel geven van trillingen loodrecht op de huid. Vibreren kan worden gedaan met de hele hand, de vingertoppen of met een machine. Het schudden van spieren past men vaak toe aan het einde van een sportmassage. Speciaal bij de armen en de benen.

Voorzorgsmaatregelen
Massage is een intensieve bezigheid. Soms ook voor de patiënt. Het komt regelmatig voor dat een patient na het masseren moet plassen, of wat slaperig is. Toen ik nog wel eens examen af nam op de Vakschool, was ik zeer streng ten opzichte van het masseren. Niet zo zeer of de student wel heel goed kon masseren, maar meer of hij/zij wel de nodige voorzorgen had genomen.
• Handen wassen
• Geen lange, onverzorgde nagels.
• Geen ringen of horloge dragen
• Geen lange halsketting om de nek.
• Voldoende tussenstof
• De patiënt moest goed en ontspannen liggen.
• De lichaamsdelen die niet werden gemasseerd afdekken.

Dat vond ik erg belangrijk. Het goed masseren leer je alleen in de praktijk en vaak pas na een paar jaar. Hoe gek het ook klinkt. Helaas wordt er tegenwoordig te weinig aandacht besteed aan het masseren. De nadruk ligt veel meer op ‘revalideren’ . Ook in de sport zie je de fysiotherapeut in een mooi trainingspak met een geblesseerde speler op het veld rondjes lopen. Dat is niet de eerste prioriteit van de fysiotherapeut. Zo een speler moet worden overgedragen aan de hersteltrainer. De fysiotherapeut moet zich bezig houden met de geblesseerde spelers binnen en niet buiten. Daar zijn andere vakmensen voor.

Hoewel ik er niet meer direct bij betrokken ben houden de sportblessures mij nog steeds bezig. Waar door zijn er in de afgelopen tijden zo veel jonge sporters getroffen door een hartaandoening? Sommige sporters zijn zelfs overleden? Met de moderne technieken moet je toch kunnen vaststellen of een sporter een hartafwijking heeft. En toch slippen er altijd een paar door, waarvan men de aandoening niet heeft ontdekt, met alle gevolgen van dien. Ik zou het graag verder willen onderzoeken. Waarom duurt het vaak zo lang voordat een blessure is genezen? Waarom wordt er zo weinig gemasseerd? Ik ben nu vijftig jaar bezig en ik ben nog lang niet klaar.
Langs deze weg bedank ik iedereen die het mij mogelijk heeft gemaakt om met zoveel plezier te mogen werken. Mijn vrouw, mijn geweldige medewerkers, de artsen, al de studenten die bij ons stage hebben gelopen en natuurlijk mijn fantastische patiënten.

Amsterdam, juni 2011

*Eerdere uitgaven:

* Sport en Ongevallen
* Alles over Sportblessures
* “Tot vanavond en lief zijn hoor”
* Mijn AJAX
* Blootgeven
* Blootgegeven
* Nunes Vaz
* Mijn Ajaxjaren