When you start your journey in the rehab sciences or medical field of any kind, you have a naive way of thinking of how things are done. It’s not any one’s fault that this happens, it’s just the nature of not knowing. In the follow post, I want to challenge those who are practitioners and their own beliefs. I recognize that some therapists may already be practicing in the way I’m going to challenge you, but the vast majority of therapists do not and I think it’s important for us to truly reflect on how we practice. These are from my personal experiences working with patients and seeing HUGE results.
When I was in school for Physical Therapy many years ago, I had a 5 year plan following graduation: I wanted to work in outpatient orthopedics, specialize in sports and obtain my Orthopedic or Sports clinical specialist title, and open my own practice. I wanted to work primarily with athletes and dove head first into fulfilling these goals, including working as the head therapist for a professional women’s hockey team (Boston Blades of the CWHL). But the more I worked and practiced, the more I realized that we, as a profession and society, know very little about the body and how it works.
It started when I’d notice that for my patient caseload, given a similar injury or diagnosis, some would get better and some would never improve as well as everyone along that spectrum in-between. Many times when I’d seek out an answer, I’d be given many suggestions – of which I’d try them all! – and yet still the same results occurred – some got responded and some didn’t. Of those that didn’t, I remember the co-owner of my first clinic job would say – 20% of all the patients you’ll encounter will contribute to 80% of your problems. And it did seem that way – many got better, but a small portion didn’t and those were my main problems. Some would even say that it was because my patients probably weren’t compliant and to not worry about it. I bought into that belief and continued with my work. However, looking back, I don’t believe that compliance should be the cop out reason that we give when a patient doesn’t improve.
Having run my own practice, I’ve realized that the vast majority of the time if compliance is the suspected issue, then it means that YOU are the problem. Yes, YOU the therapist. Why? Because the patient/client doesn’t see what you’re doing as effective or valuable. Because they aren’t getting better and you telling them the narrative of “it may take months or years to get better” isn’t something they want to hear. And you may say “but it DOES take time”, yes it does. All injuries take time, but having found many methods that provide relief to clients – my average number of visits per client for a plan of care (POC) is 6-8 visits, many with CHRONIC and/or RECURRENT pain – I truly believe that the traditional clinical methods applied by the majority of therapists is ineffective. So what was the difference?
When it comes to physical therapy, we all KNOW that everything is connected to everything, yet when we traditionally practice and treat, we’re concerned with only a few isolated parts of the body related to the injury. In school we were taught to always look above and below one joint – for example, if the elbow was the injury site or area of pain, we’d look to the shoulder and wrist. Once I started practicing and taking continuing education courses, I was more equipped to look at movement as a whole, rather than just at joints. This was a step forward, however it still only concerns itself with biomechanics, how a movement is generated. I believe that as a whole, a society and profession, we don’t ask enough WHYs.
For example, a patient comes in with elbow pain. Through evaluation and assessments (the first why – why is there elbow pain), we determine that it’s due to a “weak” shoulder/rotator cuff activation. Many will stop here and start treating the shoulder. Some will ask “why” the shoulder is weak and potentially trace it to the neck (2nd why), others may jump ahead and recognize that there is a kink along one of the movement changes linking the issue to a hip problem (2nd or 3rd why), and this line of thinking can be thought to be due to a neuromuscular activation issue or a neural tension (tightness the nerve during movement) issue. However, these “Whys” are all within the same line of thought – biomechanics. But the real and most important “WHY” that should be asked is more of a “WHAT”. WHAT ELSE could be causing this movement dysfunction that I see. I think it’s a great step forward that we can recognize that we have to treat beyond muscles and bones – that the nervous system is involved. So it’s established that the nervous system is tightly linked to how we move as well as overall strength. However, has anyone stopped to think how other systems are involved in this scenario? The cardiovascular, lymphatic, GI, or their visceral organs etc…
In the above image, the red and blue are arteries and veins respectively, the green are lymph vessels, the yellow are nerves. They run together, and you better believe that they work together and affect each other!
No two patients with the same complaint (I.e. elbow pain) should follow the exact same course of treatment for rehab because their past experiences are vastly different – Previous trauma, sports they played, movements/reps they’ve performed, even down to the food they eat. So therefore, their systems have been pre-conditioned very differently. This is a known fact. So why are we treating all elbow pain similarly – looking above and below the joint, looking only at this isolated observation – movement. WHAT ELSE can affect movement though?
In anatomy we all know that the organs aren’t just free floating in your abdomen, they’re anchored to the greater omentum and other structures through ligaments. We know that the lymphatic ducts and vessels travel along next to arteries and veins and that the lymph vessels filter venous blood. If you’re just trying to tell someone to “turn on their core”, do you think that maybe if there is rigidity in the mobility of the visceral organs it may make it hard to “activate” the core muscles that lay on top of the organs? It’s known that organs have to be able to move. When you breathe, the diaphragm creates a negative pressure vacuum to allow air into the lungs, forcing the organs below the diaphragm to descend. On exhalation, the diaphragm rebounds upwards and the organs shift upwards as well. This is why there is a shift towards improving someone’s breathing. But this is a two way street – the diaphragm and organs below affect each other, so it may not be enough to just attack the issue from a breathing perspective.
My challenge to all therapists and practicing clinicians – look BEYOND just biomechanics. Look BEYOND movement. Movement is great, but many times, you’ll get farther by looking at what else can affect movement, than just forcing a movement pattern to change in a rigid body. For a profession that actually SEES the entire body (movement analysis in rehab allows us to actually treat all parts of the body) we need to acknowledge that biomechanics and nerves aren’t the only things that influence movement patterns.
I recognize that there is more than 1 way to skin a cat, but there are efficient and inefficient methods too. If you’re not looking to be as efficient as possible, you’re just throwing a bunch of darts at a dart board and hoping that something sticks. You’ll only get the same results – some respond and get better, but many will leave you scratching your head. So ask more WHYs and WHAT ELSE when treating your patients. The examples listed above are only a glimpse at what I would look towards for treatment – stay hungry, stay motivated and learn more about how the body systems work TOGETHER, so you should treat ALL systems of the body.