When Your Treatments Are Not Physical OR Therapeutic…

How many tools are in your physical therapist’s toolkit? Five? Ten? Fifty?  Have you just been filling it up with anything you can get your hands on?  Have you been keeping all of your tools clean and shiny?  Putting another tool in the toolkit is often used to justify learning yet another new treatment philosophy, manual technique, or modality, in order to be a well rounded clinician that would have something for everybody.  Should we really be utilizing anything that is in front of us?  What sorts of treatments should physical therapists be using?  If we want to unify our profession and be an entry point for patients into the healthcare system, we need to be more selective with the tools we use.  Presumably, if we want to be physical therapists, our treatments should involve things that are, yes you guessed it, physical and therapeutic.  

There are standard tools that all healthcare professionals need to have in their toolkit because they will be used regularly.  One tool that goes in right away is the General Human Interaction Facilitation Tool.  We do not treat injuries, conditions, or diseases; we treat human beings that have emotions, feelings, thoughts, wants, and needs.  We need to be able to make meaningful connections because therapeutic alliances do not build themselves.  Along with the GHIFT, another tool that goes in every healthcare professional’s toolbox is what I would call the Scientific Literacy and Rationality Enhancement Tool  This needs to be standard-issue for all physical therapy students.  Since we are doing a bit of thinking now and then, we need to learn how to think.   We need to be able to dissect a research paper as carefully as we can dissect a cadaver.  Reason, logic, and science need to be our allies.  These are most likely the two most important tools that a healthcare professional needs to have in their toolkit for constant use.  

What tools go specifically into a physical therapist’s toolkit?  The main choice, among others of course, has to be the Meaningful Exercise Program Generator tool.  If the words physical and therapy mean anything, physical activity, exercise, and movement has to be our treatment of choice to treat health conditions.  We are not manual therapists, massage therapists, bodyworkers, modality peddlers, or CAM practitioners.  We need to be the go-to healthcare professionals to create meaningful, specific, progressive, and science-based exercise programs that effectively challenge our patients and improve their physical capacity and confidence, in spite of their pain and disability.

“If exercise could be packed into a pill, it would be the single most widely prescribed and beneficial medicine in the nation.”

-Robert Butler.

If exercise really is the most “beneficial medicine,” it seems we have a call to action.  As medical professionals that are highly educated in human anatomy and pathoanatomy, musculoskeletal, neurological, and cardiovascular conditions, exercise physiology, and exercise programming, we are in the best position to treat these patients.  Our profession has not yet earned this privilege and responsibility yet.  Part of the problem has to be the divergence of our treatment philosophy into profoundly unscientific ideas, snake oil treatments and techniques borrowed from complementary and alternative “medicine.”  

In the interest of unification and specialization, treatments that are neither physical nor therapeutic should be re-examined.  As a general rule, any treatment where a patient is lying on a table for an extended period of time and doing nothing is probably not something we should be encouraging.  The use of treatments that have not demonstrated efficacy (however we ought to define it) for the treatment of a disease in well conducted scientific trials should be questioned.  Some things that our profession utilizes fit into one or both categories;  laser, e-stim, ultrasound, whirlpool, iontophoresis, phonophoresis, heat, ice, dry needling, cupping, taping, under-dosed exercise, passive manual therapy, and the latest pseudoscientific nonsense that will be coming out.  

Even if these treatments are shown to work and thus be therapeutic in the long term, are we the ones that should be administering them?  Patients can buy TENS machines for home use, probably already own heating pads or a bag of frozen peas, and we can refer out to massage therapists who are probably better than us at massage.  There is nothing physical or therapeutic, in the sense that we ought to care about, with these treatments.  They are tangential to our knowledge of anatomy and physiology, exercise, and pain science, not aligned with it.  Our treatments need to be activity based and scientifically supported.  What is a physical therapist that does anything besides that? 

It may be that physical therapy is having an existential crisis.  We don’t know who we are or what we are good at or what we should be doing.  It seems as though we are trying to take a little from everybody; soft tissue mobilization from the massage therapists, joint mobilizations from the chiropractors, therapeutic exercise from the personal trainers, METs from the osteopaths, dry needling from the acupuncturists…..the list goes on.  We have not quite carved our niche yet, but once we settle in, we should stay there.  We should focus on one thing: using the tools of science and our knowledge of human anatomy, human psychology, and exercise to help people with musculoskeletal, neuromuscular, and cardiovascular conditions lead better, more active lives.  The tool I use the most is dynamic, meaningful, and patient-centered physical activity to manage pain and improve physical capacity.  It would serve us better if we perfected the use of a select few tools instead of grabbing as many as we can and pretending that we are the best at using them.  

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