Who Are We?

My early years as a physical therapist were marked by a lot of friction. So much friction that I started to question whether or not I even knew what physical therapy was. I guess a profession defines itself, so my definition may not be correct. That said, I think how we define ourselves drives who we are and where we are going.

When I started college, I had no idea what I was going to do with my life. I switched majors several times my freshman year. I started with a major in Environmental Sciences with the desire to be some kind of park ranger. Then I switched to Economics because math and human behavior is fun. Philosophy was intriguing because they get paid just to do thought experiments all day (turns out they don’t which is why I dropped it). I liked the idea of Sports Medicine/Athletic Training, but back then it wasn’t a major. At that time you majored in any science degree and then did an internship to log enough hours to go out for certification.

As I was thumbing through the paper catalog of majors produced by the university, I stumbled on Physical Therapy. Back then it was an undergraduate degree so as a late freshman, it was as simple as changing my track with the registrar. I still had to apply and get in, but that wasn’t for another year.

I knew very little about the profession at the time. I had a friend in high school who wanted to be a PT with a focus on spinal cord injury. And I had seen the movie Regarding Henry where the main character suffers a traumatic brain injury and is inspired to return to his life by his very personable physical therapist. What I knew about physical therapists is that they worked with people who have suffered from an injury/disease to help them maximize their lives in light of their new normal (hold this thought). Humans handled this very well automatically, but sometimes things were more complicated – that is where the PT came in. I really geeked out on human performance so the idea of doing this for elite athletes really appealed to me.

This is how I came into the profession. I was completely unaware of things like manual therapy and modalities. I did my pre-PT volunteer hours in the acute care teaching hospital on campus so I almost never saw those things.

Let me be clear here. I’m not saying this is good or bad. I’m saying this was my understanding coming in. I’m trying to explain the root of my confusion.

My PT Worldview

Think about what I said before.

Physical therapists work with people who have suffered from an injury/disease to help them maximize their lives in light of their new normal.

This is my personal definition of rehab (might not be yours). Notice the key elements here:

• Injury/Disease
• New normal

I would expand on that by saying,

This person has a hard time managing the loads of their desired life due to an injury or disease. The physical therapist works with them to find ways for them to be able to take the required loads again either via conditioning or load modification.

This is true when dealing with maximizing gait performance in a child with cerebral palsy to helping an NBA player dunk again after a tib/fib fracture.

Notice a word that is missing in all of this: “Fix”

The Rehab World

When I graduated PT school, one of my mentors recommended that I start by working in a more classic rehab setting to build my foundation as a PT. So I took a job in a large inner city teaching hospital where I could work acute care and acute rehab, and then float to the outpatient clinic from time to time. What I found really interesting was how the job flowed pretty easily from acute care to acute rehab but then seemed to become something totally alien in the outpatient setting.

On the acute side of things, pain was something you had to deal with, not fix. You worked with what they could tolerate and progressed things as they got better. If things started to plateau, you continued to practice, but also worked with how to deal with the new normal. There was an acceptance and a struggle that was empowering.

In outpatient, pain was typically THE problem. It was the sign of something being broken and that thing needed to be fixed by the therapist’s hands and/or held in place by the patient’s muscles for the rest of their lives. When you think about it, it’s just absurd.

Now I’m not saying that pain cannot be debilitating, I’m saying that it’s not a thing to fix or outright avoid. There’s nothing to fix. There’s just the SAID principle.

The other side of this coin was PTs fixing the cause of the injury. Instead of focusing on making someone more functional after an onset of back pain, the PT was concerned with fixing what they believed to be the original cause – typically posture. Or instead of getting the athlete back to maximal strength, the PT focused on fixing the cause of their ACL injury. This all seemed misguided to me back then.

Weirdly, this seems to still be what this profession wants to do/be.

Stick to Rehab

To me fixing is not rehab. Surgeons fix broken things (not that they always should). We don’t. I feel that when we lose sight of helping to assist the body to find its maximal outcome after injury/disease, we go off the rails. All the nutty things that we do and promote and ends up failing to hold up to any legitimate research is rooted in the idea of being some kind of fixer.

If we stick to the rehab model of working with people who have suffered from an injury/disease to help them maximize their lives in light of their new normal, I think we would do better as a profession. We are more honest, more realistic, and ultimately more effective.

But…

…Maybe I’m the One Who’s Wrong

This post was triggered by a little self-reflection on my part. I’ve been fighting this fight for over 25 years and, well, on average nothing has changed. Maybe I’m the one who is wrong here. As I said before, a profession defines itself. I had a view of physical therapy that was from my specific perspective. And I’ve wrestled with that my whole career. But that may be more about me than it is about the profession.

Maybe the profession defines itself as fixers and healers. I read the journals. I go to the conferences. I see the slogans and the advertising:

• “Don’t ignore any pain.”
• “Bodies are fragile.”
• “Things get out of place and will not sort themselves out.”
• “You move wrong and you are going to pay for it.”
• “A physical therapist can…no! NEEDS to fix these things.”

An evaluation is all about identifying all the flawed kinematics and how to fix them. And the profession just keeps plugging along with it.

Sadly (for me) I don’t see much push back. Even the people who agree with me say things like, “Yeah but we still need PTs to have strong manual therapy skills because it is expected of a PT.” In other words, “The profession has decided on a specific definition for itself and you ain’t it, buddy.”

Maybe this actually is what physical therapy is. Maybe I’m the outsider trying to make it something it isn’t and never was. I feel like I’m a horse asking a bunch of zebras to lose the stripes. The Science PT website was originally started as a way to say things that weren’t being said within the profession, but I felt should be. Maybe I’m a physical therapist imposter and always have been.

I’m seriously beginning to wonder…