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"I need more therapy & less exercise."


Therapy is a term that has been used in reference to many facets of the healthcare experience. This word is believed to have been used for the first time as far back as 1838. The word itself is derived from the new Latin word therapia and or the Greek word therapeia. According to Merriam-Webster's online dictionary the term therapy is defined as the, "medical treatment of impairment, injury, disease or disorder". Dictionary.com adds to this definition a bit by further defining it as follows:

  1. the treatment of disease or disorders, as by some remedial, rehabilitating, or curative process

  2. a curative power or quality

  3. psychotherapy

  4. any act, hobby, task, program, etc., that relieves tension

From these definitions we can easily see why the term enjoys such a broad range of usages throughout our world. In fact, the word therapy has been used to describe a number of professions and or interventions within the sphere of healthcare with the most common, at least when used in isolation, being that of a psychological intervention. This is so common place that when used to refer to some care or treatment other than from a psychological perspective the word is often preceded by some other qualifier, for example, occupational therapy, cognitive behavioral therapy, etc. The profession of Physical Therapy is no different. Therapy in this case is preceded by the word physical, indicating that it relates to something that has "material existence" according to Merriam-Webster. Furthermore, this entity with "material existence" is also "perceptible especially through the senses and subject to the laws of nature." In this case and as it relates to the human body, the laws of nature refer to several laws such as Newton’s law of gravitation as well as his 3 laws of motion.


So why the lesson in history, linguistics, & vocabulary? Well the title of this post, "I need more therapy, and less exercise" is a direct quote I received from a patient I treated some time ago. This was his 2nd visit following his initial evaluation. During his previous treatments we did very little in the way of exercise. In fact, the majority of his "exercise" was performed on his back and consisted of no external resistance, other than the weight of his legs and or arms. From an exercise programing perspective these could be considered by some to be the "lowest level” exercise a person can perform. So when he informed me he needed “...less exercise and more therapy” I was a bit confused, to say the least. That is until I began to question him a bit further. As we talked I began to understand what "therapy” actually meant to him.


Therapy to him was more consistent with treatments he had received some 15+ years ago following a back surgery, which consisted of moist heat, electrical stimulation, and massage. Oh and yes, very little exercise, mostly just getting up and walking around. Needless to say the profession of physical therapy has evolved considerably in 15 yrs. In fact, most of the evidence (i.e., expert consensus and otherwise) points to the understanding that moist heat and electrical stimulation aren't as beneficial in helping folks reach their functional goals as we once thought, when compared to more “active” interventions (e.g., exercise). However, given this patient’s desire to have "...less exercise and more therapy" (a.k.a. "passive" treatments), the question then becomes what really is ”best” for the patient? Or maybe even more importantly how do we ensure the patient is receiving the "best" evidence-supported care in spite of themselves or what they believe to be "best" for them? Even when it might not line up with what some might consider to be the "best" interventions according to current evidence? Well I didn't have a clear cut answer to those questions either, so I did what I always do, I began to look for and study everything I could find related to the patient-clinician interaction. The first area I turned to was the actual topic of, "what is evidence-based practice?"


Evidence-based practice, according to the American Physical Therapy Association is achieved through a blended approach of 3 equally important elements. Those elements are as follows:

  1. Best available evidence

  2. Clinician's knowledge and skills

  3. Patient wants and needs

The best available evidence is that information gathered from the scientific literature that provides reliable and valid information pertaining to the management of your patient and their unique clinical presentation. Best available evidence MUST ALSO entail information gathered through observations and interactions with our patients and their responses. Unfortunately, something that research often misses out on is the individual. Based on the scientific process, in light of statistical analysis, the majority of objective research is reduced to a mean or average value. This is great for crunching numbers, but unfortunately very few subjects in a data set actually exhibit the average value. In other words, many are not represented within the mean, not to mention others are considered outliers. Outliers include data that doesn't "fit" within a given data set, so they are either thrown out or "accounted for" through some sort of statistical correction. Of course it's the best we have as a society for making inferences about data, but it certainly means that your patient (i.e., an n of 1) should be considered when determining what the "best" evidence actually is and how it applies to their specific situation. This is something that gets lost in translation in the context of evidence based practice. The patient's response matters! Oh and contrary to popular belief, not everybody responds the same way to a given intervention, whether it be active, passive or otherwise.


Another pillar of the evidence-based approach is that of the clinicians expertise as it relates to their knowledge and clinical judgement as well as their clinical reasoning, which is considered unique to them based on their training as well as their professional experiences throughout their career. Now some might argue that this pillar may be fraught with a clinician's own personal biases and to a large degree they would be correct; however, that is somewhat inherent in a professional field referred to as a "practice". You see "physical therapy" is NOT the same everywhere you go. That is to say, it is not considered an intervention, but a profession, and each provider maintains a physical therapy practice if you will. The word practice, as defined by the Merriam-Webster's dictionary, is "to do or perform often, customarily, or habitually." A practice requires that a clinician be "professionally engaged" and perform or work in a manner that is repeated to the point of becoming proficient in their work.


Physical therapists as a whole are trained in a manner that ensures each and every licensed clinician has a baseline understanding of what it means to be an "entry-level" practitioner with what is considered to be appropriate and customary physical therapy practice across the profession. Something that should be understood is that "entry-level" physical therapy programs aren't tasked with the goal of creating expert clinicians, but rather developing a professional who is able to practice across the major disciplines of physical therapy practice (i.e., within orthopedic, neurological, and acute care/inpatient practice settings) in a way that is deemed safe and in accordance with current professional standards. It is from this point of entry into the field (hence the "entry-level" moniker) that each practitioner begins to specialize, more or less, in one of the above practice areas or one of the other many specialties (e.g., pelvic health) within the field.


It is through this specialization process where new clinicians begin to develop their approach, or philosophy, toward clinical practice. In doing so, many attend courses espousing various methodologies of clinical practice throughout their career, while others attend residency and or fellowship programs that aim to train clinicians in a specific approach to patient care. For instance, I'm personally a fellowship trained orthopaedic and sports manual therapist who has studied as well as certified through two very unique manual therapy groups over the past 16 years. Both of which emphasized the use of soft-tissue work as well as joint mobilization and or manipulation techniques; however, each were unique in the techniques they included as well as the way they taught and utilized their chosen principles within clinical practice. In other words, each were unique methodologies based on specific principles that they deemed clinically relevant according to their take or philosophical approach (a.k.a., biases) to patient management. So again it is more than likely that clinicians do exhibit biases of their own or in association with the individuals that were instrumental in their growth throughout the specialization process. For me trying to reconcile both perspectives from each of the 2 manual therapy groups was one of the most difficult aspects of my personal path to specialization.


The final aspect of the evidence-based triad is that of the patient's wants and needs. The fact of the matter is that the patient is in charge of their own healthcare and should have the autonomy to choose which treatment they receive. We as healthcare professionals needn’t lose sight of that fact, regardless of how strongly we feel (i.e., based on our own personal or specialty-based biases) one way or the other. The goal with this aspect of evidence-based practice would be to develop a therapeutic alliance with our patients by providing information and allowing them to be an informed consumers so they can make a choice as to what they believe is within their best interest. It is only from this point of mutual respect, and the belief that an individual does, in fact, have autonomy, that a patient will truly feel they are the ones responsible as well as ultimately in charge of their healthcare. If I were being truly honest with you that wasn’t my initial thought when the patient said, "I need more therapy and less exercise." I am glad to report I quickly (well for me) rebounded and as I placed electrical stimulation and moist heat on the patient I began to explain how things had changed in the past 15 or so years. He listened and seemed like he was taking it all in, but unfortunately at that point I‘m afraid he’d already made up his mind. Unfortunately, he never returned for another follow up visit.

I mentioned the concept of a therapeutic alliance above, and this is ultimately where I feel a number of medical professionals, including myself, have fallen short at one point or another throughout their career. A therapeutic alliance is a working relationship that is established between the patient and their medical provider where each party agrees upon a particular course of action to move toward and ultimately meet goals that are, yes realistic, but more importantly something the patient believes to be worthwhile. This is a concept that has been utilized in the psychological world since the days of Freud back in the 1900s and has been implemented in many different healthcare practices where there is a patient-provider interaction. The reality is that in order to have a successful alliance both the provider AND the patient have to contribute to the efforts. The following requirements of the provider and the patient are considered important contributors to a successful therapeutic alliance, according to Louw and colleagues (2019).


Provider Requirements:

  1. nonjudgmental

  2. strong communication skills (both verbal & non-verbal)

  3. strong listening skills (both verbal & non-verbal)

  4. demonstrating empathy

  5. showing high levels of competency

  6. demonstrating trust

  7. ability to collaborate successfully

  8. being respectful & validating of patient feelings

  9. developing rapport or connection

Patient Requirements:

  1. trust the provider

  2. actively engage in the intervention

  3. speak and act authentically

These factors can certainly add to or take away from any patient-provider therapeutic relationship, but there are other factors specific to the provider that can also negatively affect the relationship, such as: being too rigid; sharing personal struggles; being critical of the patient; and or not being involved in the process. As I've reflected on this encounter over the years in the context of building a therapeutic alliance, I've learned to see the interaction in a different light. On many fronts I had done my best to foster an alliance with my patient, but there were definitely some areas where I feel I fell short. For starters I would have to say I didn't really have a strong connection with the patient. My verbal and nonverbal communication were less than ideal as well, especially couched in the context of being a bit too rigid in my practice philosophy at the time.


I'm still focused on the current evidence and strive to incorporate the best intervention for my patients, but now I strive to partner with my patients in an effort to foster a healthy and worthwhile therapeutic relationship. In fact, that's one of the driving principles behind 4th Corner Performance & Therapeutic Concepts, PLLC. We wholeheartedly believe in the power of connectedness. As we've written about before, in his book, "The Power of the Other" Dr. Henery Cloud writes about the "4 Corners of Connection". Areas of connectedness include: 1) being disconnected; 2) having no Connection; 3) a pseudo-good connection & 4) True Connection. A 4th corner type of connectedness is "a place where people have true connection, where they can be authentic-not copied, not false or imitation...Finally the fuel and fulfillment can get to the need." We believe It's from this mutual place of authenticity where we as humans find what we need to more fully Rehabilitate, Recover & Restore.


How are your current therapeutic relationships? Do you, "need more therapy and less exercise"? When you are in the right place, at the right time you'll feel empowered to speak up and let your concerns or thoughts be known. This will more than likely help you move toward that place of a more collaborative and healthy journey as you strive to meet your patient-centered goals. I mean, you ARE in charge of and ultimately responsible for your own health.


Start taking responsibility today!


References


Louw A. et al. Integrating Manual Therapy and Pain Neuroscience: Twelve principles for treating the body and the brain. Minneapolis, MN;OPTP:2019.

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