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The Paradigm Shift

I’m not sure if you know this, but all health and wellness professionals have bias. Good ones recognize this and consciously question their inclinations when it comes to clinical decision-making. We can blame schooling – clinicians are essentially taught algorithms when it comes to diagnoses and treatment: clinical decision-making flow charts that ask yes or no questions to determine the best course of action. To make matters worse, most medical professionals are over-worked, so they rely upon their biases and adopt something of a dogmatic approach to care. On one hand, this makes things more efficient – providers can see more patients, ergo do more good, or so the logic goes. But, what really happens is that people aren’t seen and treated as individuals, and they don’t receive quality care.

I’m guilty of doing this.

It’s been one year since I opened my own practice.  And a lot has happened in this past year – on a large scale we’ve seen a global pandemic, and on a much smaller scale I sustained major injury that made me question everything I thought about being a PT.  So, as I reflect upon this past year, I want to talk about how my approach to clinical care has changed.

When I entered PT school, I was ALL about biomechanics. I truly believed that how people moved dictated where they would sustain injuries and where they’d have pain. PT school reinforced this bias for me. In PT school, you learn about how forces are transmitted through the body from a Newtonian perspective.  You’re also taught an array of “special tests,” which are meant to rule in or out musculoskeletal conditions. PT’s learn formulas called “clinical prediction rules,” which help to guide clinical decision making. My examination of a new patient started the moment I saw them sitting in the waiting room: How was their sitting posture? What strategies did they use to stand up? Where was their weight when they walked I prided myself on being able to predict where they had pain before they even said a word to me.  I relied upon my validated special tests and clinical prediction rules to help me determine what exactly was going on. And then I addressed every single deficit I noticed. A patient presenting with low back pain may leave with 3-4 exercises for their feet. This “whole body” approach was overly thorough, and often times was too aggressive for someone was realistically wouldn’t even commit to 3 minutes of stretching per day.

But, the more clinical experience I gained, the more I realized that things don’t always follow these predictive rules.  Occasionally I’d evaluate someone who had symptoms that I simply couldn’t reproduce. And more often than not, I’d see people who presented with horrendous posture, significant core weakness, or minimal functional mobility who really didn’t have any amount of pain.  I started taking continuing education courses from renowned practitioners who purported that perhaps muscle weakness, soft tissue restriction and poor motor control really didn’t matter. Instead, maybe we just needed to encourage people to move in different ways. They encouraged us to empower our patients, rather than scare them. They shared statistics showing that most people have low back pain at some point in their lives, and suggested that disc issues really aren’t that big of a deal. After all, many people show disc bulges on MRI’s and have no pain. So, perhaps pain is due to other factors (like the nervous system) and not about the physical body.

Admittedly, I want to rely on observable science – I’m talking about biomechanics, or physiological processes like inflammation. But, I do agree that things like sleep, stress and fear play a huge role in how we perceive and process pain. I can speak from personal experience that my pain is often worse when I’m sleep-deprived, when I’m stressed, or when I haven’t been eating my best. I also know firsthand that low back pain that I experience tends to be worse after doing activities that I’m afraid of, like gardening or shoveling snow.

The more information I consumed from this point of view, the more I started to implement it into my clinical practice. If someone said they weren’t walking because they were afraid it would flare them up, their homework would be to walk for 20 minutes. “Face your fears!”  “Push your boundaries!” “The human body is resilient!” “What’s the worst that could happen if you flare your pain up?” I felt like a more of a therapist than a PT when I repeated these messages over and over to my patients.  This certainly was beneficial for some of my patients, particularly those who had experienced chronic pain.

After a while, I started to take this advice myself. After dealing with recurrent flare-ups from a herniated disc, I would avoid heavy deadlifts unless I had plenty of time to warm up and I could really focus on perfect form. Historically, at the first sign of back soreness I’d step away from the bar and hit the foam roller. But now I was telling myself that my body had healed and that the pain I was experiencing was in my head, not in my body. I continued to participate in activities that the old me would have discouraged a patient with a disc bulge from doing (e.g. ab mat sit ups and heavy deadlifts). After all, my disc was healed, wasn’t it? My body was resilient, right?  Wrong. I sustained yet another injury, and one that took me nearly 4 months to recover from.

I won’t go into the details of this injury, because they’re not relevant to this discussion. But what is relevant is that my bias failed me. 

As a practitioner, I assess everyone as an individual. It’s why I’ve sought training in many areas to complement physical therapy (e.g. functional nutrition and behavior change coaching).  We are all unique and deserve to be evaluated as such.  If you’ve been dealing with a recurrent or ongoing issue (>3 months), work with someone who will truly address all aspects of your life, who values your perspective, and who actively involves you in developing your plan of care. If your provider seems overly dogmatic or speaks in absolutes, question their approach. Don’t be afraid to ask what would happen if you didn’t take their advice or follow their suggested treatment protocol. Because if there’s one thing I’ve learned, it’s that there are no absolutes when it comes to healing.

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