Thursday, November 1, 2018

Are Passive Physical Therapy Treatments Worthless?

The other day, my mentor said something I thought was so profound that I asked him to elaborate on it for the entire first-year Doctor of Physical Therapy class I help out with.

“I tend to be a hands-off PT,” he said.

For context, we were discussing a case study in which a patient presented with several limitations. The patient couldn’t straighten or bend his knee all the way, and his kneecap wasn’t moving as much as it should.

The students were tasked with determining which restriction they’d go after first in the clinic. There were basically two camps: (1) the students who recommended bending and straightening stretches and exercises for the knee and (2) the students who recommended mobilizations for the kneecap.

Mobilizations for the kneecap

Now, both schools of thought are valid. Stretching and exercising the knee is a more “global” approach. It’ll address the flexibility of lots of structures around the knee, including the kneecap. Meanwhile, mobilizing the kneecap is a more “targeted” approach. Getting the kneecap moving more freely could also create more overall motion of the knee. Without any additional information, both approaches seem about equally likely to yield favorable outcomes.

That’s when my mentor piped up in favor of the global approach. “I tend to be a hands-off PT,” he said. I asked him to clarify for the class what he meant by “hands-off.”

He explained: in this case, when two approaches appear equally valid, the decision of what to treat first comes down to agency (i.e. the person who’s producing the therapeutic effect). With the kneecap mobilizations, that’s largely a passive, therapist-administered intervention. (Granted, a patient could learn to self-mobilize their kneecap, but for the sake of argument let’s suppose that’s not an option here.) Conversely, once shown, the patient should be able to actively execute exercises and stretches on their own.

This is a game-changing distinction and one it took my mentor many years of clinical practice to come to terms with himself.

With the stretching and exercise, the therapist essentially gives the patient the power to actively heal themselves (under the therapist’s watchful eye, of course). In the process, the patient and therapist build a strong therapeutic alliance.

On the other hand, with the kneecap mobilizations the therapist runs the risk of the patient crediting him or her with the power to “fix” them. This may not sound like a big deal, but downstream, the patient may develop a reliance on this passive treatment style for every little ache and pain. In some cases, the patient might even believe the therapist is the only one who can help them with their pain, leading to reduced self-efficacy and feelings of helplessness.

Now, all of this isn’t to say that passive treatments are worthless (although some therapists would certainly argue for that viewpoint). While active treatment is often preferred for the reasons stated above, sometimes passive treatments can help get someone “over the hump.” For example, a passive treatment might acutely reduce a patient’s pain enough to allow them to engage in an active treatment.

The reason I asked my mentor to elaborate on this point was that in physical therapy school, the students spend a lot of time learning hands-on treatment techniques. My mentor’s hands-off approach seems to fly in the face of much of what the students come to know as physical therapy. What a terrific exposure to this alternative school of thought in just their sixth week of school!

Related: Is There A Science to Physical Therapy?

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