When Biology Fails
When you graduate school as a physical therapist you are convinced that every person who comes in contact with your now skillful hands and keen mind are going to achieve a full recovery with no limitations or pain and a renewed sense of self! How could they not?! After all, you just spent 7+ years of your life perfecting your craft and learning from some of the brightest minds!
The reality is that, if we were really honest, very few people experience full recoveries from their injuries because of our skill. Certainly the skills, knowledge, expertise, and demeanor of a physical therapist will have a large impact on the success of the patient. But this is a small fraction of what actually determines success when compared to the attitude and ownership of the patient/client.
I have found time and time again those who have a positive attitude and feel a strong sense of ownership over their injury, pain, surgery, etc., will generally always have a better outcome as measured by function and pain compared to those who feel powerless and have a poor outlook regarding their condition.
This of course is based on my experience, but I feel certain if I dug into the literature this would be empirically supported.
There are, however, layers to this. There are those patients who are naturally internally grateful, have a strong sense of self-efficacy, and have clear motivation to overcome. There are also those who have been discouraged by their experience or lack of progress, but all it takes is guidance, encouragement, and a small amount of improvement to reignite their vigor. Then there are those who have completely resigned themselves to never improve, whether they are aware of it or not… “nothing works,” “I can’t do anything,” “no one knows what’s wrong with me,” “I’ll never get better.”
This is not to blame them. This is the experience of a large portion of the people we see. For whatever reason, their ability to overcome has vanished. Sometimes this is the byproduct of years of no progress. Sometimes this is the result of poor healthcare management. But generally speaking there is a sense of loss, low self-efficacy, glass-half-empty, with no clear end goal. These people tend to place all the power of improvement in the hands of their providers. This almost never ends well…Or better yet, almost never ends. There will be years of searching for the “magic bullet,” or a new diagnosis, or the “best” provider.
I hope this does not come off as “holier than thou,” but this is real and this is the experience of a significant percentage of the people we try to help.
Physical therapists are equipped to help people according to a biopsychosocial model, which equally takes into account the biological, psychological, and social factors that influence an organism’s ability to thrive. Oftentimes, too much emphasis is placed on the biology, and not enough placed on the psychology or sociology of the individual.
This is truly the crux of this meandering opine: psychological and sociological factors MUST be a large part of the rehabilitation process.
There are plenty of individuals who I used to treat thinking that my skills and knowledge of physiology could strong-arm the magnitude of the clear disparity of their mental and/or social health, this was rarely a successful approach. When I began to see patients as people with complex social lives and long histories of experiences and began pulling in providers with the appropriate knowledge and skills to help people mentally and socially, only then did those individuals begin to experience the success they wanted.
But this was always at the willingness of the individual to be proactive and see their situation for something more complex than just biology (which is already complex enough). When these people regained their locus of control and began seeing through their condition they reclaimed a sense of power. Their attitudes toward their condition changed. Acceptance of their place in life provided peace because of a renewing of their mind.
I’ll end with an example… I began seeing an individual about a year ago who had an injury, that in truth was very minor with very little tissue damage. However, this injury left them feeling entirely powerless. They had seen multiple surgeons who always gave the same opinion: “I don’t see anything wrong.” That’s because pathologically speaking, nothing was wrong. Functionally there was a lot wrong. But these multiple opinions without a clear sense of understanding left this person perplexed, frustrated, and on the brink of spiraling. When I evaluated this individual they explained they had multiple bouts of PT with minimal success, they were fearful to move/exercise, they stopped doing the things in life they enjoyed…There was a very real role strain on this individual.
I knew that nothing I could DO physically would help this individual. So I began probing into some of the social factors: “how has this impacted your ability to be the spouse or parent you want to be?” … “Oh completely! I can’t be there for my kids and it's really frustrating.” I began to dig into the psychology: “What is your understanding of what’s going on? And do you think you can recover?” … “I honestly do not know anymore. I’ve seen everyone and sometimes I feel like people think I’m crazy.”
From there I knew that influencing their ability to see the “light at the end of the tunnel” would be important and I knew that helping them regain their role as a parent/spouse would be important. It is worth noting that I RARELY laid my hands on this person, the last thing they needed was feeling as if their success was incumbent upon what I did to them. Instead I provided them with small, bite sized goals, a clear plan, and empirical data tracking to show objective improvement. I essentially handed this person the “keys to the kingdom,” reinforced good movement patterns, encouraged and celebrated success.
Fast forward, not more than 8 weeks later this person reported feeling 80% better and was able to be the parent and spouse they had been before then. 12 weeks later: “I feel stronger than I was ever before.” The kicker? I only saw this person a handful of times. They did ALL of the work. I merely listened, provided a path forward, allowed them to experience a sense of control… their outlook began to change, they began to view themselves as powerful. I rendered myself essentially useless: which is ALWAYS my goal! But most importantly, this person took control. They changed their attitude. They had a sense of gratitude about their place in life. They took ownership once they were “given permission” to do so.
These things go a very long way! My encouragement to you if you are struggling with pain, injury, loss of function, begin to look at your role in this. Eliminate the NEED for others, instead rely on the guidance and help of experts who will empower you and allow you the freedom to be yourself again.
I will leave you with two quotes:
“Who am I being that others eyes are not shining?” – Benjamin Zander
“If it’s to be, it’s up to me.” – my father (and probably lots of other moms and dads too)
Dr. Jacob Reynolds PT, DPT, OCS
Board Certified Specialist in Orthopedic Physical Therapy
Follow Jake on Instagram: @theswimmingphysio