The Myth of the Prognosis, and “Outside the Box” Patients
Common Question: “So, doc, how many sessions will this take?”
It’s an understandable question. For one, my patients are sizing me up, to make sure I know what I’m talking about, and two, for budgetary purposes.
Many people are surprised that I do not recommend the typical 2-3x/week dosage of physical therapy, that I believe is based in 3 myths.
Myth 1: Physical Therapy is to gain strength.
One of the “nails on a chalkboard” statement I hear all the time is, “I had ___ condition, that I was doing __ treatment for, I asked my primary care physician if I need physical therapy and he/she said “maybe, just to get a little stronger.”
The prescriptive activities of a physical therapist are rarely for brute strengthening (there are plenty of good personal trainers for that).
Reason 1: Often times people are initially in too much pain to strength train.
Reason 2: Often times, had I seen the person the day before the injury, I would have assessed them to be strong; ergo lack of brute strength is not the reason they got hurt.
Reason 3: I often give activity recommendations, coordinated movement pattern motions, or graded exposure motions. Some may consider these “exercises” 9becasue they still associate physical therapy with exercising) but patients typically do not break a sweat, nor do they get bulging muscles. The goal of these activities are to ingrain a new functional patterns to better use your body. If I do give strengthening, it is targeting a specific functional weakness, or is to teach my patient how to transition to home use of BFR/ blood flow restriction.
Back to dosage & frequency.
The dosage of activities that are more coordination/functional pattern-based are variable. Have you ever tried to learn something, tried some more, then it just clicks? Coordination, is not linear. Whereas for other patients, once they have the painfree motion, the coordination was just “on deck” and is now ready to use.
When exercises are given for multiple times per day: You might be given an activity to do multiple times per day and think that it is for strength. More often, you may be given “graded exposure” activities. This helps your body gain confidence in using an injured area in a way that is non-threatening, and thereby decreases your brain’s subconscious fear mechanism that can actually shut off active control to an area.
The dosage of frequency for manual therapy varies widely person to person and there does not exist a global, professionally decided upon correct answer.
What you need to know: If you are going to PT, given a home exercise program, do the program, and do the same thing in your sessions- you do not need to go to those sessions. I believe after a PT session you should feel better, feel challenged, and/or learned something about your body.
Myth 2: All conditions should have a pre-determined end date.
This one is mainly insurance company propaganda. If you’ve known anyone who’s had PT, they probably went somewhere 2-3x/wk for a month. Coincidentally, this corresponds to the allotted visits allowed per calendar year by most insurance plans. That number could be 4, or 8, or 12, maybe you have a good plan and you get 20 visits. Who you are and what you have going only matters in a small percentage of special cases.
Functional outcome “success rates” are often measured by standardized questionaires, that while good in many respects, don’t take into account how well YOU think you’re doing…which is really what matters.
The dangers: If you are still having problems, you may think “There’s nothing that can be done. Everyone said I should be better by now. I already did PT. I guess I just have to live with it.”
What you need to know: If you’ve been “kicked out” or “graduated” from other PT, but felt that that was premature, and you’d like to be better, OPT can probably help you.
Myth 3: All tissues heal in a specific timeline. There are some hard & fast guidelines for how long a broken bone or a sprained ankle will heal…which assumes- under the right conditions.
Broken bones & post-operative conditions: In my experience, most people who break a bone, get it set & have a cast- these are very controlled circumstances, and also assuming proper nutrition are those right circumstances. Also, in my experience, many people who have an orthopedic surgery follow a fairly predictable timeline.
In my experience, sprains managed medically (patients who go to urgent care), are given a wide range of treatments. Sprains in the ankle are treated with bracing, and assisted devices, while sprains in the back are treated with muscle relaxors & rest, while sprains in the shoulder are issued exercises or not treated. In any case, the message seems to be that time heals all wounds.
At OPT, we consider all the factors: Are you having episodes of reinjuring? Are there treatable neural or biomechanical factors predisposing you to reinjury? Do you have underlying personal or medical conditions that may extend your timeline? All of these conditions are going to make you more “outside the box” patients, and that’s okay. That just means there is more to you than your diagnosis.
What do I mean by neural or biomechanical? Neural Example: Let’s say you had a lateral ankle sprain. During the injury, the responsiveness of your musculotendinous tissue is your first line of defense, with your ligaments as structural back up. Maybe your ankle sprain was because your L5 nerve root wasn’t telling your peroneal/fibularis to respond fast enough? Now I’m the bad guy because I’m telling you that you have a back problem (despite no back pain), in addition to your sprain. You might feel sad & confused, but then we do some treatment in your back, and your ankle muscles get stronger- fantastic. Biomechanical example: Now let’s also say that you tend to weight-bear on the outside of your foot. That may be due from a soft tissue strain going all the way up your inner leg into your pelvis, or it may be due to a joint limitation in the ankle. Either way, I can treat it, and get you weight-bearing through your whole foot evenly, getting you out of the position of injury.
My goal is always to get your body functioning better. I hate seeing people figuratively banging their head up against a wall doing “all the right things” when there is just a little missing link in the chain.
I tend to see people years after the injury. They’ve never trusted that knee, or shoulder or whatever it was, have measurable muscle mass loss because they’ve been avoiding it, and now their back hurts. This all goes back to #2 of wanting everything to be tied up in a neat, easy package.
So, what to do?
I can give averages: On average, I see people 6 visits for an acute injury.
I can factor in your wants and needs. If you just want to have a little less pain, sure, 1-2 sessions might do it for you. If you’re looking for me to really look at all of you, determine causes, and make a chronic condition resolved or at least fairly less chronic, then that is a different answer. I see people once a month for years- whatever works for you.
For me personally, I would rather know the uncertainty. We’ve all heard of someone who was given 6 months to live and went on to live another 10 years, and someone who was sent home from the hospital with a clean bill of health and died the next day. If you’re up for the honest, uncertainty that fits the complexity that is the human body, OPT might be for you.
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