What Is The Language Of Physical Therapy?
Whether physical therapists want to admit it or not, the profession is suffering an identity crisis at a very critical time. Direct access (with stipulations in many states) notwithstanding, the level of professional autonomy and earning potential for in and outpatient PTs is not commensurate with cost and duration of entry-level education. To be fair, achieving legitimate doctoral status will take time, which is all the more reason PTs need to develop a unified message consistent with a professional identity that resonates with the public. Physical therapy is struggling to incorporate evidenced based medicine while also establishing itself as marketable and relevant. It is not uncommon to see the self-anointed physical therapy intellectual elite criticize commercially successful colleagues who, in an effort to speak to the public in a language that it can understand, simplify complex phenomenon like pain. Should private practice PTs be directing their message to other clinicians or directly to the public? How much deviation from scientific dialect and randomized control trials is acceptable if it helps distinguish physical therapists from health care providers and even non-clinicians who provide similar services? I don’t have definitive answers but without asking the right questions, the profession will never achieve its full potential.
A recent conversation between Kelly Starrett and “Healthy, Wealthy, & Smart” podcast (which I highly recommend by the way) host Karen Litzy raises some very important questions. You’d be hard pressed to find a physical therapist with greater popular appeal and presence than Kelly. He successfully launched an online educational platform that empowers the general population to achieve the orthopedic equivalent of basic first aid. He manages a multi-disciplinary facility in a large market that attracts recreational and high level athletes from around the world.
In addition, he regularly advises professional sports clubs and special military units internationally. While I cannot objectively and fairly speak to his clinical aptitude one way or the other, in many ways Kelly represents the fullest potential of the profession in terms of outreach, entrepreneurship, and autonomy. At one point during the interview, Karen asked Kelly how he incorporates pain science concepts into his treatment model, after which it was suggested that Kelly might be received more favorably by some physical therapists if he qualified his work with that degree of nuance more often. Would Kelly and other private practice PTs, however, be as successful from a business standpoint if they spoke to the public about ion channel sensitivity, increased amygdala activity, and cortical smudging? I contribute to the popular media from time to time and if I handed my editor something written in the clinical vernacular, my relationship with his publication would likely come to an abrupt end. Why should any PT who runs his own business waste any time seeking to gain favor with detractors on the Internet? Many physical therapists graduating from private universities assume up to 500k in debt when accounting for undergraduate loans. Entry-level salaries for new graduates average 60-70k/year even in cities with a very high cost of living. Having started a private practice myself, I do not feel even remotely compelled to justify how I practice to other professionals besides those with whom I co-treat patients, nor would I ever anoint myself the moral or intellectual gatekeeper for other PTs. None of us are good enough to be that self-righteous. Science still yields more uncertainties than answers in rehabilitation medicine. Nobody is above criticism but that doesn’t mean that one’s detractors deserve any explanations short of a flagrant ethical or safety infraction. One can be so nuanced that he/she stands for nothing. When it comes to branding and professional identity, you have to stand for something. The idea that many humans have unfulfilled movement potential, that movement matters, is not incompatible with anatomical variations, genetic predispositions, or biopsychosocial thinking. Physical therapy branding efforts cannot have so many caveats that nobody knows what the profession represents. The false dichotomy between biomechanics and psychosocial factors is compromising the growth of the profession. While many of the practices perpetuated by some providers are antiquated and unsupported by current evidence, physical therapists need not become movement nihilists. Sacral palpation testing is not reliable or valid. Deviations from a plum line are not predictive of pain. DPT programs shouldn’t waste students’ time making them memorize things with no clinical utility. Pain reduction is just one component of physical therapy, however.
Regardless of what setting one works in, physical therapy patients are discharged once they achieve a movement-related objective, whether it’s crossing the street safely or lifting a thousand pounds off the floor. Physical therapists need to have a message to promote the profession. Movement expertise is the quality that best differentiates physical therapy from other disciplines. That there may not be a particular movement ideal does mean that movement cannot be objectively assessed, systematically cultivated, and individually scaled. In summary, physical therapists should not speak the same language to the public that they do to one another if they want the public to take notice. Striking a balance between branding and responsible delivery of the message is never easy. Physical therapists do not have the luxury of eating their own though. Context always matters. There will never be a definitive way to “do” physical therapy. Besides, that would be boring. We should not fixate on the flaws we perceive in other providers to the point that they blind us from the things that need to occur to elevate the profession. That kind of closed-mindedness will ensure that physical therapists remain “doctors” in name only.
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