Speaker 1:
Speaker 2:
It's Jared. I'm gonna ask a question straight out of the gate here. What is a physical therapist? It sounds like a question with an obvious answer or perhaps a question too basic or too stupid to bother asking, but stay with me now. Try to answer the question without simply listing the things we do. No hands, no exercises, no modalities, no needles, or whatever else you do.
Speaker 2:
If we remove the verbiage, what is the identity underneath those individual tasks that you do? Most of us either haven't thought about it or simply revert to. We are what we do, the hands, the exercises, so on and so forth. The doing is the identity. I would like to spend this episode if you'll permit me too bad. Anyway, it's my show arguing that this, the collapse of who we are into what we do to a body is a damaging idea in our profession. Our profession, physical therapists or physiotherapists did not begin as fixes. The fixer is not our origin. It's something that was actually trained into us with good intentions by science done in a particular way by the incentives of the systems that we have come to work within. In this episode, we are going to explore the question, what is a physical therapist?
Speaker 2:
And see what this exploration does for your perception of who you are and what you do. Let's start with where we came from. The clean story you'll read on every clinic website is Physiotherapy was born in Sweden in the early 18 hundreds with a man named per Henrik Ling. Whilst this is directionally true, it certainly did begin with per Henrik Ling. In a certain sense, professional history can also be traced back to the Greek times and the Roman times, and also has origins in massage therapy and something called mechanical medicine. But for the purposes of this episode, we're going to start with per Henrik Ling. Now, Ling was an interesting man himself. He was a poet and a fencing master who developed what he called the Swedish Movement Cure. And when the Swedish government set him up with the Royal Central Institute of Gymnastics, the system he taught had four branches, military, medical, educational and aesthetic.
Speaker 2:
So fencing, therapy, physical education and dance, all done under one roof. Physiotherapy is born as one limb of a much bigger project about the moving human body. The Swedish word for physiotherapist actually comes from shook MNAs, which captures this perfectly shook MNAs, and I'm very sorry for butchering that pronunciation. Sorry to all my Swedish listeners. This translates to more or less Sikh gymnast. So therapy as gymnastics for the unwell movement applied to a whole person to restore them. That's the seed, that's the philosophical seed of what physical therapy has become. That's where we've come from. Now, Ling didn't exactly have it all worked out. Ling's worldview was romantic and nationalist and frankly, a bit mystical. He talked about a doctrine of harmony. He was not a proto scientist with a theory of self-organizing systems that we're gonna discuss in this episode. He also did plenty of hands-on manipulation himself.
Speaker 2:
So the fixer identity was present at the origin of our profession as well. What I'm saying is at the very beginning of our profession, there were two philosophies which sat side by side. One was the operator or the fixer philosophy, the person who does something to a passive body. And the other was something richer, the movement, the adaptation, the whole person in their context. Both philosophies were there at the origin of our profession several hundred years ago. And then over the next a hundred years and a bit, we selected hard for the operator or fixer, and we starved the rest of our identity. We leaned too hard into what came to be known as mechanical medicine and defined it and fix it. Motto that still defines our care. So our history suggests that this whole person philosophy of physical therapy was always there, what went wrong?
Speaker 2:
So what trained it out in a word reductionism. I don't mean that as an insult. Reductionism is the most successful idea in the history of medicine. It's the philosophical move of locating disease in smaller and smaller units, going from the organ and then the tissue, then the cell, then the molecule. It's basically why we can now cure many diseases. The physio version of that move is to locate pain and disability in a specific structure or a specific measurable deficit.
Speaker 2:
For example, the torn rotator cuff or the weak external rotators, the stiff spinal segment, the faulty movement pattern, or more recently, the dysfunctional nociceptive apparatus. And once that philosophy reaches the clinic, it transforms into what I'd call the deficit model. The person walks in and we see a set of gaps in them against an idealized norm. Either they don't have enough range of motion, they don't have enough strength, there's not enough symmetry, and our job becomes this gap closing to try and restore that person, restore their deficit to some sort of idealized norm. In a sentence, find the deficit, fix the deficit. Poetic, isn't it? Reductionism also got physical therapist, a seat at the table of being a bonafide and legitimate medical profession. It was the only way back in the day that physicians would work with us. The version of physiotherapy that survived and ultimately got absorbed into mainstream healthcare was the version that accepted its place.
Speaker 2:
Take the referral, the diagnosis from our esteemed physician colleague, and then treat the name, structure, or deficit that we were meant to treat. So the deficit model is what the profession looks like once it has accepted being the hands that carry out someone else's reductionist reasoning. Now, I'm not here to make reductionism a villain. Reductionism is how physio learned many, many things, healing, timelines, biomechanics, mechano, biology, and much, much more. So I don't think there's a problem in the philosophy of reductionism itself. The late philosopher Daniel Dennet has a lovely phrase, greedy reductionism. That's when a method that's brilliant for studying something transforms into the claim that the part is the whole, the deficit model becomes insufficient when the deficit becomes the entire explanation and the only target. So if we're not operating on a passive body, if we're not just fixing deficits, what the bloody hell are we doing?
Speaker 2:
Firstly, recovery is always intrinsic to the person. It always happens inside an individual. You are not making a shoulder move again, the person is a living, adaptive self-organizing system and movement and capacity emerge from that system interacting with the world. You can't just reach in and install the appropriate software. What can you do? The only thing you can do is shape the conditions that system organizes around. There are three levers to this, and this comes from a motor learning researcher called Carl Newell, and it underpins what's called the constraints led approach. Lever one is the task, what you ask the person to do, the specific movement, the load, the speed of movement, the constraint you impose that makes a certain capacity show up, change the task, you changed. What emerges lever tube is the environment. Now, the environment goes beyond the gym space or clinic setting and includes the informational and the emotional, which is the words you use, the story you tell about what's happening in their body, what you allow a scan to mean the expectation you set.
Speaker 2:
That's all environment and it shapes the system as powerfully as any piece of equipment you use. Lever three is the person themselves, their current capacity, yes, but also their beliefs, their fears, their expectations, the things they value and want to get back to. You can't control this, but you can partner with them in this journey and perhaps coach it. So here's the whole job. Reimagined the fixer manipulates tissue or provide an exercise to restore a deficit. The clinician I'm describing manages those three levers, the task, the environment, and the person so that the human in front of them self organizes towards more capacity and less threat. There's a really great metaphor for this from the psychologist Alison Gonick. She contrasts two ways of raising a child, which is relevant to me and may not be relevant to you. She uses the examples of the carpenter and the gardener.
Speaker 2:
The carpenter has a blueprint and builds the thing to exact specifications. The gardener can't dictate what the plant becomes. The gardener simply makes the conditions they focus on the soil, the water, the light, the protection and the living thing adapts to them in ways you can't fully predict. I submit we are not carpenters of the body. I think we're much closer to gardeners where we're architects of the environment and the conditions. So let me formalize this potential academic waffle into a case study that you may relate to. Let's say a 54-year-old man walks in. He has six months of lateral shoulder pain. It's worse with overhead movements. It wakes him at night. When he rolls onto his shoulder, he's had a scan. This shows a partial thickness, supraspinatus tear and degenerative changes, whatever that means. They've arrived in your room frightened because the word tear did exactly what the word tear does.
Speaker 2:
They've stopped using the arm, they've stopped going to the gym, they think they've broken something, and that moving it will tear it further. Does this ring a bell? Now imagine two different clinicians with two different approaches. The first is a good fixer. Now properly good. I'm not trying to build a straw man case out of the fixer identity here. They examine the shoulder, they find weak and painful external rotation and a painful arc, and they reason there's the deficit, a weak rotator cuff, likely an irritable rotator cuff tendon. They then prescribe a sensible progressive loading program that's say free exercises, certain amount of sets and reps, and they make progress in a couple of weeks. That's an evidence-based intervention. It's competent and for a significant chunk of patients it will work because exercising or moving or loading a painful shoulder is a reasonable thing to do.
Speaker 2:
But I want to bring to your attention that there is something significant that the fixer in that case didn't touch. They worked one lever expertly the task and they aimed it at the tissue or the deficit. They treated the strength deficit as the explanation and didn't touch the person's beliefs about their shoulder that it is damaged and that movement is dangerous. That belief is a constraint or a bottleneck to recovery. Now let's introduce the second clinician, and for argument's sake, let's say it's the exact same clinical presentation, but this second clinician has a very different approach. They ask what does this person need to be able to do? What's stopping them from doing it? And what's the smallest change to task environment or belief that moves them toward it? The answer to this is rarely weak external rotators, although in some cases it may be.
Speaker 2:
The answer is often, and in this case, there is a terrified person who has stopped moving because of what a radiologist report did to them. So the highest leverage move here is informational and contextual. It's reframing what the scan means, explaining that rotator cuff changes like these are extraordinarily common in pain-free shoulders that tear on a report at 54 years of age is often more like gray hair than a snapped rope, that the tissue is not fragile and that the load or the exercise is the thing that makes it more robust. Once you've engaged with that belief and ideally changed it or influenced it, once you've worked that environmental lever, the informational one, the exact same exercise that the first clinician prescribed now does completely different work. It's, it might be the same sets, it might be the same amount of reps, but now it's not exactly rehab for a damaged tendon.
Speaker 2:
It's evidence delivered through the person's own body that the shoulder is safe to move and can indeed stronger or more robust or develop more capacity. So the exercise itself may be identical, but the meaning is transformed. So this is imaging overinterpretation, and this can be a constraint design failure. The scan has installed a constraint, a constraint of fear avoidance, and a belief in fragility that now actively shapes how this person moves and whether they recover or not, the fixer tends to treat around this whilst the conditions clinician treats it specifically, you'll notice that the second clinician didn't abandon strength work. They didn't go all holistic alternative or woo woo and ban exercise. They did the exercise and the reframe because they understood which constraint was limiting and they worked the right or most appropriate lever first. That for me is part of being an expert clinician, knowing for this person on this day which lever moves them most and it changes from person to person, which is exactly why a protocol can't do it for you.
Speaker 2:
So I think a good physio sets the conditions for flourishing, but this might seem a little bit abstract and vague. So let's examine it in finer detail. There is a body of psychology research called self-determination theory. You've probably heard of it that says, human motivation and wellbeing runs on three needs, autonomy, competence, and relatedness. Let's translate this into physio specific talk. The first is competence. The person becomes more capable and crucially, experiencing themselves getting more capable. This is graded success exercises provided so they're hard enough to mean something and achievable enough to build belief. Every session, every rep becomes self-evidence that the body is becoming more able, more able and capable and robust. These small wins fact build a mastery, which is a core component of self-efficacy. And if you've been following my work for a while, you'll know that self-efficacy is important for recovery.
Speaker 2:
The next is autonomy. The person having ownership over their path, having choice and understanding of why. Why are they doing these exercises? Why are they here seeing you? What are you gonna do for me? So the locus of control sits with them rather than with you. And the third is relatedness, which is the relationship, the thing that makes a frightened person willing to attempt a hard scary movement. You are for a while, the person in their corner supporting them. You are setting the scene, you are setting the context, you are setting the positive environment. You are creating safe conditions for movement and recovery. So in a nutshell, the fixer optimizes for impairment correction. The clinician I'm describing optimizes for a person who increasingly doesn't need them, doesn't need you, doesn't need a physical therapist like a good parent who sets the conditions for their child to eventually not not need them, although they always know they'll be there if needed.
Speaker 2:
So being this type of physical therapist is much harder than a fixer. I agree. Running a protocol is pretty easy. Finding a deficit, applying the matching intervention and then progressing on schedule is pretty easy. You can even put it in an app. You could even outsource it to a chatbot, like you could outsource it to a chatbot right now, and that should worry anyone whose entire value is. I know which exercise goes with which deficit, but reading, which constraint is limiting this person? Is it load? Is it fear? Is it the meaning of the scan? Is it something happening at home you haven't asked about yet? Designing a task that makes the right capacity emerge for them. Knowing when the lever is the tissue and when it's the belief and having the judgment to choose building the relationship that makes a scared person brave enough to load a shoulder they think is broken.
Speaker 2:
Not that automates easily. It's not replaceable by an app or a chatbot that is higher order clinical reasoning and human connection. And it is the most valuable lease replaceable thing we do. So I view this as a relocation of expertise out of your hands and your technique and into your judgment, your knowledge and your relationship. The technique was always the easy part. We built our identity on it because it was visible and it looked impressive, and indeed it earned us a seat at the table with our physician colleagues. So I think it's important to know the history of ideas and how they have endured often with social ramifications and meanings. So let me come back to our original question. What is a physical therapist? The physical therapist is the person who understands you as a living adaptive system who understands the conditions you might be stuck in and helps you to change them, the task, the environment, the story you've been told about your own body so that you can flourish.
Speaker 2:
This is an old idea that we got disconnected from. It's in our DNA and I think it's time we remembered it. Thanks for listening to this episode of the Shoulder Physio podcast. I'll chat to you soon. The Shoulder Physio podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
