During my on-site visits to check on students’ progress during their clinical internships, I could not help but notice a consistent pattern among some of the therapists I observed.
In several of the skilled nursing facilities where my students were assigned for their clinical rotation, I observed that PTs and PTAs tended to use the same treatment framework. In general, the patients were:
- Assisted to transfer from wheelchair to bed.
- Assisted to lie down in supine.
- Asked to perform ankle pumps, heel slides, windshield wipers and short arc quads exercises.
- Assisted to get up from the bed.
- Assisted by the therapists to walk using their assistive device for several feet and returned to their wheelchairs.
- Taken to their next scheduled therapy session or returned to their rooms.
The only variations I saw were the number of exercise repetitions, amount of resistance used during these exercises, and the levels of assistance and cues provided to the patients during the sessions. And these were done with every single patient, regardless of diagnosis. This made me wonder what these therapists had learned in school. Certainly, these therapists did not graduate from the same school.
I had the same observation when I went to a number of acute care facilities to follow up on a different group of students. Therapists in this setting were using the same framework. The only noticeable differences were the therapists performing the exercises at a slower pace, and with fewer repetitions. In this setting, patients also were gait-trained for a shorter distance and with more assistance and cues from the therapists. Certainly, these therapists did not all graduate from the same school as the therapists I observed in the skilled nursing facilities.
I thought it would be different when I visited my students assigned to complete their clinical rotation in outpatient settings. However, I was disappointed. I observed a number of therapists in this setting using a slight variation of the framework that I described with the addition of using modalities: moist heat, electrical stimulation, ultrasound or massage. Then, they proceeded to stretch the patients, followed by — you guessed it right — ankle pumps, heel slides, windshield wipers and short arc quads exercises. Certainly, these therapists did not graduate from the same school as the therapists I observed in the skilled nursing and acute care facilities.
To make matters worse, I have seen the same phenomenon in other parts of the country. So, what is going on?
I know that in PT and PTA schools, instructors teach their students to be creative in their treatment approach. They also teach students to tailor their treatments to the needs of individual patients. The instructors even reinforce the learning process by having students attend local or national conferences where they can get exposure on contemporary and evidence-based treatments. However, it seems the skills they have acquired and mastered while in school become undone once they get to practice professionally. They become these tainted therapists, whose passion and love for what we do in physical therapy has started to be extinguished.
The tainting of these therapists is alarming because in my opinion, anybody can do what they are doing with their patients. I also am unsure about how they might be charging for their services.
Without knowing why these therapists might have changed or lost the creativity they once possessed, I cannot offer an antidote to reverse my observations. All I can offer are the following words from Charles Darwin: “It is not the strongest of the species that survives, or the most intelligent, but the one most responsive to change.”
I hope these therapists recognize the need for change, have the willingness to make the change, and find a way to reignite the creativity, skills and passion for physical therapy they used to have. It is vital not only for their survival but also for the survival of our profession.
We are told to perform these same exercises by higher ups. We also are informed to use OTAGO ,BERG
I was taught in school to be innovative with treatments (20 years ago) but now assistants are becoming robots
It was probably the safest and most efficient way to perform these activities. Why change something that’s not broken.
In these types of settings safety and basic instruction are important. One has to crawl before he can walk. These are all very basic activities that are tried and true.They work. Lets not forget about the litigious society we live in.
I’m sure that the therapist will become more creative when the time calls for it. Someone that’s is more involved for what ever reason.
Wow this is a great article!
I can tell you that I have worked in clinics and with many PT’s/PTAs who actually have pre written out flow sheets for different body parts. No thinking, no variety and no consideration for individuality. Its sad to hear and see students following in these foot steps. I think part of the issue is the managed care system – therapists are more worried about productivity and paperwork than being creative and engaging. My wife and I are putting together an online course now about the assessment and programing for ther-ex and the importance of making exercise fun, functional and dynamic.
It’s much easier to unretsdand when you put it that way!
Hi Nelson!
Did you take under consideration that our job is repetitive in nature. Yes, we work with different patient with different problems, but at the end number of variations is limited. I catch myself many times (and yes, more often recently) that my treatment is getting boring, but I do change my routines when I get “the right patient”.
I can be more creative with patients with good combination on MOTIVATION and physical abilities (I work in outpatient rehab with mainly neuro patient). Yes, also my skills must match my patient’s situation – I can be more creative when you have more tricks behind your belt.
With “average patient” treatment sooner or later will get “boring”.
How many years did you work full time with real patients? Working with students is not REAL LIFE physio.
A appreciate your call for creativity, but we should not be obsessed with changing routines which are effective, safe and economic (not only monetary, learning is also an investment of our energy and we do expect fair return on our investment e.g. time, money and intellectual effort needed to take a course)
Thank you for your post. In my opinion and somewhat ideal world, these types of PTs wouldn’t be allowed to accept students and DCEs would do a better job of screening for such terrible clinical practice behaviors. There are bad PTs out there of course, and we should not allow them to be mentoring the future of our profession. I know some student slots are difficult to fill, but there should be higher standards than a pulse and current license for teaching students in a clinical setting.
My observation also, much to my dismay. And I graduated in 1969! I have also attended continuing education every year since then.
I totally agree….have observed this for years now.
Thank you for broaching the very important topic about the lack of creativity in rehabilitation Dr. Marquez. I’ve made similar observations, as have many of my patients that had tried PT in the past. I actually published a textbook last year on the very topic as I believe our bubble of demand for such rote, mundane care has a very short shelf life.
The book, “Fostering Creativity In Rehabilitation” is a collaborative effort with a number of rehabilitation colleagues sharing my concern across professions http://www.creativityinrehab.com .
My conclusions however differ markedly from yours re: the role of schools, conferences and associations on creativity. It has been my experience that a number of systems issues actually thwart creativity rather than foster it as you suggested.
My colleague Staffan Elgelid, PT, PhD, GCFP contributed an excellent chapter on the topic and you can hear a summary of his insights in this pod/videocast. http://www.rehabandcreativity.com/podcast/2015/11/27/-4-staffan-elgelid-pt-phd-gcfp
I’d be happy to share a desk copy of the textbook if you wish to explore this topic further. Again thank you for raising this “elephant in the room” to your reader’s attention. ~ matt
As a PT student who recently finished my first affiliation, I know exactly what you’re talking about. Some of the problem comes with institutional hierarchy. My CI did the same exercises with all patients and I was expected to do the same. When I did vary from his limited exercise repertoire he basically thought I was wasting my time. Why spend time with a patient, talk to them, and work on functional exercises when you can just throw ankle weights on them?
We look to CIs for knowledge and direction but sometimes they aren’t the best role models and it’s tough to go against them. I did and it made for some uncomfortable times but I had to do what I thought was right, and most importantly what was in the best interest of my patients. Luckily, I thought my school did a good job reinforcing the idea that I can stand up for myself and be a patients’ right advocate.