We Treat People, not Pathologies

"The Problem with Underdosing in Rehab": https://www.loonstatephysicaltherapy.com/movebetterblog/the-problem-with-underdosing-in-rehab

"We do chronically underload MSK conditions": https://twitter.com/profjillcook/status/1293107811593752577?lang=en

"Way too many physios underload their patients": https://www.reddit.com/r/physicaltherapy/comments/sa9io8/way_too_many_physios_underload_their_patients/

Physiotherapists around the world are releasing blog posts, Instagram reels, and LinkedIn summaries talking about the patients who aren't getting better because they are being "underloaded" or being given the "wrong" exercises.

This squabble amongst physiotherapists is part of the reason why we are so poorly funded, and why we are struggling to progress as a profession - we don't act like a team.

We don't advocate for our patients or our profession (no matter how much we say we do). Rather, we spend our time blaming each other (physios) for rehab stagnation that should really be attributed to a failing healthcare system and absent social supports from youth to the final years of life.

These posts are toxic, unhelpful, and completely disregard the human side of rehabilitation. Moreover, they ignore a physiotherapist's comprehensive and extensive role in healing and system navigation. Posts like these assume that all pain is mechanical or musculoskeletal, and that lifting heavier weights is the solution to the ever-increasing complexity of conditions we are seeing in clinical settings.

I want to make it clear that I am in no way stating that progressive strengthening is wrong. I am a strong proponent of active rehab, and it is the foundation of my philosophy of care

Physiotherapists, like many other clinicians, go through extensive schooling that (hopefully) emphasizes a holistic approach to care. My program in particular heavily focused on the social determinants of health, and how complex rehabilitation is. They told us to "never hang all your hats on one hook", and to evaluate our patients as a whole.

I loved being reminded at the end of basically every lecture, tutorial, or lesson, that we have a real life person in front of us, not a shoulder, or a knee, or a hip. A person.

Not all patients are wealthy, or have health benefits, or take preventive health measures, and some have literally never exercised a day in their life. Some sit 23 hours per day at home on their couch. Some are obese. Some have cognitive impairments. Some can't carry over instructions or education very well.

Patients exist beyond private practice, and not all populations should be treated as if they have equal capacity.

Inflation is high.

Groceries are expensive.

Housing is expensive.

Wages are stagnant.

Layoffs are abundant (despite the "worker shortage").

People are sick.

People aren't just sick of having arthritis. They aren't just sick of their nagging shoulder pain. They're sick of sleeping poorly, worrying about bills, not having enough to eat, and not being able to buy Christmas gifts for their children. They're sick with anxiety, depression, and loneliness, and fear of the future. They're of drained savings accounts, and sick of long wait times for urgent care.

In an era of poverty, housing crises, food insecurity, job insecurity, and in many regions human rights issues, we are still treating people as if their quads are the issue (which, in some cases, they are, but I digress...)

So why are physiotherapists acting like it all boils down to a heavier dumbbell?

Has our profession really become a battleground of "best loading" practices?

What happened to "person centered care", or "individualized care plans"?

In my humble opinion, the biggest mistake we make as physiotherapists is not how low or high we load our patients, rather, it is not meeting people where they are at.

What good is a perfect loading program for hip pain if a patient can barely stay awake because of uncontrolled blood pressure and blood sugar?

What good is a perfect loading program if a patient can't understand or remember your instructions because they have brain fog from long COVID?

What good is it to tell a patient they need to do their exercises when they can't even afford to meet their daily caloric intake before burning energy?

What good are we as physiotherapists if we don't see people as the complex beings that they are?

It can be appropriate to underload a patient with a program if it means they will be able to adhere to it confidently and progress at a pace that is comfortable for them. Progressive loading is not okay when it is intimidating, overwhelming, non-transferrable outside of gyms with equipment, and not maintainable.

We as physiotherapists should strive to collectively achieve lifestyle, belief, and behaviour changes in our patients, than short-term pain resolution that will return when a patient stops attending physio appointments and are no-longer held accountable for exercise completion.

Moreover, sometimes patients aren't actually ready for rehabilitation. To all who may have forgotten, the term "rehab ready" doesn't only apply to post-op knee and hip replacements, it applies to the entire state of a person - mental, physical, emotional, cognitive, social, and cultural.

We also cannot undermine the fact that we work as a team, no matter how broken and disconnected it is, and we need to remember that services like Social Work, Psychology, Occupational Therapy, and Dietetics exist for a reason.

Sometimes we need to take a step back and meet our patients where they are at to determine if they are truly ready to engage in rehab, and if not, how can we get them there?

Loading is only one tiny piece of the puzzle, and we as physiotherapists need to put our egos aside for a while and learn to advocate for better patient care as a whole.

Not for better loading.

Not for more strength and conditioning courses in university.

Not for less manual therapy.

Not for less modalities.

But for more funding in hospitals, clinics, elementary schools, community centers, emergency departments, and doctor's offices.

But for more recognition as primary care providers who can rule in and out red flags and make appropriate referrals.

But for more of a voice at policy making tables.

But for more community funded exercise programs for youth, adults, and elderly.

We treat people, not pathologies, and perhaps it is our behaviours toward one another, and toward our patients that need to change, rather than our loading principles.