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What’s the Evidence for Compassion? The Art and Science of Physical Therapy.

Physical therapy is having an identity crisis.

A clinical doctorate earned us the title of expert in the science of human movement. Simultaneously, our core values set forth by the American Physical Therapy Association emphasize subjective, empathetic goals: altruism, compassion, and social responsibility.1

 

Current DPT curricula across the country echo the need for “evidence-based practice,” giving clinical decision-making rigor and objectivity.2 Yet, where is the evidence for our evidence? How do we contextualize the individual experience amidst the relentless need to scientifically justify our value in this competitive healthcare climate?

 

We may not have all the answers yet but approaching our profession as both an art and a science encourages more sophisticated, critical thinking. Below we discuss the rapid evolution of our field, the complexities of how we practice, as what we can do to make sense of it all.

While the subtitles on evidence-based practice include clinical expertise and patient circumstance, all too often the emphasis is heavy on the literature, the science, the objectivity. The biopsychosocial model is ingrained in us. Yet, we must also grapple with the reality that the biomedical model, though technically outdated, still infiltrates the very fiber of our practice. We are deeply embedded in the cloth of healthcare textile that emphasizes the science of cure.

“By virtue of leaning on “the evidence”, which implicates scientific literature, we overestimate the objectivity and underplay the subjectivity of our practice.”

What is “the evidence”?

How does every physical therapy lecture end? I still have dreams of the phrase, “future research needs to be done to address…”. The reality is that our literature is in its infancy, not unlike our profession. Physical therapy began only one hundred years ago during the polio epidemic, so of course we have a lot of catching up to do compared to our medical colleagues.3

 

For comparison, let’s take a look at rehabilitation related publications versus medical publications in the United States. In 2018, a nationwide survey revealed that a total of 3,282 peer-reviewed articles were published by physical therapist-researchers in academia.4 By comparison, in the New England Journal of Medicine (arguably the most prestigious medical journal), a little over 400 articles get published per year from U.S. trained medical researchers.5

This means that physicians generate 12% of our research volume in just ONE JOURNAL annually.

That is staggering, especially considering the myriad other medical journals available. Other than the fact that we need to educate and encourage researchers with physical therapy training, it is obvious that the evidence that we predicate our practice on is not comprehensive, at best. I am not suggesting that there is no scientific reasoning for our clinical decisions as movement experts. Rather, we must consider that we do not have all the answers yet for why or how we should treat our patients. In fact, there is a ton of individualization that takes place in each plan of care.

What is "the art"?

The art of physical therapy is rapport. Multiple studies have shown that a strong therapist-patient alliance predicts substantial functional improvements.6 The relationship that you build with your client will help heal them. So, does trusting your PT make your rotator cuff tear disappear? Of course not, but this is the magic of the art and science relationship.

 

As long as we emphasize patient-centered care, we must acknowledge that there are complexities beyond the cellular, the mechanical, and the post-surgical protocol that impact our therapeutic results. How many times do we gather boatloads of symptom history without really knowing if that person thinks PT is going to work? We can develop an efficient, evidence-based plan of care but do we know if that person thinks it’s valuable to their life?

 

Do we foster autonomy when we teach our clients to rely on passive strategies like trigger point canes and massage? It is inherent to the role of a physical therapist to facilitate meaningful dialogue with our clients.

O.A.R.S

A constructive approach to increasing rapport is the use of OARS related to motivational interviewing.7 OARS stands for:

  • Open-Ended Questions
  • Affirmations
  • Reflective Listening
  • Summarize

By acting as a mirror for our patients, we let them know they are heard. Repeating important dialogue emphasizes its power when that person leaves your session. It is our job to simplify the complicated feelings that injury creates in addition to physically therapeutic interventions.

Conclusion

It would be nice if everyone’s shoulder could be treated with the exact same protocol. But then we’d be technicians, right? Isn’t the central premise to our stake as a doctoring profession that we can make sound clinical decisions based on the individual in front of us? How do we reconcile the inseparable connection of the art and science of physical therapy practice?

 

I am not proposing that we stop generating meaningful research. I am also not saying that the only reason why physical therapy works is motivational interviewing. I am advocating for an interdisciplinary mindset, and a thoughtful discourse on the necessity of utilizing both art and science to facilitate the individual’s physical therapy journey.

 

To practice honestly, acknowledging that we have far to go and much to learn. To analyze our literature through a critical lens while remembering that a good deal of our current practice cannot be searched on PubMed. To consider our value beyond the clinic; in research, writing, consulting, and policy change. To spend more time advocating within and outside of our profession for the art and science of healthful movement.

References

  1. Professionalism in Physical Therapy: Core Values. American Physical Therapy Association. https://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Judicial/ProfessionalisminPT.pdf. Accessed February 18, 2020.
  2. Evidence-Based Practice & Research. American Physical Therapy Association. https://www.apta.org/EvidenceResearch/. December 11, 2017. Accessed February 18, 2020.
  3. Shaik AR, Shemjaz AM. The rise of physical therapy: a history in footsteps. Archives of Medicine and Health Sciences. 2014;2(2):257-260.
  4. Aggregate Program Data: 2018-2019 Physical Therapist Education Programs Fact Sheets. Commission on Accreditation in Physical Therapy Education. http://www.capteonline.org/uploadedFiles/CAPTEorg/About_CAPTE/Resources/Aggregate_Program_Data/AggregateProgramData_PTPrograms.pdf. April 22, 2019. Accessed February 18, 2020.
  5. About NEJM. The New England Journal of Medicine. https://www.nejm.org/about-nejm/about-nejm. Accessed February 18, 2020.
  6. Hall AM, Ferreira PH, Maher CG, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Phys Ther. 2010;90(8):1099-1110.
  7. Pignataro, R. Transformative Dialogues: The Use of Motivational Interviewing in Physical Therapy. American Physical Therapy Association. http://www.apta.org/Blogs/PTTransforms/2018/7/12/TransformativeDialogues/. July 12, 2018. Accessed February 18, 2020.

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