Barrett L. Dorko, P.T.

"When the external act decreases,
the internal act increases."
          Marsilio Ficino - Fifteenth Century Philosopher

          Sometimes I struggle to impart the specific nature of my manual technique to other therapists. I think this is because there is an aspect of its clinical application that is foreign to today's practice; contemplation. Specifically the contemplation of another's internal activity as it changes.

          The word contemplation itself comes from con meaning "to examine carefully," and templar, referring to a period of time. Taking significant time to thoughtfully examine any portion of our patient's functioning is increasingly difficult given the constraints of modern (read reimbursable) practice.

          Historically, the movement of physical therapists from technicians to professionals has been dependent upon our skills of assessment. These are typically skills the physician does not possess, and it follows that our identity as a specialty separate from others will suffer if we lose the opportunity to show the worth of our distinct vision. We have thus become known as movers, not contemplators.

          But beyond measuring strength, endurance and function, it is possible to reliably assess the patient's autonomic state and reaction to provocation. These findings are perhaps more subtle, but that makes them no less important. They are also subject to very rapid change, and this leads me back to my original point regarding contemplation.

          Ficino's comment quoted at the beginning of this essay refers to the internal processes of thinking itself. He felt that the answers to life's more difficult questions might be discovered when the body became still, and most schools of meditative practice would agree.

          But physical therapists know that it is movement that leads to correction and restoration of normal function. This has led to an emphasis on training, motivation and the application of forceful passive mobilization. Such things lend themselves to protocols and insurance codes. Most can be assigned to ancillary personnel, and when this happens profits can grow exponentially.

          Suppose you were shown one day that the movement leading to pain relief was most likely to emerge slowly from a patient when the caregiver was willing to wait quietly on the surface, encouraging a larger and more visible expression of correction. This movement would logically be accompanied by a change in their autonomic state, and, in my experience, training and exhortations to increase effort don't produce it. This is why a lot of people with painful problems end up viewing therapy as some kind of torture, and not as a place where they find relief.

          Waiting on the surface for internal processes to grow describes what I try to teach, and I often find in a short period of time my students display the ability to do this. There is an immediate positive response from those who are handled in this way.

          But then the questions start: "How do you bill this?" "How do you test your patients?" "Suppose nothing happens?" "What if my boss sees me doing this?"

          Each implies an understandable, if unfortunate, mistrust of simple contemplation, mistrust of the patient's own choice to act, and a fear of no action in a profession increasingly bent on doing more and thinking less.

          This is where the struggle to teach something like simple contact lies. Not in its reasonableness or effectiveness, but in our profession's striving to churn out the numbers, and hope that this will be enough.

          For many of our patients in pain, it isn't.