To the Editor,
I feel that our profession’s future has been determined by the economic reality of the present, and I say this as one who has watched the evolution of our work carefully since my first job as an orderly in the PT department of a small general hospital at the age of 16. I am now 48.
Allow me to digress briefly. In the short story The Rocking-Horse Winner by D.H. Lawrence, there is a description of a pleasant house and garden whose family was haunted by a message continuously “whispered” by the walls and possessions of those who lived there. “…the unspoken phrase: There must be more money! was heard all the time, though nobody said it aloud. And each one saw in the eyes of the other that they too had heard. The whisper was everywhere, and therefore no one spoke it.”
Lawrence shows how such an unspoken but constant message has the power to affect behavior well beyond reason, and, how as long as the message remains unspoken, heeding and acting upon it does nothing to reduce its insistent nature. Ultimately, it will overwhelm and control us. In the story, the message is never spoken aloud by the parents, there is never enough money, and the son dies trying to get more.
What messages do modern physical therapy departments convey?
In the department where I worked in 1967, there was an atmosphere of quiet caring. The soft banter of a staff that had time for such things was heard over the rushing water of the whirlpool, and some gentle, encouraging words from the chief therapist to an elderly gentleman in the parallel bars drifted from the gym. The lighting was low, and no one rushed, at least that I recall.
I recently walked into a state-of-the-art department here in the Akron area. Directly behind the reception desk manned by a muscular young man in a form-fitting shirt there was a large glass wall. Behind it, an enormous gymnasium throbbed with the pounding of feet upon treadmills and step machines. Steel plates clanked in a syncopated rhythm and everywhere there was a milling about of sweaty, heavy-breathing citizenry. Many were there to “treat” their painful problems, and many others to simply to become more fit.
For me, the message, You aren’t strong enough, was everywhere. It was in the eyes of the man at the desk, the gleaming machinery shouted it, and I could smell it in the locker room. The bank of mirrors covering one whole wall made it louder still.
Now, I know I’m being a bit dramatic, but perhaps you recognize here your own workplace, or one nearby. These departments rarely offer the patient the chance to speak to anyone about the disruption of their life, or to move without being measured and judged. For the most part, unlicensed personnel leave patients to fend for themselves after a modicum of instruction. A columnist for my local paper recently wrote of her experience of therapy for a backache: “A woman on the cusp of turning 18 tells me how to set the machines. “It’s easy,” she chirps. …Each week a different therapist hands me the clipboard and I wander aimlessly from machine to machine. All around me other patients look like they know what they’re doing. We’re all faking it. We’re like kids in gym class trying to stay off the gym teacher’s radar screen so we don’t have to redo everything when it’s discovered we did it wrong. Each week my back hurts in a different way. I can’t distinguish if this is “good pain” or “bad pain.””
In my experience, this describes “therapy” for many patients with painful problems. As long as therapists believe that pain and weakness are strongly correlated (although this has never been shown to be true), and as long as this kind of treatment is easily billed and reimbursed, it will grow. In short, our tendency to train people rather then care for them, no matter what the diagnosis calls for, has overwhelmed us. Understandably, the public approaches physical therapy for painful problems with fear and dread. I hear them speak to me of that fear much more now than I did twenty years ago, and I see no evidence that we are more effective at treating painful problems. Therapists certainly seem better at blaming the patient for their lack of motivation, and an increasingly popular form of training for spinal pain (McKenzie MDT) advises against touching people because it “fosters dependence.”
This is not just the present; I believe it is our future. I can’t imagine that cost effective therapy like this would ever by abandoned. It is what we’ve become, and our clinic walls speak their messages of judgment louder then ever. We never speak about it, and our patients feel that they can never by strong enough.
Barrett L. Dorko, P.T.
The Portable D.H. Lawrence (The Viking Press 1946)
Exercise plan brings nothing but headaches by Regina Brett in The Akron Beacon Journal Sunday July 18, 1999