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Toni Talks about PT Today

Brain or Brawn

Published February 21, 2012 6:35 PM by Toni Patt

Last week, I found myself following in the footsteps of a therapist who truly believed in hands-on therapy. No matter how hard I tried, I couldn't replicate his treatments. His patients were walking with only therapist-assist. I could barely get them to stand. Finally a tech let me in on his secret. The man was a weightlifter. He was substituting his strength to compensate for patient impairment.

No wonder I couldn't do it. As the week progressed, I discovered he manually assisted all of his patients. He even gaited his SCI patients. The facility had a BWS system. He didn't use it because it was too difficult. He physically supported tall, heavy patients who lacked trunk stability. His patients expected me to do the same thing. A few of them had no idea how much assist was really being provided.

So where is the line between physically assisting someone and doing it for them? Physical therapy is a labor-intensive job. In many cases, the only way to mobilize someone is to lift him up. I do that all the time with the expectation that the patient at least attempts to assist. That hopefully triggers some strengthening and motor learning so next time it will be easier.

Evidence shows us that doing it for the patient doesn't work. Perfect practice results in poor performance. Animal studies demonstrate the need for hundreds of repetitions. The ability to create high repetition is one of the arguments supporting BWS training. It's labor-intensive but the number of steps taken is significantly greater. Carr and Shepard stress the need for practice, changing the environment, high reps and meaning tasks. Our guy got one out of four.

By physically doing it for the patients, he was short-circuiting any motor learning that could have occurred. Sure he got a great workout. The patient felt like he was doing something, particularly if it involved walking. But the next time it was back to square one. He would be better served putting his paraplegics on the treadmill if he really wants them to walk.

I couldn't reproduce his treatments or results because I lacked the strength, but I have the skill to do something different and get the same results. Instead of doing for, I taught how and then assisted with the motor learning. Yes, we stepped in place a lot. I went through a roll of duct tape marking off lines on the floor. Instead of trying to manually force the pusher patient, I inhibited the pushing. By the end of the week I had accomplished as much or more than he had with significantly less effort.

I never met the therapist. It could be he is brilliant and it truly is easier for him to provide manual assist. Or, maybe he doesn't realize how much assist he is really providing. Patients need to make mistakes to improve. They can't when someone is doing everything for them. I hope he figures this out.


Good for you for figuring out what was really going on, and for doing things your own way instead! I have a love-hate relationship with BWS training and overly "hands-on" exercises. I don't like to rely too heavily on devices and methods that patients can't continue with at home, but I do love the confidence and excitement such devices can bring to them! (Plus of course their is some good indication for their use). We recently installed an anti-gravity treadmill at Toronto Physiotherapy, which is a great BWS aid for two reasons: (1) it allows patients to un-weight with more normal gait and (2) it allows patients to gradually increase their workload in 1% increments. This way a therapist can get their patient excited and making the gains that BWS training can help provide, while at the same time having a very simple patient-controlled metric for monitoring progress (% assistance). Much better than "I felt like I wasn't lifting you as much this time"!

Lindsay April 5, 2012 4:16 PM

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