When a scientific disciple is “Soft” it invariably has schools of thoughts. Physiotherapy is no exception to this. In our field, we refer to these different perspectives as approaches, named after their proponents, or sometimes using names that sound scientific like craniosacral therapy or sensory integration.
In medicine, well in biology finding casual pathways is difficult, probably easy if it's infectious disease. As the systems are complex and nonlinear what are the causes for the symptoms is difficult to ascertain. This is compounded by the 2 uniquely complex systems we deal with: movements and pain. Both are poorly understood by scientist and always make clinician feel like they have understood them even if we don’t have a clue.
Birth of Approaches in neurology:
As theories on how movements are controlled in healthy individuals were developed- clever PTs with intuition, and experience developed ways to use that in neuro-rehabilitation. From proximal to distal, cephalic to caudal, developmental sequences, facilitation to inhibition with sensory inputs were some of the ideas which were fixed in different manner to invent approaches.
If you look closely these approaches looked at sensory systems as the dominant boss of movements. Dealing with sensory systems alone has the advantage of dealing with a complex system. It makes the approaches which were developed look clean and probabilistic.
They rarely talked about the perceptual systems, learning, importance of practice to change the system, long term change or patient centric change. These are complex phenomenon and need far more than just facilitation or inhibition, proximal to distal.
When never understanding of movement control and behavior started emerging, which took into the account the complexity of the system, we have a different set of schools or approaches.
As we have empirically tested these “approaches” and we have a slightly clearer path to walk forward. So, what does this mean? It means the schools or approaches must go to history of PT. It means from Bobath to pseudoscience like sensory integration should be in our history of PT not in syllabus. They should all go the sterilizer way- you know the one we sterilized the syringes and needle for injection.
Sadly, that is not going to happen, we are unable to throw them out. When I was small all the hospitals will have a sterilizer.
Can we change:
When I taught at a college in Pondicherry some years ago, the focus of the entire day was on encouraging students to think critically and identify flaws in their judgments. One topic of discussion was the supposed effects of ultrasound on tissue. I questioned why ultrasound couldn't produce any of the intended effects, and someone responded by referring to experiments on how cavitation is generated when applied to tissue. They argued that if there were such experiments, how could I claim it was wrong?
I pointed out that while we had indeed read about those experiments, it was worth noting that they were all conducted in vitro. However, when in vivo experiments were conducted on live humans, cavitation could not be observed.
Curious about the reasons behind the lack of cavitation in live human experiments, I posed the question to the group. However, since it was an open question, I opted not to provide an immediate answer here. I invited the five people who read this to think about it and respond to me via WhatsApp.
During the thinking workshop we had, I had a valuable experience. I cannot say for certain whether anyone liked it or had a change in their thinking. However, what saddened me was the concluding remark during the vote of thanks given by a staff member. They emphasized that everything discussed throughout the day was merely a school of thought. I had to use so much energy to stand up and tell him ““He is the best idiot I have ever seen in my life", but did not. I still don’t know why I did not. What to do to change:
Being angry aside, I think the PT staff was afraid to let go of Ultrasound, PNF and all other things I was poop poohing on that day. We are afraid, to say something is wrong or right. Lack of this confidence sadly stops from developing interesting never ideas. We still think US, IFT, Bobath and all we learn in school is PT. Not really as you know what makes your patient better is PT. Let go, we will grow. Let go nothing is ours. Bobath is not our god, let go, Traction and IFT are just a bunch of motors and wires, they are not PT, let go. Let go off most of the syllabus and we will grow. Let go- better science which helps patients will occupy the space.
With so much love Hariohm
Let's see school of thoughts in relation to pain some other time as this one is long.
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