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TOOLKIT

The prudent text-books give it

In tables at the end

'The stress that shears a rivet

Or makes a tie-bar bend—

'What traffic wrecks macadam—

What concrete should endure—

but we, poor Sons of Adam

Have no such literature,

To warn us or make sure


The Hymn of Breaking Strain, Rudyard Kipling


Toolkit


Physiotherapy is like art, science, and pottery. In all of those practices, knowledge and the application of skill is used to solve problems, which is obvious. In physiotherapy, the problem is typically that of human insufficiency, discomfort or injury, while in art the problem can be more abstract such as the interpretation of a concept or brief, or the stuffing of a 3D image from real life into a 2D plane. In science, the problem is one of testing a hypothesis, and in pottery the problem is the shaping of matter into a form that fulfils a function that itself can be practical or artistic. Physiotherapy is unique not in that the matter we attend to is human, nor that the concepts we address such as pain are abstract, nor that it tests hypotheses. Physiotherapy is unique because in its practice, it has the potential to empower, educate, and expand the patient's awareness of themselves and the world around them. Done well, treatments will not simply address discomfort or deficiency but clarify otherwise abstract truths about the body, about disease, and about how the human fits into the world. Done very well, physiotherapy gives the patient a set of skills that they can use to solve their problems to a degree of independence.


Attending a session with a clinician achieves three aims - the assessment and management of discomfort or another problem, a discussion and prescription of home-management, and more importantly, education. Educating a patient isn't just about teaching them the names of muscles and bones, or the pathophysiology of scar tissue or the loading effect of exercises, but revealing the relationship between their body, their lives, their world and their selves. That relationship is a complicated and nuanced one, informed by preconceptions of health, notions about what it means to be healthy, a person's attitude to exercises as well as the medical profession, and their relationship with their clinician. All of these things weigh and balance, and all of these things are taken into consideration to make a toolkit that the patient can use to address their problems themselves, using what faculties they have available.


The Brain.


Giving someone the skills to solve their problems means educating them on the nature of their problems, the tools they have and their use, and how to define the relationship between where they are and the point at which they want to arrive. In physiotherapy, the tool is the human body, used to solve problems with the human body. This is as incredulous a prospect as a nail that hammers itself, but it's the truth. The human body desires a state of functional capacity, not due to some confluence of energies or romanticism but because biological organisms tend to maintain a level of health that allows them to live in their environments. Educating a patient on the nature of recovery from an injury means not only discussing the body but the progression of disease, how to discriminate between injury and irritation, how to manage pain, and how to know when something is really serious. Beyond that, the patient needs to know how to use their body to improve their body - how the use of sustained postures, repeated movements, stretches and resisted loads all elicit physical and chemical responses within the body that can strengthen and alter the way it works.


More importantly, the therapist queries the relationship between where the patient is and where they want to arrive. This could be as simple as asking someone how soon they want to be able to return to sporting, or how they plan to get back to work. At the deeper level, discussing the gulf between deficit and destination lets the patient define the treatment trajectory in broad strokes, with the therapist assisting here and there. The patient sets the destination, and the therapist guides them there with helpful nudges and course correction, like a GPS, a compass, or Patrick Swayze in that one scene in Ghost. Every corrective touch, review or revision is the imparting of practical knowledge to the patient, strengthening their body as well as strengthening their relationship to their body. A patient doesn't need to become a physiologist or an anatomist but knowing is half the battle - the next step is applying.


The Hand.


Knowing about recovery, how to use the body, and the destination between the two points is one thing, applying the knowledge is entirely another. I might know how to use a sprocket drill to remove the cowl cover over the camshaft of my car, but actually getting into the engine and removing the glorious slabs of German plastic to get to where I want to means I have to solve so many different other problems. It's like when a cookbook tells you to sautee ingredients - there are so many artful, skilful steps that contribute to the quality of execution of even just one step in the process. Similarly, giving someone the means to solve their problems means teaching them how to use the tools at their disposal. This is always the hardest and most burdensome step of treatment, because to teach someone how to use their body, they need to become acquainted with their body. Most people aren't acquainted with the full range of capacities their body is capable of reaching, unless they remain active sportspeople throughout their lives or they need to use their body for work. For most people, their body and physical form consist of a series of assumptions - that their muscles will largely be able to address the demands of their lives, that their joints will always maintain a level of flexibility and smoothness of movement, and that their endurance is largely maintained. Experiencing an injury or discomfort upsets these assumptions - the patient needs to have their discomfort managed as well as their assumptions dismantled in such a way as to avoid shattering their somatoconception in the same way as Camus' mirror, necessitating a reassembly of physical identity.


Instead, physical skill is built by building knowledge of movement, by breaking down rehabilitation into its fundamental steps and building up from there. Even concert pianists practice their scales, and so even regular people gain benefit from movements as simple as bending forward and touching their toes. This is hand-knowledge, or knowledge of application. The awareness of the self that is necessary for success grows when assumptions are tested against the tough surface of reality. When assumption meets reality, one or the other has to give, and it's usually not the immovable object. By testing peoples' assumptions and knowledge, then nudging those assumptions and burnishing that knowledge, the therapist not only educates the patient but contextualises that knowledge in an experiential basis of evidence that the patient can refer to in the future, giving them not only a point of reference but a resume of success on which they can bank in the future, as well as a self-reflective capacity that allows them to assess their progress and how to manage it.



The Heart.


Throughout all of this, beyond education and application of knowledge, the therapist's job is to contextualise those interventions in a process that builds confidence - confidence in the patient's knowledge about themselves, confidence in the patient's ability to use their body, confidence in the patient's ability to meet the demands of their lives. A lack of confidence in oneself is as crippling as a destroyed limb or a separated nerve, because it separates the patient's physical capacity from their willpower and their direction. The proof of this is seen in those patients who are capable of walking upright but hunch themselves from fear of falling, ironically becoming more likely to fall as a consequence of their compensation, or in an athlete who performs well on the tests but who flames out on the track. The proof of this is seen in the patient who ticks all the boxes in clinic but who goes home and loses their steam.

Building a patient's confidence is about building confidence in knowledge, in application, and in themselves. A patient who doesn't believe that they will get better, that they can solve their problems, that they can move on from treatment will forever be dependent on the therapist, forever stalled in their progression, forever separated from their goals as well as a combination of a hundred things more. Empowerment is taking knowledge, skill and awareness and lighting a fire underneath all of it to catalyse personal growth and development. This is the step that is most easily manipulated because it comes at the tail end of managing pain and restoring function - the therapist can claim to be responsible for all of the progress experienced until this point and therefore cast themselves at the heart of the process. This is how dependence is built. Using tools isn't building dependence on tools, it's knowing what implement to select to manage a problem. However, if an electrician were perpetually dependent on their old master to teach them how to do things, then you'd get another electrician. The greatest gift a therapist can give their clinician is given incidentally - the confidence to meet the world in a body that is theirs, whose limits and capacities they know, and whose nature they understand.


The Soul.


At the end of it, the point of the process is to fortify life. Physiotherapy may be separate from art, science and pottery but all four of those activities embrace and uplift dimensions of life and the human spirit. All of those activities address needs and deficits, be they the need to express emotion or the need to put a man on the moon. All of these pursuits, qualitative and quantitative, rely on using tools to solve their problems. In physiotherapy, the patient is tool, solution, and substrate. Not only that, but done well, the patient will leave the clinic knowing how to use their body to heal their body - a level of empowerment that can't be beat. Imagine if your car engine could repair itself, your laundry clean and fold itself, or your bank account grow itself outside of interest? That's what the human body can do, and more. It can repair, fortify, and advance itself beyond what it could do at the end of the day. It strengthens itself through exertion. It heals itself through use. To impart that understanding and to make it an implicit and explicit element of the individual experience is to embrace the thing that makes us human itself - that even though we're finite and imperfect, we can always be more than we are.


Oh, veiled and secret Power

Whose paths we seek in vain,

Be with us in our hour

Of overthrow and pain;

That we - by which sure token

We know Thy ways are true—

In spite of being broken,

Or because of being broken

May rise and build anew

Stand up and build anew.