Handling Front-line PT

Some patients reach my pool too late for me to help. This essay is about why that happens, and what it would look like if aquatic PT were a front-line option.

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Healing is a matter of time, but it is sometimes also a matter of opportunity.

—Hippocrates, Precepts, ch. 1

As an aquatic physical therapist, I must sometimes look at many patients and confess, "I can't fix that. I'm sorry, but it's too late." As a physical therapist, it sits heavily on me; as a person, it baffles me.

The scenario is invariable, predictable. Almost interchangeable. The pool door opens. A woman struggles in: her purse is draped, uncomfortably, over her sling. Her sling is draped, incorrectly, over her cast. Her fingers are purplish, swollen, immovable. Her elbow is cocked. Her shoulder is painful. Her face is contorted — a delicate mix of exasperation and pain.

Behind her, a mother and daughter tag-team the door. Mom pushes with a combination head butt/hip check; girl slides in quickly before the rebound. She would be graceful if it were not for the ankle-to-hip, blue, fuzzy, hospital-issue, leg immobilizer. And the crutches.

They are followed by a stream of others. Patients. And why are they coming to see me? Because they broke a bone? Because of their knee sprain? Their herniated disk? No. These people walk through my door every day because of the after-effects of their injury. Their injury has healed, but their body has not.

Why? Because no one sat down and spent time explaining how the body reacts to injury.

Because no one looked at their fractured wrist and said, "Your wrist will heal. Now let's talk about keeping that elbow and shoulder mobile while it does." Because no one told the mom in the emergency room that the knee immobilizer was only for walking and that the knee should be — no! — must be moved. And that the cardiovascular system should be challenged. Because no one told the post-menopausal woman that her posture was more important than her calcium.

Because no one remembered that the information which is "common knowledge" to us, the health care providers, is a mystery to the patient.

The human body is remarkable. It can heal from almost any injury in three weeks to three months. And yet if that same body is immobilized, or moved incorrectly, or neglected, the simple injury can turn into a lifelong problem.

I have had a dream. In that dream I find myself on a first name basis with every resident in the ER, every doc on ortho, every GP who refers to a specialist. And in that dream, I casually say, "Hey Bob. Blue knee immobilizer? Bad choice. Send them down to the pool and I'll talk to them about those weight bearing cautions while maintaining their flexibility and reducing their edema in the pool." And, "Janice. Why don't you send her to me? In two visits, I'll show her a program she can do during our community water exercise hour so she'll maintain her shoulder and wrist mobility without disrupting that elbow set." In that same dream, I also eat everything I ever wanted — twice — but that's a less compelling issue.

I have a dream that our aquatic PT statistics reflect accurately the effectiveness of aquatic PT. That we don't get "stuck" with the impossible cases three years after everyone else has given it a go, then told that aquatic PT doesn't work because the patients don't get better.

I have a dream. In that dream, we, in the pool, are the first line. An option, to be discarded only when inappropriate, not used as a last-ditch effort when desperate (and all the insurance money is nearly used-up).

In that dream, I never see another fuzzy blue knee immobilizer on a patient's knee six weeks after she should have taken it off. In fact, I never see the fuzzy blue knee immobilizer again.

In that dream, I never have to say "I can't fix that" — because they came to see me early in their care. And I can.

For education only; not a substitute for individual clinical judgment.