Building Snowballs in Physical Therapy

We live in a world where correlation is all too often mixed up with causation

Physical therapy is one of the biggest culprits.

We live in a world where correlation is all too often mixed up with causation.  Physical Therapy is no exception, and I see it all the time in the clinic.  A patient’s hip is feeling significantly better one day, and the attributions start – maybe it was the manual therapy two days earlier, the supplement they just started taking, or that magic new exercise or stretch.  It can be frustrating for patients and us clinicians to then parse out what has really been helping, and what’s extraneous.  Individual factors can certainly make a difference, but I’d argue that it’s really the accumulation of these effects that makes all the difference.  In rehab, we’re looking to start a “snowball” effect – one small change helps us to make another, and as we gain momentum the gains become more massive.

                  I recently had a patient start to make some meaningful gains with his persistent Achilles tendinopathy.  As we spoke about what had been helping, one thing came to light: there were several small changes that seemed to be adding up to get him to the point he was at.  He had begun focusing on the simplest but most meaningful exercise for his Achilles tendinopathy (a modified resisted heel raise), had stopped trying to go out for “full” 45 minute runs and stuck to the shorter planned intervals, had a mental shift away from “getting better on a timeline” towards accepting a gradual healing process, and had a recent bout of food poisoning had forced him to take several days completely off from exercise.  None of these factors acted independently; instead, they were forming a snowball.

                  I’d be remiss to mention that the opposite type of snowball also occurs – it’s how this patient and most others like him end up with me in the first place.  Stress at work becomes poor sleep, which turns into missed training sessions or under-recovery, which decreases tissue load tolerance and becomes injury.  Again, all these factors work together and isolating one as the reason someone is getting injured just doesn’t pan out.  Common boogeymen like the “wrong shoe,” gait deficiency, and tight hamstrings just don’t tell the full story.  If it were that easy, people wouldn’t come to me – or need help stopping that negative snowball and turning it around.

                  My job as a PT is twofold – part one is recognizing the snowball and helping you see it for yourself; part two is parsing out the meaningful levers to pull to get the momentum going in the other direction.  Providing physical therapy for runners is rewarding not because it’s like being a “body mechanic,” but because of the privilege of watching patients recognize and turn around their negative snowballs.  When momentum gets going in the opposite direction, hope starts to resurface and excitement begins.  That’s where I feel grateful for the opportunity to walk with people.  The real causative factors have become clear to them: the marginal gains from their consistent effort over time, gradually building momentum to become a massive snowball.