Process-Based Rehabilitation – The Way Forward

Rehabilitation, and much of healthcare, has reached a point of reckoning. We are stuck in a world where we operate in “protocol-driven clown suits”, putting on an entertaining simplified show for the world to watch. These suits ultimately relegate us to the future of becoming replaceable technicians (hello AI & robotics) that worship the idol of a “specific diagnosis” leading to some sort of step-by-step cookbook approach to intervention. We see this growing daily as all around us as “evidence-based” healthcare providers are scraping, bruising, and poking needles into people like pins into pin cushions based on false “specific diagnostics” and a poor understanding of neurophysiology. While many of these providers are well meaning and attempting to help the person in front of them, ultimately, whether consciously, or unconsciously, they are entering into a theatrical show that sells a false value of their shiny interventions. The show continues to grow in popularity despite access to the evidence that consistently demonstrating no additional value from their new treatment addictions. This show goes by the name “XYZ might just be the thing that finally works!” even when it doesn’t, because we haven’t even defined what “working” is and what it is “working” for. This show is not just about our hands on interventions, but it also speaks to our exercise interventions where we randomly throw exercise based on such false diagnoses as an “instability” of some imaginary sort, without knowing what the exercise actually does for that individual, in what context under what instruction. The show can also sometimes sell this idea that exercise alone is this holy grail. Exercise is medicine, right? …But do they really need medicine right now? Are we medicalizing something that does not need to be medicalized? There also is this lingering belief, often from academics, that we can save the day by protocol-based clinical reasoning. Graduate education, post grad courses, certification, residencies, and fellowships promise clinical reasoning and critical thinking but all they’re doing recycling the same inadequate protocol driven drivel that has very little to do with the person in front of us.

Like our psychology colleagues before us, the time is here for a complete paradigm shift in the way we look at the problems of the people who come to see us. The person before us comes with an individual history, a story, and that story in large part determines how that person and their body is operating now. The way the biopsychosocial processes function in this moment was built on years of interconnecting biomechanical, physiological, psychological, and social behavioral relationships and networks unique to that individual in that moment and time. No diagnosis or protocol for syndrome can possibly meaningfully, or practically, be useful in the context of past and present behavior. When someone comes with a report of knee pain, but then also notes significant impairments associated with shoulder pain, and that they have a history of chronic back pain, not to mention they struggle with anxiety and depression, how many diagnoses do we assign them? How many tests do we need to do, how many interventions, how many referrals need to be made, and how many healthcare providers need to be involved only to ultimately not communicate with each other in any meaningful way? Even a single pain complaint is far more layered if we actually ask more closely about the nature of their complaint. Why does lifting their 20-pound child not hurt their shoulder but a sandbag roughly the size and weight of the child in the same manner cause excruciating pain? Why does that shoulder only hurt on Saturdays when doing the same movement as they would on Tuesday at work does not? History and context are key! Even if you are looking simply at sensorimotor and loading capacity variables, what preceded and what is present in the environment and inside of that individual person changes everything! This is the core of a process-based approach to evaluation, intervention, and prognostication, a science-based, critical clinical reasoning approach rooted in learning how to see where people get stuck across of a lifetime and how to help them get themselves unstuck. No more collecting diagnostic labels, no more piles of homework for the client, and no more handing fish to a hungry client when you can teach them how to fish for themselves!

At Dynamic Principles, we are committed to a future of educating clinicians in a process-based approach. We are excited about what this means for humanity in the future of helping people and we hope you’ll join us in this journey!