The “So-What” Factor
I’m honored today to introduce you to Aidan’s physical therapist. Karen has been with us since Aidan’s birth. She’s seen us through several orthopedic surgeries, supported him outside the school setting, and has put up with my, um, instense honesty.
“Is this just a “therapy-thing” or is it something functional?”
This is a great question, posed to me by a savvy, experienced and weary parent, one who has been involved with a wide variety of therapists, all of us eager to make therapy recommendations that invade their house and time with their child. After 14+ years, she’s quick to weed out the “not gonna happen” therapy activities, and I appreciate being held to her gold standard.
As a pediatric physical therapist, I am trained to evaluate a child and, amongst other things, note any “deficits” or “impairments” such as sub-optimal strength or flexibility or bone structure or endurance and more. Years of anatomy, physiology, and kinesiology and ongoing continuing educational courses have taught me to consider body structures and body function. And our documentation requirements – typically driven by insurance reimbursement – force us to quantify those impairments. Compared to typically developing peers, how is this child’s gait or walking style? How is their joint mobility? What are their strength measures? As a data-geek, I confess I like objective measures as well.
But then comes the “so what?” factor. So what if a child’s flexibility is lacking 20 degrees? So what if their ankle mobility is limited? So what if their strength measures are impacted by their disability? How do all these impairments (define) impact their FUNCTION and participation in desired daily activities? How does XYZ limit them at home, school, or in the community? We need to look beyond the “impairment level” and focus on activity, participation, and function.
So I continually challenge my clinical doctorate in physical therapy (DPT) students with my endless “so what? Why does that matter?” comments as they evaluate a child. And I silently think this as I evaluate and work with a child and speak with a parent/caregiver or the child. The impairment is the nuts-and-bolts but the critical question asks what those nuts and bolts build. What problem does this “therapy-thing” improve?
Therapeutic suggestions for activities at home need to be functional, to make sense in the day-to-day activities for that child and need to be easily (relatively) integrated into daily tasks. And parents/caregivers need to have an explanation about why they are being asked to do it. We are adding to their already complex days; we need to explain why it’s important.
- “We want to increase Hermione’s flexibility so she can sit more easily and comfortably in her wheelchair and prevent bony deformities. You can do XYZ at home after bath time, as you get her dressed.”
- “Let’s increase the amount of supported walking practice that Sue gets so she gets stronger and more confident with it. Pick one transition each day to practice walking from point A to point B rather than using the wheelchair for all transitions. How about into the bathroom from the bedroom each morning or evening?”
- “When you change John’s diaper on the changing table, put an interesting and attractive toy here so he turns his head to this side and holds it for a few moments as you gently do ABC.”
- “When you put Baby down on the floor or mat to play, place him on his tummy each time so he practices lifting his head and upper body. This will help strength his upper body so he will then…..”
- “Amanda needs to use the supported stander to stretch out her hip and ankles and prevent bone and muscle orthopedic issues. To be effective, we need to work towards LMNO time each day. A great time to use the stander might be to use it during computer/TV time or meals or…..”
Ask the parent or caregiver what is challenging in their day with their child.
What part of caregiving is difficult or impossible? What do they wish the child could do more easily or efficiently? What do they need help with?
Parents often express the most important functional goals and answer our own “so what” questions. And if we can both buy into a therapy need and plan, the chances of our succeeding increase as we work as a team, with the child and families best interests at the core with a carefully designed, reasonable plan. Re-evaluate the plan frequently to ensure that these recommendations are still necessary and appropriate. As the child ages, the plan may need to be tweaked to address their changing needs and abilities.
Apply the “so what” factor to your child’s therapy. Whether you are a parent or caregiver or a therapist, determining if a recommended activity is a “therapy-thingy” or a functional necessity can make a difference. And don’t forget that “fun” is part of “functional!”
Read more from Karen on her blog at Scatter Joy.