Physical therapists work with so many different populations and within those populations are completely different expectations for how quickly the person will achieve their goals. This is a significant issue when dealing with insurance companies. I have been frustrated many times when an insurance company wants to treat a child with a developmental disability with the same progress expectations as an adult with a knee replacement. On the other hand, it is also an issue when children are coming for therapy week after week for years and sometimes it develops into an unclear end and amorphous goal.

Clinically, I have swung back and forth with my frustration and expectations for speed of progress. As a PT fresh out of school it was an eye opener that I wasn’t going to “fix” the problem in a session. I learned patience and to appreciate the baby steps of progress. When I took my NDT certification course 5 years later I learned how to make a session mini-goal and how to build a treatment plan to achieve that goal. The results for me have been fair.

Since progress for children with disabilities can be slow and gradual, parents are used to doing home program activities for long periods of time. They are used to being given stretching programs that they are told to do everyday for years/forever. Now that I have been implementing concepts of positional release and strain/counter-strain into my practice (shortening, not stretching the soft tissue) in the format of TMR the speed of progress is increasing exponentially. Changes are happening within minutes. Functional changes take longer and are more unpredictable, but the instant flexibility changes stack one on top of the next and lead to quicker functional changes.

Parents are confused as I am asking them to alter their expectations. I saw an 8 year old boy last week who has a developmental disability, poor balance/coordination/gross motor skill development and very significant tightness throughout his body. His upper trunk could twist to the left, but not at all to the right. His shoulders could turn, but his ribs wouldn’t budge. After a week of doing the new exercises at home for a few minutes, several times a day, he came in yesterday able to twist to the right, ribcage and all. His mom couldn’t believe this had happened in a week. She was so used to being patient, like I had become. The big gross motor changes will come over time, but for now I can be sure that he is breathing better.

Parents are used to focusing on a home program for months. Its a perspective shift for them that I may be changing it every week. If that exercise worked, why are we altering it? As we loosen up the body, and this happens rapidly when done consistently and reinforced with challenging functional movement, different areas of asymmetry become greatest. We keep chasing each asymmetry, like peeling the layers of an onion, and work to resolve it. We speed up progress, satisfy insurance companies with rapid changes, and most importantly help children to achieve their goals more quickly.

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